Street EMS vs. Transport

[JPINFV]

Believe it or not, BLS crewed are regularly, often and very consistently paged out for these calls.

The question is not whether they are paged out, it's whether they should be paged out for it. If you're loved one was symptomically hypotensive, would you be happy with someone besides an EM physician working your loved one up at the ER? Oh, sure, the EM physician is available, we just don't want to disturb him for you.

Then you work in the EMS System from Heaven. The NHs on Chicago's northside are notorious for killing their patients. When they decide to finally call for help (hopefully before rigor has set in) they give the absolute worse reports one can possibly imagine. Ever.

Gosh, I recall one call tony1 and I did. Paged out as a "fever". We got there and the guy was COOKING, clearly pneumonia, lungs filled with fluid, mostly dead. Yet it was paged out as "fever".

...but he did have a fever, correct? Sure, the pager says "congestion" but that coming from a SNF is not going to make me thing "slight cough and sneeze" like what I would define as congestion for myself.

 

[JPINFV]

See what I mean! A dead pt does not have general weakness. They have complete, irreversible weakness!

What's your definition of generalized? Dead is definitely not focal weakness and what sort of "generalized weakness" are you expecting from a SNF instead of ALOC? I'm not arguing that you can take SNF CCs at face value. Just that once you realize that you can't take them at face value they make perfect sense.

 

[bstone]

The question is not whether they are paged out, it's whether they should be paged out for it. If you're loved one was symptomically hypotensive, would you be happy with someone besides an EM physician working your loved one up at the ER? Oh, sure, the EM physician is available, we just don't want to disturb him for you.

Come and work in the Chicago system for 3 months and you'll understand what we're talking about. You'll probably pull out all your hair from the frustration. We just kinda shrug and do our jobs the very best we can.

 

[tony1]

I don't think anyone is saying it is right that BLS units get dispatched to these calls, but it is what it is in this system and all we can do is go one day at a time. The nursing homes and half-way houses, and psych facilities and all the rest of them refuse to call 911. I have been told directly by police that I had to call to the scene, that the city keeps records of stuff and the nursing homes do not want records kept. If the private company has no ALS available, and they hold the call until an ALS clears up, it will be a long time with no response at all. Believe me I have worked in other systems in IL and it is not like this. I do however love my job and I like this company alot. My current partner is an RN student and has only one semester left and can't wait to get away from this stuff.

 

[bstone]

I don't think anyone is saying it is right that BLS units get dispatched to these calls, but it is what it is in this system and all we can do is go one day at a time. The nursing homes and half-way houses, and psych facilities and all the rest of them refuse to call 911. I have been told directly by police that I had to call to the scene, that the city keeps records of stuff and the nursing homes do not want records kept. If the private company has no ALS available, and they hold the call until an ALS clears up, it will be a long time with no response at all. Believe me I have worked in other systems in IL and it is not like this. I do however love my job and I like this company alot. My current partner is an RN student and has only one semester left and can't wait to get away from this stuff.

Pretty much the hammer on the nailhead.

No one says it's good to call BLS for these calls. But if we get paged out and have a critical patient, what should we do? ALS is times 40 minutes away and we're 5 minutes load-and-go to the ER.

 

[JPINFV]

I don't think anyone is saying it is right that BLS units get dispatched to these calls, but it is what it is in this system and all we can do is go one day at a time. The nursing homes and half-way houses, and psych facilities and all the rest of them refuse to call 911..

...which is why I support dispatch protocols requiring referral to the 911 system for specific calls. It takes out the problem of not calling 911 for the patient with chest pain when every call taker outside of the 911 system refuses the call at the dispatch level.

Pretty much the hammer on the nailhead.

No one says it's good to call BLS for these calls. But if we get paged out and have a critical patient, what should we do? ALS is times 40 minutes away and we're 5 minutes load-and-go to the ER.

Show me where anyone has argued that an EMT unit on scene shouldn't transport. Argued that ideally they shouldn't have been dispatched? Yes. Argued (minus the caveat about specialty centers) that EMTs shouldn't transport? No.

 

[tony1]

That's all I am saying. I am not trying to start a debate, or defend this system, I was merely informing people of how it is within this system. I have been in person to the system office and voiced my concerns on more than one occasion. After explaining how my company operates, and the types of calls I run, and how I have to run them, I was told by the RN educator that I have obviously figured out how to work effectively in this system and if it was still a problem for me then maybe I should consider going to another company in another system. That was the last conversation I have had with them. This is my secondary system but as I said I do love my job and this company and I do not want to leave.

 

[clibb]

Here's the problem. There's absolutely zero reason a BLS unit should be dispatched for abnormal vital signs, ALOC, or a handful of other complaints. If a BLS unit is getting a page for a patient in a nursing home who's ALOC and hypotensive (that 70/40 was the chief complaint on the pager for a call I was actually on), then the system is failing that patient. I fully understand if what was dispatched and what was found was different. I fully understand if the patient's status changed. However if the complaint is, for example, "congestion" (nursing home speak for acute pulmonary edema secondary to congested heart failure normally), then there shouldn't be a BLS unit on scene deciding whether they should transport or call for paramedics. Paramedics need to be a first response, not a second response to these calls.

