There are NO BLS patients.

[Jon]

Where i run PA (mont, Berks, and northhampton counties) we have ALS and BLS squads. Depending on which county i am running in ALS is almost always dispatched with BLS. However if the call is the ALS territory they run by themselves. But if it's in our area they are dispatched as a medic responder to assisst the BLS crew. I run with both an ALS and BLS crew. I havent reall yhad any calls where there was no medic dispatched. actually i find it kinda, well, like they think EMT's don't know their job because i think we could have handled alot of the calls as BLS, i mean a cardiac or something liek that i would understand a medic but not the normal run of the mill calls.

Around here, we get medics for "ALS Nature" calls... Cardiac/Respiratory, Arrests, Elderly Pt. fall (either 80 or 90 y/o+), Head injuries, MVA reported Serious, Entrapment, Ejection, w/ Fire, or Motercycle, Aircraft incident, Shootings, Stabbings, any fall or assualt with a possible Loss of consciousness, Overdose EXCEPT For BS ETOH overdoses.

That is MOST of the list of what gives us an ALS response.

Most anything else is BLS - Fall, generic sick person, etc.

 

[BossyCow]

I really don't think asking for medics to transport someone just because they're in pain would go over very well.

Our protocols state we are to call for ALS for pain management. Perhaps due to our long transport times.

 

[FFEMT1764]

I work for a county service which employs all levels of EMT's (B,I,P). We have a medic on every truck, but that doesnt mean the medic rides all the calls. If it is a basic call the basic or intermediate can ride the call in. That allows the medics to not be tired when a true ALS call occurs. We feel that letting the BLS partner run the BLS calls allows for development of better assessment techniques for the basic and intermediate EMT's.

 

[Jon]

Our protocols state we are to call for ALS for pain management. Perhaps due to our long transport times.

Around here it varies... Some places and/or providers NEVER give narcotics for analgesia, a few give them out like candy.

The big question in many heads is "Is this a drug-seeker, or are they REALLY in pain?"

 

[BossyCow]

The big question in many heads is "Is this a drug-seeker, or are they REALLY in pain?"

I had a new EMT ask me how I knew someone was looking for pain meds and probably not really in pain.

Hmmm let's review the events....... Called to 22 yo female c/o 10:10 back pain. We arrive to find her sitting on the front porch, bent over tying her shoes. There was drug paraphenalia on the coffee table and her last oral intake was.. ."Um.. some chips, popcorn, a few cookies, some leftover pizza, candy bar, ....." Her back pain was so severe that she was almost unable to retrieve her purse from behind the sofa. Also, on the walk to the ambulance, she mentions.. "Oh by the way..... you should probably call my parole officer, I'm not supposed to leave the house" and shows us her government issue ankle bracelet.

Why did we transport? Because our protocols state that we in the field are not to make a determination about a pt's pain level. That we are to take them at their word.

 

[FFEMT1764]

Um, yeah, gotta love the ankle jewelry...makes me glad that we have a Reeves sleeve!

 

[jeepmedic]

One thing you have to remember is that all calls are not ALS no matter who is riding in the back with the pt. If I ride in with a Pt with a broken ankle who refuses pain medication does that make it a ALS pt? NO. It is a BLS pt. with a paramedic in the back as AIC. And if I have an inexpirenced EMT-B on the truck then it is a good way for them to get expirence with Pt. assessment. The thing alot of ALS providers forget is where they came from. You are always a BLS provider first.

 

[trauma1534]

I would like to address both topics.

1. No, not all calls are ALS. There are a couple reasons for this. If the ALS provider takes over all calls, than this leaves not room for EMT-B's to define thier skills. Many times in the department where I work, EMT-B's try to use ALS providers as thier crutches. This should never happen. EMT-B's should be in some ways thrown in and made to perform at thier skill level. Us ALS providers can sniff out when something is logicly ALS and when it is not. I am all about teaching new providers and helping EMT-B's define thier skills. This does not happen with I am gung-ho and want to start an IV on every patient just because I can, or when I want to AIC everycall because I am ALS. That is rediculis. I was once a BLS provider. I would not be the ALS provider today if someone had not put me in the back and said do it when I was comming along.

