When to Upgrade to ALS!

n7lxi said:
I hope you're kidding.

If you are, it's not all that funny.

If you're not, please leave my profession immediately.
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If I remember correctly, for anal impalement we are supposed to run the ABCs and a rapid trauma assessment and then immobilize the object and package pt for xport, with detailed assessment and monitoring vitals in the truck on the way. What's your location? How big is the stick?
 
RanchoEMT said:
When running BLS when do you guys upgrade to ALS?
(obviously when you're not comfortable running the call, but what other tips, tricks, advice and General Rules do you guys have for upgrading code3?)
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When I note any type of AMS, ALOC or any issues with ABC's except for things that I know can be addressed within my scope
 
With the particular unit I'm on, we'll respond solo to ALS or BLS calls. If there's a complaint on a BLS call that can be resolved with ALS treatment, I'll upgrade. Example, a BLS dispatch for a sick person. I'll gladly upgrade to ALS in order to administer some Zofran if the Pt is feeling nauseous, in order to prevent them from puking all over my rig.

Note that "upgrading" to ALS doesn't mean turing all of the lights on and driving like a bat out of hell to the ER... In most cases around here, the difference between using L&S, or just driving cold is a MAX 1 minute difference in transport time.
 
Reading my notes, I have 2 "Recommendations" for when MICA (ALS in the US) should be called but this is not official so its not the gospel according to the Ambulance Service but these recommendations are

  1. Patients do not respond to Ambulance Paramedic (roughly ILS in US) treatment within their scope of practice
  2. Patients are not expected to respond to Ambulance Paramedic (roughly ILS in US) treatment based on scope of practice
Number 2 further goes on to specify

  • Cardiac arrest
  • Cardiac chest pain
  • Arrhythmias
  • Major Respiratory distress
  • Hypotension
  • Hypovolemia
  • Major trauma
 
Brown thinks the key point is patients who do not or are unlikely to respond to Paramedic treatment. The kid who Brown picked up who was hypovolaemic coz he had really bad NVs didnt need Intensive Care.

Stay dry mate.
 
High Speed Chaser said:
  • Cardiac arrest
  • Cardiac chest pain
  • Arrhythmias
  • Major Respiratory distress
  • Hypotension
  • Hypovolemia
  • Major trauma
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These points can be quite complex in actual practice. I'm glad they've actually talked to you about when you need MICA. We were never formally taught as far as I can remember.

Arrhythmia - every second person we go to is in Af. Which ones need MICA? Some are brady, many are tachy, not too many need MICA.

Cardiac chest pain - I've been to plenty that didn't need or get MICA. That bit in a scenario when the person conveniently describes there pain as a dull, retrosternal crushing sensation and you turn to the CI and say, "Oh yes and I'll have MICA thank you", doesn't seem to happen. Even with chest pain, they've generally gotta have something extra.

Major Trauma - I was chatting to someone on a placement the other day who said, "People get the colly-wobles when they get a sick pt and scream for MICA, when in actual fact, short of RSI and maintenance of a tension pneumo, MICA can do that we can't". The "ALS" package for AP was brought in for trauma. Still, one of the advantages is that they are more experienced providers though. Kinda like a junior doc calling their senior reg when they get a sick pt.

Hypovolaemia - MICA have nothing in their box to treat this that we don't. Again, its never a bad thing to have a more experienced provider, but MICA are in short supply so you kind of have to get used to the idea that you can't call them to hold your hand :P
 
Meh, just noticed you were responding to ANOTHER Aussie.
 
Melclin said:
MICA are in short supply so you kind of have to get used to the idea that you can't call them to hold your hand :P
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Especially if you are in say, Essendon and the closest is oh Brown will say perhaps, MICA 7 in Dandenong .... true story :P
 
I get to see this from both sides. In addition to working as Medic, I volunteer with a BLS service. I've upgraded BLS calls 2x this week. First was some impressive pain from a possible hip fx., with a family request for the 2nd closest hospital, and a 15-20 min eta there.

Second was diaphoretic and weak patient from home. No other complaints, just "I really don't feel good". History of NIDDM, HTN, and some CAD. No previous MI. Borderline hypotension (106/70?) borderline bradycardia (60-66). On a beta blocker.

Was looking at 15-20 minutes between loading Pt and getting to ED. I was kinda on the fence, and figured I'd add a medic out of an abundance of caution, and a desire to not bring that pt. Into the ED BLS, have them run a 12-lead and actually find something going on (and me having pissed away another 15 minutes of time by bringing them in BLS). While the medic didn't really like it, I explained this thought process to the doc, she concurred w/ my heightened suspicions.
 
Update.

Had to Upgrade this week, 65 year old male at a nursing home normally responsive and talkative with ALOC.(originally admitted for dehydration)

Patient was obviously altered, he was confused, at times unable to answer my questions, unable to move extremities upon my requests. blood sugar level was in normal range. PIN-POINT PUPILS, UNRESPONSIVE TO LIGHT.
Patient had a 148/84 B/P prior to our arrival. Upon assessment B/P had dropped to 90/50... Took it a second time about a minute later and it had dropped to 84/48.. We got the PulseOx out and he was 80% room air. Short little spurts of apnea(he almost appeared to forget to breathe every so often) we put him on oxygen and called for upgrade, further questioning with the charge nurse reveled he had not been eating for the past couple of days and he was given a dose of oxycodone earlier.

ALS roled up on-scene and gave him Narcan, he Snapped to very quickly...

So i don't know much about oxycodone and other drugs but he was overdosed via the nursing staff i'm assuming.. iunno if he woulda' crashed but i guess it was a good upgrade.
 
The VFD/EMS i'm with is BLS lvl, is 30 minutes from the closest facility and has a policy to ship everyone asap except MAJOR trauma. The reason is that the company I work for is also our ALS support and is close enough to the hospital to hit with a rock. We call for ALS after assessing necessity and they meet us along the way. My company's ALS fly car response is <60 seconds from call to out-the-door and meets along the way, hops on-board and off we go once they do their assessment.

Usually, the necessity is as has been previously stated (CP, VT, trauma, comp shock, etc....)

- Trip
 
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