What would a Paramedic do different to a patient with Pulmonary Edema due to left sided CHF than a EMT-B? The only thing you can do is apply positive pressure ventilation.
If that patient is going to die from the left sided CHF at that moment you respond to this call. Well, the only thing you can do is load up and hope he'll make it to the hospital so that the physician can do something about it.
Oh and in our system Paramedics are almost ALWAYS second to respond. Here Fire Dept and Ambulance are two separate agencies. Fire are almost always on scene first because we have 14 fire stations and only 4 ambulance stations.
BLS saves lives.

 

[looker]

That's all I am saying. I am not trying to start a debate, or defend this system, I was merely informing people of how it is within this system. I have been in person to the system office and voiced my concerns on more than one occasion. After explaining how my company operates, and the types of calls I run, and how I have to run them, I was told by the RN educator that I have obviously figured out how to work effectively in this system and if it was still a problem for me then maybe I should consider going to another company in another system. That was the last conversation I have had with them. This is my secondary system but as I said I do love my job and this company and I do not want to leave.

So basically it sounds like they are saying it's our way or the highway.

 

[jjesusfreak01]

What would a Paramedic do different to a patient with Pulmonary Edema due to left sided CHF than a EMT-B? The only thing you can do is apply positive pressure ventilation.
If that patient is going to die from the left sided CHF at that moment you respond to this call. Well, the only thing you can do is load up and hope he'll make it to the hospital so that the physician can do something about it.
Oh and in our system Paramedics are almost ALWAYS second to respond. Here Fire Dept and Ambulance are two separate agencies. Fire are almost always on scene first because we have 14 fire stations and only 4 ambulance stations.
BLS saves lives.

I don't know if this is what you were referring to by PPV, but a paramedic could pull out a CPAP and give nitro for the edema, when an EMT usually can't use CPAP, and can't give nitro without chest pain.

That said, we page out fire to most ALS level calls here. They almost always arrive first and (since they usually have at least one EMT on a crew) can give nitro and do compressions on an arrested patient. They aren't going to transport anyone, but they provide a valuable service and are probably responsible for some of the saves our system gets every year. The same could be said of a BLS unit responding to an ALS call. How can you argue its not good to send them if they can get their first and start treatment, and then either maintain the patient while awaiting ALS or transport more quickly than ALS could get there. It all comes down to what type of system you have and the response times for each type of unit, but in the end earlier access to trained providers is better than waiting for ALS.

 

[tony1]

Correct, their way or that's it. I didn't mean to start such a fuss over this but maybe I can expain it a bit more for those not from here. So you have the FD's and their ambulances and then the private companies. Privates are contracted with facilities. Each one chooses the type they want to be contracted with and the number of. It's all about the almighty dollar so when that CP call comes in and the ALS rigs are all busy, they are not going to refuse the call, but I understand the other guy's post about why they should. I understand that it should go to another provider who can respond ALS, but unfortunately due to it being a for-profit situation, they are not going to risk losing that account. If they start refusing calls the account will seek another provider that can service them better. This is how we got our accounts and the other guy gets his and so on. The facilities are always looking for that perfect company that responds quickly and makes them happy. Unfortunately if all that is available is BLS, they are going to get dispatched. We use radios at this company BTW, not pagers. The company hopes that the BLS can "first respond" and assess the pt and if ALS is close behind and still needed, the BLS can package the pt and meet the ALS downstairs. What ends up happening is the ALS is either far behind and it's not worth waiting, or they slow their roll because they know that the BLS will most likely take the pt and that is one less call for them. I know that sounds terribly negative but I know this to be a fact. The whole issue is that these companies will put the B in a sticky situation where they have to not only CYA, but look out for the pt also. It's a tricky balance because you have to cross the t's and dot the i's and the best way is to call the resourse hospital and tell them what's up and get permission to transport. Once they give their blessing, you are covered as far as having the ALS pt in your care and transporting them. Now, if there is no time to make a call and that happens alot due to a very crappy pt (possible CVA for example), one is driving and the other is doing pt care and as long as you can show it was best for the pt to load and go w/o a phone call, you are ok but you must justify that decision.

Not all privates in my area are like this. There are many that serve the city of Chicago, and they are in all different systems. Some systems are suburban hospitals but the company can operate in Chicago and they have different rules and different equipment etc. Not all privates will even allow a BLS to transport into an ER. Suburban hospitals out here do not recognize BLS ambulances and if you call in a run to them they will flip but then we have to explain that we do not operate in their system and we have our own resource hospital and they say it's ok and we follow their SMO's. This system I am in secondary allows us to check b/s as a BLS unit. My primary system says that's an ALS skill and does not allow glucometers on BLS rigs. Huge differences from system to system and hospital to hospital and definitely from city to suburban. One big thing is that other systems do not have a BLS protocol. This system I am in is the only I have found out here that has an actual written BLS protocol.

