What is considered a BLS call in your area

[skyemt]

One thing with CVA's. Don't get stuck on the "3 hour" time window.

Most stroke centers have multiple treatments available. They can go up to 16 hours out. You need to find out from your local stroke center, what they have available.

the reason i say "3 hours" is that it is our protocol. after working with our stroke centers, the state made our goal to get the patient there in under 3 hours.

not disagreeing with you... just explaining that that window is what our protocol says.

 

[firecoins]

do you endorse canceling ALS for a CVA patient? it doesn't seem like your approach...

if you would not, then you are disagreeing with the basics who are posting otherwise...

cva is an als call. They need more transport than minor interventions and transport.

75% of the time medics beat me to a scene. Alot of times they triage it down to me. Many times they come in my rig and take it down to ER. This is where I get the experience from. It isn't from being a medic student as I did this before I was a student. Being a medic student helps though.

25% of the time I beat the medics to the scene. I can see if the patinet is just in need of transport or need greater interventions. If i can handle it, cancel the mefics. If I am unsure for any reason, I don't cancel. At least I get their opinion and take it from there.

 

[reaper]

I understand. Everyone has to follow their protocols.

This may be some thing that you could work on, to get the state to change their protocol.

Ours is at 6 hours now, but the stroke centers vary on what they will still do in different treatments.

 

[Ridryder911]

What I have learned from this thread.

Many of the EMT"s & even Paramedics are not currently informed and even understand current medical care involving emergency cardiovascular care and stroke management. Frightening is that many systems allow lower care to be delivered to patients without proper assessment from a qualified healthcare provider.

This is not just scary, and frightening but very discouraging. Only knowing your local protocols is not enough. Look outside the box, make recommendations to your medical director or committee to keep upon current care!

This is not just essential in patient care but legally as well. Ignorance is NOT blessed.

Read periodicals, journals, methodology of treatment outside just EMS. Keep informed.. it is your job! (be it paid or not).

I am currently an EMT-Basic... I was a Paramedic student in a 2-year degree program that I 3/4 completed before dropping for personal, non-academic reasons. I was 2nd in my class with an "A" average and completed most of the core ALS classes including A&P and clinicals I and II. I performed all the ALS modalities... IV's, meds, intubation (field, OR, and ED) in the field and IO's, surgical airways, and chest decompressions, and more intubation practice on cadavers at the University of MD.

So you see I speak from both perspectives..

This bothers me. We have a person that acclaims to be a Paramedic drop out student but acclaims to practice as one? Maybe I misunderstood. Yet, how can one even critique EMS or medical care if one is not at equal or higher level?

ALS around here aren't to big on pain management. If you keep them for an isolated ankle fx because you want pain management... you will get some evil stares. I understand Firecoins position. He isn't saying pain management isn't a good idea. But when you have such a short transport time, by the time the medic starts a line, gets med command, pushes the med, were at the hospital where the pt. would be getting pain medication pretty early anyway.

Again, how long does it take to administer analgesics? Really, what is the hurry to run back to the hospital? Would it not be better to provide analgesics, splint appropriately calm, non hurried, smoothly? Med control for analgesics? What decade is this? Provide better education, maybe med control will have standing orders?

Really, I would want someone to provide me pain control for my ankle fxr (which is considered, one of the most painful fxrs.) before transporting me. That is undue pain, and really not being in the best interest of the patient.
Again, this has been debated to death ten years ago Get on with the current treatment plans. Again, show medical control the current trends and treatment. Prevent litigation and mainly prevent undue pain & suffering to your patients.

In regards to door to drug time, Three hours from time of onset to treatment, is the National Recommend Time allowable. Geez folks, that is even a AHA test question! We are supposed to be supporting and encouraging the common laymen to seek treatment as soon as possible and here we are presenting the common man may know more than EMS personnel ?

Yes, some centers may have increased time allotment as the may perform the Merci technique but be forewarned it does not have the same results or outcomes. Let's promote the national standard and leave the increased time for those that want to perform on their own protocols.