2. As for BossyCow's post, sounds like this patient needed to be introduced to the ole refusal form. No, we can't technicly make a determination of someone's pain level, however, as I always tell people, LOOK AT YOUR PATIENT. If your patient looks sick, then they are sick. I know some people can present asymptomatic, but you can sniff out BS. This was a pure case of a BS call. I would inform them that the Dr. office would be open at whatever time. I would inform them also that they would be placed in triage. If they are in major pain, then they can't walk to my truck. They would get a bench seat ride in, IF I did transport them, and they would be seated in the ER waiting room. ER would be advized enroute that you have a stable and triagable patient. People like that like to think that if they are transported by ambulance then they will get seen quicker. I like to prove them wrong. But, ultimatly, I will push for a refusal with this idiot. This will accomplish a couple things. #1. It will get me more down time. I can go back to the station, kick back, watch TV, take a nap. #2. It will put my perfictly good ALS truck back in service for a real emergency call. Why take a ALS truck out of service for BS when you don't need to? #3. This is the best one yet... it will keep the county from obsorbing another bill that obviously will not get paid, so that they can afford to put another truck on the road, this will give me even more down time, or they will be able to sent more providers to our state EMS conferance so that we can become more educated on the finer things in the EMS world.

That is my opinion.

 

[jeepmedic]

I would like to address both topics.

1. No, not all calls are ALS. There are a couple reasons for this. If the ALS provider takes over all calls, than this leaves not room for EMT-B's to define thier skills. Many times in the department where I work, EMT-B's try to use ALS providers as thier crutches. This should never happen. EMT-B's should be in some ways thrown in and made to perform at thier skill level. Us ALS providers can sniff out when something is logicly ALS and when it is not. I am all about teaching new providers and helping EMT-B's define thier skills. This does not happen with I am gung-ho and want to start an IV on every patient just because I can, or when I want to AIC everycall because I am ALS. That is rediculis. I was once a BLS provider. I would not be the ALS provider today if someone had not put me in the back and said do it when I was comming along.

2. As for BossyCow's post, sounds like this patient needed to be introduced to the ole refusal form. No, we can't technicly make a determination of someone's pain level, however, as I always tell people, LOOK AT YOUR PATIENT. If your patient looks sick, then they are sick. I know some people can present asymptomatic, but you can sniff out BS. This was a pure case of a BS call. I would inform them that the Dr. office would be open at whatever time. I would inform them also that they would be placed in triage. If they are in major pain, then they can't walk to my truck. They would get a bench seat ride in, IF I did transport them, and they would be seated in the ER waiting room. ER would be advized enroute that you have a stable and triagable patient. People like that like to think that if they are transported by ambulance then they will get seen quicker. I like to prove them wrong. But, ultimatly, I will push for a refusal with this idiot. This will accomplish a couple things. #1. It will get me more down time. I can go back to the station, kick back, watch TV, take a nap. #2. It will put my perfictly good ALS truck back in service for a real emergency call. Why take a ALS truck out of service for BS when you don't need to? #3. This is the best one yet... it will keep the county from obsorbing another bill that obviously will not get paid, so that they can afford to put another truck on the road, this will give me even more down time, or they will be able to sent more providers to our state EMS conferance so that we can become more educated on the finer things in the EMS world.

That is my opinion.

Well said my young Jedi. Welcome to the dark side. ckb

 

[yowzer]

I would like to address both topics.

1. No, not all calls are ALS.

Heck, MOST calls are BLS. There isn't anything useful that can be done that involves ALS skills and knowledge for the vast majority of calls, that can't wait till the hospital... Today so far: Old lady fell out of bed, done broke her hip. It doesn't take a medic to pick someone up off the floor on a clamshell and drive 'em to the ER. Younger lady who slipped on wet sidewalk. 50ish guy, crushing chest pain for 3 days before he decided to go to a clinic, whose doctor invoked 911. Medics do a 12-lead, shrug, give him to us, even though the hospital he's going to is the one they're stationed at, and we get there at the same time. That one's just lazy on their parts. Chronic back pain. Siatica. Old guy who fell, probably breaking his hip, wife helped him into bed, then he started getting really shaky and weak. Might have been worthy of a medic eval, but a) the hospital he goes to is 2 miles away, b) there's a multiple partial structual collapse downtown, so all the local ones are busy. 1 ALS-involved response out of 6, which pretty typical.