I inquired about employment a few years ago with Superior. I asked them flat out what systems they operate in and "pretty much all" was my answer because they are so big and spread out. I then asked which of them has an actual written BLS protocol and they told me "none". The system I am in has only 3 companies in it but I am glad to have an actual BLS SMO's packet and protocol packet to follow. Other companies do not have that and their BLS rigs are basically what everyone on here calls IFT rigs. They do dialysis and hospital returns and believe it or not some companies I worked for do not even carry an AED or combitube becuse the system does not require it. Basically they have oxygen and linen and are a glorified medi-car that lets the pt lie down on a cot.

As far as any facilities calling 911, they do not want records kept on their facility and will not use them. We are their 911 service. As far as house calls, if someone calls us directly with a complaint, it's responded to the same way as if it were a nursing home. We can recommend to them to call 911 but they already have their mind made up not to call 911 because they do not want transport to the closest, they have a preferred destination and believe me people are stubborn with this. B's,....and even p's, also have to try to always get the pt to the desired if possible because believe me too many diversions and the MD will yell at the NH who will yell at the company who will not let that B or P risk losing the account so his/her career may end abruptly. It all rolls down hill. This is why I said it's a fine line and you have to balance and CYA in addition to your pt care. Lots of politics also I guess you could say.

Well I just came off a 24 and have been up for about 48 so I probably seem rambling to some but I wanted to clear this up if possible. Thanks.

 

[JPINFV]

What would a Paramedic do different to a patient with Pulmonary Edema due to left sided CHF than a EMT-B? The only thing you can do is apply positive pressure ventilation.

Nitro and c-pap comes to mind off the top of my head yet, and I haven't even had resp yet.

If that patient is going to die from the left sided CHF at that moment you respond to this call. Well, the only thing you can do is load up and hope he'll make it to the hospital so that the physician can do something about it.
Oh and in our system Paramedics are almost ALWAYS second to respond. Here Fire Dept and Ambulance are two separate agencies. Fire are almost always on scene first because we have 14 fire stations and only 4 ambulance stations.
BLS saves lives.

Are you talking about second response as in "paramedics arrive second" or second response as in "paramedics aren't even dispatched until the fire department is on scene." There's a big difference between those two types of "second response."

As far as "BLS saves lives." Well, POV saves lives too, so let's encourage everyone to throw patients into POVs instead of calling an ambulance.

 

[JPINFV]

That said, we page out fire to most ALS level calls here. They almost always arrive first and (since they usually have at least one EMT on a crew) can give nitro and do compressions on an arrested patient. They aren't going to transport anyone, but they provide a valuable service and are probably responsible for some of the saves our system gets every year. The same could be said of a BLS unit responding to an ALS call. How can you argue its not good to send them if they can get their first and start treatment, and then either maintain the patient while awaiting ALS or transport more quickly than ALS could get there. It all comes down to what type of system you have and the response times for each type of unit, but in the end earlier access to trained providers is better than waiting for ALS.

Few quick points.

First, see note above about the difference between "ZOMG send EMT first response to save 40 seconds!" and "send EMTs to determine if paramedics are needed."

There are systems that allow nitro administration by EMTs in patients with pulmonary edema? Interesting.

"How can you argue its not good to send them if they can get their first and start treatment"

Simple. If it's routinely happening, especially routinely happening with EMT transport due to extended paramedic response time, then that's a big indication that the system needs more paramedics. More paramedics means less need for an EMT first response as a replacement for paramedic response.

 

[bstone]

One thing that must be said- if the City of Chicago were to require that all ambulances be BLS, then about half of the ambulances on the road (if not more) would disappear. Response times would go way, way up and you'd see a lot more taxis blowing through red lights.

 

[tony1]

Well bstone you and I know how this city and particular system work and we know it is not going to change any time soon. Again it's all money so there won't be a huge increase in additional ambulances being purchased and there will not be a huge number of additional medics getting hired anytime soon.

 

[bstone]

Well bstone you and I know how this city and particular system work and we know it is not going to change any time soon. Again it's all money so there won't be a huge increase in additional ambulances being purchased and there will not be a huge number of additional medics getting hired anytime soon.

That's true. A way to get rich is to open a private ambulance service in Chicago.

 

[tony1]

Hmmmmm, when are you going to have your MD bstone? Travis is one semester from his RN. Look at that, we are on our way to a new company. We can add one more to the long list of existing ones. You can be the Medical Control. Then we can steal accounts too,lol.

 

[bstone]

Hmmmmm, when are you going to have your MD bstone? Travis is one semester from his RN. Look at that, we are on our way to a new company. We can add one more to the long list of existing ones. You can be the Medical Control. Then we can steal accounts too,lol.

Hah! I am not TOO far from the MD, but then there is residency, fellowship, etc. Don't count on me for about, oh, 10 years!!

 

[tony1]

ok, I will prepare. Since I have phlebotomy experience, I would like to mount a centrifuge in the ambulance so I may draw labs and spin tubes while en-route. I am thinking of maybe also an x-ray machine. Let's just use a semi and have a rolling lab also. I will let Travis drive and when I need medical control I will call his cell and he can simply tell me what to do under your license,lol.

 

[bstone]

X-Ray? No dude, my ambulances will have MRI.