In regards to only certain ER's can perform fibro on CVA. That is B.S.! After performing a CT and verifying there is not a hemorrhage as usually confirmed by a radiologist (some ER physicians will make the determination) can administer fibro. If they can administer "clot buster" to the heart, then they have the ability to fibro CVA's. Again, successful litigation has been made against the archaic thinking.

Again, these posts reveal many of those in EMS have no clue to even what an emergency is or is not. Obstetrics is such an emergency and have potential complications, just ask what the procedure of an O.B. patient is > 20 weeks gestation is at your local ER? Some of the medical liability insurance will not even cover ER physicians for emergency deliveries.

I propose that we should really look and evaluate current care. Maybe discussion with citations and references should be made as much as possible. Yes, every one follows protocols, so do I but this does not mean I do not know or aware of current medical regime. This is how protocols are revised and brought up to date.

I just wonder if most here ever attend increased education such Advanced Stroke Life Support, PALS, NRP or APLS courses? From what I have read many may not go past their initial first course. Remember, the EMT & Paramedic curriculum has not been updated over 12 years.
R/r 911

 

[reaper]

Rid,

I did not post about the CVA times, to have people push them back. I see way to often EMS show up at a stroke call. They determine that the pt's S&S are more then 3 hours old and treat it as BLS, since it's outside the window.

Everyone needs to find out what their local stroke centers use for treatment. There are treatments that can be used after the 3 hour window, with excellent results. I have seen venom do wonders after 12 hours.

I just want everyone to know that there are a lot of options out there and not to treat a 5 hour old CVA likes it's to far gone!

 

[Ridryder911]

I totally agree, not my point actually. Mainly that EMS systems should pay attention to the new national data and DEFINITELY not a BLS issue. My point as well as you described was not to treat a CVA as an old one if it is greater than 3 hours. (We all know the perception of time of family members). As you described it may be treated even if longer than 3 hrs. in length.

I believe we are on the same page, maybe lacking of communications on my part, and I apologize if so.

I am frustrated though an EMS forum in the U.S. would have systems still operate that it was in the 70's as well as people attempting to defend it. I admit my systems has some major flaws, some I can attempt to change and things I will never change. This does not mean I cannot or will not continue to be up to date on patient care and current emergency medical trends.

R/r 911

 

[reaper]

I agree 100%!

 

[Keith]

among the elderly, weakness may be the only symptom of an MI...
yet you list that and strokes as BLS calls??

sorry, makes no sense.

I agree, it may not seem to make sence, but I do the best I can with the calls I am sent too. I don't get to make those choices, I go where dispatch sends me. One of the ups to being in this area is ample ALS if I need an intercept from the city service that operates out of a level 1 trauma center in downtown, as well as numerous private companies. I never stated that I belived those all SHOULD be BLS calls, I just stated thats how they are dished out, So I would like to clarify that. In this city, from any point within the limits, there are 2 level 2 trauma centers and 1 level 1 trauma center within 5 minutes. I believe a well trained basic is going to spot a CVAin just as much time as a medic, and then its all about transport time and a good CMED patch to alert the stroke team. I'm not trying to jump into an argument (thats obviously going on), I'm just going by how it is here.

 

[skyemt]

I agree, it may not seem to make sence, but I do the best I can with the calls I am sent too. I don't get to make those choices, I go where dispatch sends me. One of the ups to being in this area is ample ALS if I need an intercept from the city service that operates out of a level 1 trauma center in downtown, as well as numerous private companies. I never stated that I belived those all SHOULD be BLS calls, I just stated thats how they are dished out, So I would like to clarify that. In this city, from any point within the limits, there are 2 level 2 trauma centers and 1 level 1 trauma center within 5 minutes. I believe a well trained basic is going to spot a CVAin just as much time as a medic, and then its all about transport time and a good CMED patch to alert the stroke team. I'm not trying to jump into an argument (thats obviously going on), I'm just going by how it is here.

so, there is ample ALS available, including intercepts, but dispatch decides that CVA's are BLS calls? No, i don't think so.

then, you decide to run a CVA BLS, even though you state that you have ample ALS available to you?

have you been reading the posts on this thread?