I'd hate to work in a system where you can't poke a stick without hitting a medic. Save them for sick people, please!

 

[trauma1534]

So true and very well said!!!

 

[jeepmedic]

I was once told by the best paramedic that I know (if I forgot who it was all I had to do was ask him) out of 100 calls we are not needed on 90 of them, we make no diffrence in the out come of 8 of them, but its that 2 out of 100 that makes this job worth it. So Als only matters on 2% of the calls.

And by the why this paramedic stood toe to toe with James Page on calls and precepted most of the paramedics in the GSO area at one time or another and his reach has far exceded his sight because some of the things he taught me I teach to my students now.

 

[BossyCow]

I would like to address both topics.

2. As for BossyCow's post, sounds like this patient needed to be introduced to the ole refusal form.

An introduction is no guarantee that both parties will agree to dance!

We are a publicly funded agency. When someone insists they need to go to ED, we have to take them. We can strenuously emphasize our opinions on the matter, but the end result will be in the hands of the pt. I do document on my report the inconsistancies in the pt's behavior vs. stated problems, terms like... 'not in any obvious pain or distress' or.. 'pt's movement clearly shows full range of motion' followed by 'pt insists on transport'

This one ended up being a teaching moment for the new EMT on the call with me so had some value.

 

[FFEMT1764]

I But, ultimatly, I will push for a refusal with this idiot.
That is my opinion.

Doing that here would end your career as our director has made it abundantly clear that we are to do everything short of kidnapping the patient to get them to go to the ER. If we are caught pushing the ole refusal form out we end up out the door, and would probably get a nice visit from the state EMS office and one of their fun investigators...

As we have learned here recently, talking people out of going will get you in serious trouble, no matter how "petty" the complaint may seem. We have transported a toothache at 2 am just because the patient wanted to go, and we knew that if we mentioned the refusal that she would call the supervisor, and we all know where that goes from there...

 

[FFEMT1764]

Today so far: Old lady fell out of bed, done broke her hip. It doesn't take a medic to pick someone up off the floor on a clamshell and drive 'em to the ER.

50ish guy, crushing chest pain for 3 days before he decided to go to a clinic, whose doctor invoked 911. Medics do a 12-lead, shrug, give him to us, even though the hospital he's going to is the one they're stationed at, and we get there at the same time.

As to the first one, here if you have a hip fracture, and the patient is not allergic to morphine, it is an automatic ALS call, pain managment is required, as per our protocols. Not to mention that a hip fracture in the elderly usually means a femur head fracture, which can lead to a lacerated femoral artery...see where this is going.

As to the second one, one ALS is started (12 lead), ALS must continue to the ER, after all, that is the national standard...and ALS giving a CP patient after they felt the patient needed a diagnostic 12 lead is abandonment...and illegal...and leads to lawsuits...etc, etc, etc...

 

[trauma1534]

FFEMT1764, you have very very good points! Yes, once we start ALS precedures, we are bound to riding in with that patient. Very well said. Every call can be turned into ALS, no doubt. Alot of the calls though, can be handled by an EMT-B. Your Resp distress calls, although we are able to start a saline lock, administer Neb tx, in some cases, Lasix, depending on the transport time, an EMT-B can handle some of those mild cases by just placing the patient on high flow 02.

As fo rhte refusals, well... I guess this will have to vary from state to state and what your protocol says. Our area, the ED and OMD for that matter is glad for you to get a refusal from those who do not need to come in by EMS. I'm not saying that all patients should be offered a refusal, however, if they can safely be transported via POV, then we have the right to suggest that, and push for that, for that matter. It all depends again on where you are at as to how you handle refusals. In the state of NC, they are starting to do what is called "referals". This is when an ALS responce vehicle responds with a BLS truck. They triage the patients, and decide if that patient warrents an ambulance ride to the ER, or if they can go by taxi, or POV, or any other form of transportation other than by ambulance. This is a great way to keep trucks available in a busy system for true emergency calls. My friends and I joke all the time about getting refusals, but when it comes down to it, we actually get very few, fewer than we should, actually. Again, it all depends on the area you are practiacing in.