 

[BossyCow]

Again, these posts reveal many of those in EMS have no clue to even what an emergency is or is not.
R/r 911

Hmmm so should we have a paramedic in every livingroom so the pt can decide if they need to dial 911 or not? How far do we take this? After all, none of this care comes for free. Should I call ALS for everthing that might turn into a life threatening situation, at $800 per trip? If the people of my district live within the boundaries of a BLS district, what is my responsibility? We are a strictly BLS agency and to say that my agency doesn't count because of our rural exception is a cop out.

The majority of the calls we run do not need ALS intervention. Sure it would be nice to have a paramedic evaluate everyone for that one odd call that isn't as initially presented. But, I don't know many paramedics who are going to work for free. Someone has to pay the cost. You can say that you can't put a price on a person's life, but that really isn't accurate either. Otherwise we'd all be lined up outside of the most expensive state of the art Cancer Clinic, Stroke Rehab Unit, Cardiac Care Facility.... etc.... Money matters!

 

[Ridryder911]

The majority of the calls we run do not need ALS intervention. Sure it would be nice to have a paramedic evaluate everyone for that one odd call that isn't as initially presented.

Is a CVA or chest pain, Shob an odd call? Really, what is an odd call that require someone would need EMS services that did not need some form of evaluation & intervention? If that was the case, then they don't need an ambulance they need a transfer taxi service. Reality, what are you offering your patients more than that? Oxygen, some splinting and availability to lie down for transport. Are you offering pain control, anti-emetics, really what are you doing that the family could not do?

But, I don't know many paramedics who are going to work for free. Someone has to pay the cost. You can say that you can't put a price on a person's life, but that really isn't accurate either. Otherwise we'd all be lined up outside of the most expensive state of the art Cancer Clinic, Stroke Rehab Unit, Cardiac Care Facility.... etc.... Money matters!

Actually, how about consolidating and having a regional EMS service. Does your community have water regions, CoOp services, Public Health Department, Law Enforcement? See, there is services, again I guess it depends upon the priority.

Just because someone chooses to live or so happen to drive in rural area, should not mean that they have less or poor care. Again, I have worked in very rural areas, most of the problems was it was easy to give excuses and not work on the problem. Amazing, they could find answers and funding on other of interest. When it is you or your family member & knowing that there is something could had been done, but was not may present a different feeling than the "feel good" I was able to help.

In regards to being "lined up outside the state of the art medical facility", I would agree it happens. I drove over 600 miles a week for over a year and will be in debt for ever for my wife's cancer treatment, all because it was better and more progressive. Again, I guess my priority was different..money did not matter, when involves my loved ones health.

R/r 911

 

[Arkymedic]

Wow! Thank you for proving my point of ignorance. If you cannot determine the difference of a AAA and general back pain after assessing, something is wrong. As well, dispatch is not the "end all" of medical clearance.

I guess regulating blood pressure to prevent AAA from rupturing, is something you would not understand? Who in the h*ell, pushes fluids on a AAA? Go back to school!

As well, there are many documented problems with the "old and tried" priority dispatch system. Would you like to review the litigation's of that system? Yes, there has to be a system in place, but it is NOT without flaws. Sure there are non emergency calls, alike there are non emergency injuries and illness that arrive to ED, but guess what each one has to be evaluated by a person that can provide advanced care and be assessed to determine that there is not a life threatening event.

Sorry, a person with 150 hour course is not qualified to make the determination and definitely not reading Clawson's dispatch program eleminates these errors.

I don't play doctor, but I suggest you awake to 2008 and look around and look at over crowded ER's, and no hospital rooms. If you do not think that our role is not about to change, then continue to keep your head in the sand.

Field termination of codes, treating and releasing, etc. is now becoming an everyday event. The Paramedic Practitioner is not a "dream" rather a needed reality not just because the system needs it rather it but also an economical outlet that insurance corporations sees as feasible too.

If you think this is B.S., then I refer you to the CEO of NREMT, Bill Brown and his statements at the Eagles Conference and articles in JEMS, EMS, etc.

R/r 911

See Rid, this is exactly why I was for the extended scope of practice for Paramedics that was put forth...

 

[Arkymedic]

Yep, and all hospitals should have a neurologist on board too! And who's paying that salary??

We had a CVA pt, who needed fibrinolytic therapy. She was picked up by EMS within 45 minutes of first onset and by a system close to the hospital. Unfortunately, the airlift that was to take her to the closest center for the procedure was grounded due to fog and ground ambulance transport put her arrival outside the 3 hour time limit.

Now, you can say that if our hospital had the ability to perform this procedure (as all should according to Rid) the outcome for this patient may have been quite different. But, at what cost? The cost of the facility, staff and infrastructure needed to perform this one procedure would have had to be at the expense of other services our hospital offers.

We run into the same situation with Peds calls. Our ability to diagnose and treat Peds pts is limited. Most are airlifted to Seattle, but our location makes it a crapshoot as to whether airlift is going to be able to land or even see where we are under the fog.

Yes technological advances are wonderful and increase positive outcomes. But the sad old reality is, that a public district hospital cannot afford the latest and greatest technology in all areas. So, they pick those that get the biggest bang for their buck. Those what will provide the greatest benefit to the greatest number of patients.

So, is it technology that is 'stuck in the 70's' which is the problem, or is it a financial issue? None of this technology comes for free. Who pays for it?

Do not forget how common CVAs are. That one procedure is absolutely worth it if it saves a single life. The same is true of trauma centers. Many states are doing away with trauma centers because they are money pits; however, what about the individuals they save? If it saves a single 12 year old and allows them to grow up then hell yes it is absolutely worth it.

 

[BossyCow]

Again, who pays, and how does a paramedic keep up skills running less than 200 calls a year? Certainly there are some services offered to rural areas, but in most cases, water is private well, sewer is on site personal septic and garbage is haul it yourself to the dump.

Your perfect scenario for everyone to have ALS can go right up there with everyone should have a roof over their head and 3 meals a day. How about good preventive healthcare, or maybe, since we're waving a magic wand, college education for all those who qualify academically instead of just financially.

Its nice to toss about all those 'shoulds' but bottom line, someone's gotta pay for it.

 

[el Murpharino]

Again, who pays, and how does a paramedic keep up skills running less than 200 calls a year? Certainly there are some services offered to rural areas, but in most cases, water is private well, sewer is on site personal septic and garbage is haul it yourself to the dump.

Your perfect scenario for everyone to have ALS can go right up there with everyone should have a roof over their head and 3 meals a day. How about good preventive healthcare, or maybe, since we're waving a magic wand, college education for all those who qualify academically instead of just financially.

Its nice to toss about all those 'shoulds' but bottom line, someone's gotta pay for it.

I think what's being said is that if 4 or 5 agencies combine their efforts and resources, you will find that the one conglomerate agency not only runs more calls per year, but will allow your medics to run more calls, thus helping them "keep up their skills". Also, you will probably end up with only 2 or maybe 3 total stations, down from an original 5, which could provide you with more medic help. Does your agency not bill patients or receive any tax revenue from the community? I know of alot of rural, volunteer agencies that still practice this way...but they're slowly wasting away.

 

[ffemt8978]

I think what's being said is that if 4 or 5 agencies combine their efforts and resources, you will find that the one conglomerate agency not only runs more calls per year, but will allow your medics to run more calls, thus helping them "keep up their skills". Also, you will probably end up with only 2 or maybe 3 total stations, down from an original 5, which could provide you with more medic help. Does your agency not bill patients or receive any tax revenue from the community? I know of alot of rural, volunteer agencies that still practice this way...but they're slowly wasting away.