Great points though FFEMT. You are a very contious provider, I can tell. I like that. You are not burned out, and you still care about your patients. I just don't want to dismiss the fact that BLS providers are still greatly needed in the field of EMS. In all practical cases, they are our future paramedics, atleast that is how it is here in Virginia. We need to utilize them when at all possable so that thier skills will grow. We don't need to be thier crutch, yet we should be thier resorce, thier teachers, thier influances, and thier motivation to become good providers.

 

[Ridryder911]

Heck, MOST calls are BLS. There isn't anything useful that can be done that involves ALS skills and knowledge for the vast majority of calls, that can't wait till the hospital... Today so far: Old lady fell out of bed, done broke her hip. It doesn't take a medic to pick someone up off the floor on a clamshell and drive 'em to the ER. Younger lady who slipped on wet sidewalk. 50ish guy, crushing chest pain for 3 days before he decided to go to a clinic, whose doctor invoked 911. Medics do a 12-lead, shrug, give him to us, even though the hospital he's going to is the one they're stationed at, and we get there at the same time. That one's just lazy on their parts. Chronic back pain. Siatica. Old guy who fell, probably breaking his hip, wife helped him into bed, then he started getting really shaky and weak. Might have been worthy of a medic eval, but a) the hospital he goes to is 2 miles away, b) there's a multiple partial structual collapse downtown, so all the local ones are busy. 1 ALS-involved response out of 6, which pretty typical.

I'd hate to work in a system where you can't poke a stick without hitting a medic. Save them for sick people, please!

Does the patient with a hip fracture does not need analgesics for pain?..
Do you know what the call medic who rule out an AMI with an XII lead?......
Defendants. I agree, it was probably not .. but an ECG cannot rule one out.

Yes, there is a lot of bull.. but that is nature of the beast. BLS non-emergency calls should be teched by Intermediate or Basics so they can obtain experience for later on advance level calls.

R/r 911

 

[yowzer]

As to the first one, here if you have a hip fracture, and the patient is not allergic to morphine, it is an automatic ALS call, pain managment is required, as per our protocols. Not to mention that a hip fracture in the elderly usually means a femur head fracture, which can lead to a lacerated femoral artery...see where this is going.

She had good CMS in her feet, and decent vitals. In my area, asking a medic to transport just to give morphine would likely result in a complaint against you.

As to the second one, one ALS is started (12 lead), ALS must continue to the ER, after all, that is the national standard...and ALS giving a CP patient after they felt the patient needed a diagnostic 12 lead is abandonment...and illegal...and leads to lawsuits...etc, etc, etc...

Doing ALS stuff is not a good enough reason to do an ALS transport here. I've taken in people who've been woken up by IV glucose, narcan, given breathing treatments, having heart attacks... King County medics refuse to transport BLS patients, and they have a rather unique definition of such. It's been that way for decades, so I suspect it's held up in court.

 

[fm_emt]

Yes, there is a lot of bull.. but that is nature of the beast. BLS non-emergency calls should be teched by Intermediate or Basics so they can obtain experience for later on advance level calls.

BLS 911 calls would be just fine with me. Even the BS calls are still a chance to use some skills. Someone has a toothache and wants a trip to the ER? Ok, no problem. As long as they're there, they can have some vitals taken on the way to the hospital. Who knows, maybe there's more behind it, like "my tooth hurts because I hit my head after falling down the stairs." Or maybe they just didn't brush.

 

[FFEMT1764]

She had good CMS in her feet, and decent vitals. In my area, asking a medic to transport just to give morphine would likely result in a complaint against you.


Doing ALS stuff is not a good enough reason to do an ALS transport here. I've taken in people who've been woken up by IV glucose, narcan, given breathing treatments, having heart attacks... King County medics refuse to transport BLS patients, and they have a rather unique definition of such. It's been that way for decades, so I suspect it's held up in court.

Here if you don't give morphine for a patient in obvious pain then you could count on an investigation by the med control doc, the service director, and the loving State EMS office's field investigation staff. This all would likely lead to losing your job, and maybe your cert.

Secondly, I hope to never get sick in your area, as far as I know a basic cant transport an MI anywhere, at least not do it and meet the National Standard's, and I sure would be getting a lawyer to look into malpractice, negligence, and possibly criminal complaints...but this is just my personal thoughts on the matter.