How do you propose to cover a larger area with 2 or 3 stations, while at the same time maintaining minimum response time requirements?

 

[Outbac1]

Bossy it can be done, and yes it costs some money. Where I'm at we had the old way and our provincial gov't wanted better. They made changes which didn't happen overnight. The result is an EMS system that covers the whole province including a helicopter for an avg. cost of $83.00 each per year. Personally I don't consider $332.00 per year of my taxes for my family of 4 to be a lot of money for 24/7 coverage. The majority of which is ALS. With about 6,000,000 people in Washinton state at $83.00 thats $498,000,000.00 You could have a very nice EMS system for that much money.

Just my thoughts.

 

[skyemt]

Again, who pays, and how does a paramedic keep up skills running less than 200 calls a year? Certainly there are some services offered to rural areas, but in most cases, water is private well, sewer is on site personal septic and garbage is haul it yourself to the dump.

Your perfect scenario for everyone to have ALS can go right up there with everyone should have a roof over their head and 3 meals a day. How about good preventive healthcare, or maybe, since we're waving a magic wand, college education for all those who qualify academically instead of just financially.

Its nice to toss about all those 'shoulds' but bottom line, someone's gotta pay for it.

there is a big difference between acknowledging that ALS is necessary but not possible in certain areas, and saying that ALS is not necessary on most but the odd few calls...

you keep jumping between these two different lines of thought, and frankly your posts are confusing for this reason.

if you deem ALS necessary, but it is a fiscal issue, have you tried to increase public awareness? does your public know they are getting substandard care? if they did know, and were given the chance, would they pay for it? the answer might very well be yes.

the agencies in my area, rural as well, that were having trouble providing ALS all day, went to the public... would they want to pay for this service?
the answer, a resounding yes, and they did pay.

have you dont this? have your ems leaders pursued such an idea? i highly doubt it from your responses.

recently, from a leadership conference given by our county EMS...

our two most dangerous ideas:

"we are rural, we do the best we can"
"we are volly, we do the best we can"

sound familiar? well, it just isn't good enough. the public doesn't deserve "we do the best we can", they deserve the highest standard of care possible. if you are not providing it, do something proactive about it.

 

[reaper]

In your RURAL area, do you law enforcement? Are they volley's? Do they shoot 30 suspects a month?

I think the answer to all 3 is YES,NO,NO!

How do the LEO in your area keep up their range skills? They practice.
If your county wanted ALS service it would be there. If it was and you had good medics, they would find a way to keep up on their skills and education.

I used to live in a rural county, pop. 3200 people. We had 24/7 ALS coverage. They combined with surrounding counties to make one service.

Someone mentioned longer response times with fewer stations. I for one, would rather wait 10 minutes longer for a service that can treat me, then get picked up and driven 30-40 minutes with no treatment! Maybe thats just me!!

 

[ffemt8978]

In your RURAL area, do you law enforcement? Are they volley's? Do they shoot 30 suspects a month?

I think the answer to all 3 is YES,NO,NO!

How do the LEO in your area keep up their range skills? They practice.
If your county wanted ALS service it would be there. If it was and you had good medics, they would find a way to keep up on their skills and education.

I used to live in a rural county, pop. 3200 people. We had 24/7 ALS coverage. They combined with surrounding counties to make one service.

Someone mentioned longer response times with fewer stations. I for one, would rather wait 10 minutes longer for a service that can treat me, then get picked up and driven 30-40 minutes with no treatment! Maybe thats just me!!

Waiting 10 minutes when brain damage can occur in 4-6 minutes?

Yes, we have law enforcement in our area. Average response time for deputy is 30-35 minutes for a critical call, 45-60 for a routine call. Using your analogy, that's a helluva long time to go without any treatment whatsoever.