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ALS or BLS? Help me decide...

49 posts in this topic

Posted · Report post

Hi, I am new to this forum but have been active in other ems forums. I am an EMT-B in (I'll say the Greater Puget Sound Area (Seattle-ish) so as not to be pinned down by the locals I am bashing.) The system is set up so that city bls FD is primary resp on all 911 calls. If needed they request ALS, also city FD. After evals, if pt determined to be BLS tx, they call private AMB. But SNFs call private AMB directly most of the time without using 911. So, pretend you are the private BLS AMB called by SNF to tx pt to ER:

80 y/o male STH decreasing LOC/increasing SOB x 2 hrs. RN @ SNF states pt normally A&O x 3/3, active motor able to support self in wheelchair. Hx NIDDM, A-FIB, HTN, Arthritis, pneumonia 2 mo. ago

Pt presents lying 45 degrees in bed, pale/hot/diaphoretic, barely responsive to px, very congested upper resp., RR 40 very labored, HR 90-120, BP 140/80, sats initially 79% RA, 88% after 5 min highflow NRB. There is no pedal edema, temp 102.0, glucose 160, full code. You call for the FD medics to come but will they take him?

You decide.

What is this guy's underlying problem and what ALS Rx could he benefit from?

I already have my opinion but I want it to be confirmed un-biased first.

Thanks a lot!!

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Posted · Report post

Well based on that information, its not hard to figure out who you work for and who the other agencies are. Anyways, this guy sounds septic. Could he use ALS intervention? Sure he could. Would it make an immediate difference..I dont think so. Could BLS run him to the ER which is only a few minutes away? Sure they could. Should BLS do this? I don't think so, since a higher level of care can and should be provided when possible. Should the RNs at the SNF stop skipping the process that is established in order to ensure quality care to all residents regardless of the condition. I think so. They should not be circumventing the system that is in place. That leads to problems and questions such as this one.

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Posted · Report post

I would have to agree that a BLS transport would be appropriate if the ER is with in a short distance. However ALS would be preferable because the patient is a full code. I used to work for one of the major private ambulance services. Many of the facilities in the area had standing orders to call on a private service instead of FD. Granted we we also the primary ems for the city on all levels, but still unless the patient was coding the would call for a non emergent response on everything. Many of these facilities I have been to have less ability to respond to patient needs than any BLS crew would. Many times we would send BLS and ALS to a facility on a call just for that reason, you never got the true story from the staff. In many areas this isn't possible. In my area it was because we always had a minimum of 5 ALS crews and 7 BLS on a shift. But those are my expereiences

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Posted · Report post

Echoing the others, if the transport is short, BLS should begin the transport to the closest receiving facility. Cardiac monitor and vascular access would be nice, but they aren't going to make a huge difference in the end.

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Posted · Report post

That sounds like a very difficult system to work within. As if our jobs are not already enough of a gray area, you have interagency/interfacility politics and complicated procedures do deal with. Not knowing the legalities etc. of your system I will just have to go with the common sense answer. This pt does sound septic but he is not decompensating, so a quick trip to the ER with a BLS crew will not be detrimental to him, and ALS could not do any real interventions for him anyway.

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I think that in order for a private ambulance service to hold a contract with anyone, they should be able to at least meet or exceed the ability of the local FD. If they can't afford to become an ALS provider and they are the only provider around (or better then the alternative company that runs ALS), then maybe the private service should calling FD for assistance when a call like this comes in. That way if the patient is bad, or does code between the initial call and your arrival, at least ALS is already enroute, or there with you. I mean, if it turns out to be a true BLS call then FD can go back in service and the private company can transport.

I think instead of this municipal vs. private war going on that some people like to start, we should start looking at ways to integrate the two. Contrary to some EMS personnel's belief, there are private services that actually are more capable then municipal services. Last time I checked, I was the same paramedic whether I was working at the city or at my second job on the private ambulance.

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Posted · Report post

I think instead of this municipal vs. private war going on that some people like to start, we should start looking at ways to integrate the two. Contrary to some EMS personnel's belief, there are private services that actually are more capable then municipal services. Last time I checked, I was the same paramedic whether I was working at the city or at my second job on the private ambulance.
Excellent point Nate. Where I am is by no means Houston, but we still have the GF & R vs Private here. Most ALS outside of Greenville are volly, but there is still the " we're better than you " BS. It is high time this mentally was put to bed and pt care became paramount. In class, the instructor won't let the fire guys wear their uniforms. We are all equal and there to learn the same curriculum. When we complete the class, we will all be Paramedics, regardless of what colour our shirt is.
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Yeah, around here if you get MCI (which happens more then you think down here) you will usually see five to six different Fire/EMS services, plus the chemical plants fire/EMS, and then you get the private services that mutual aid for transport, so what happens is you end up with paramedics from one service on another services BLS ambulance, etc.

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While you guys make valid points, it just doesnt hold water with this particular area. If I am not mistaking, this may or may not be referencing to Seattles Medic1 which happens to be one of the top services in the nation. Their medic ambulances do not run BLS calls, only ALS. They have very rigourous hiring and training programs and in return you get a nice salary and schedule and are guarenteed to run only ALS calls. How sweet is that? I would have worked for them but I can not go through paramedic school again as is required by their hiring agreement. They dont care who you are or how long you have done it, you will redo their medic program for 10 months. They do pay you but it is only 3k a month while in school. Their program also has very low turnover, no big surprise there.

So, to make a long story short, please do not start the private vs municipal argument because it is irrelevant with this particular system. Read up on Medic 1, good stuff...

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So is Medic1 the private service or the FD based service? Because if it is the private service that has only ALS rigs, why was a BLS crew from them on a call if they don't have BLS rigs?

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AMR is the private service..

JEMS has done many stories on them as well

google Medic1...lot of good info. They have been pioneers in many new treatments and therapies.

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Be careful when you Google. There are many EMS organizations in Washington who call themselves Medic1. It's all a play off the original which is King County Medic One. When you Google it, make sure you include the "King County" as part of your search criteria.

King County Medic One has one of the best EMS systems in the US. They have a very progressive and involved medical director. They are ALS only which means their paramedics only do ALS calls. If it's BLS the local BLS truck takes the call. While their system won't work everywhere, I think they do an awful lot from which the rest of us could learn.

Hope that helps.

-be safe.

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I did some homework, but I'm still confused one issue...is it AMR that provides the BLS transport for King County, or does a King County ambulance staffed by a BLS crew do the BLS transport?

They seem like they are actually from another world, their education standards should be used to model similar service IMHO. I think that the citizens of King County seem to have a pretty awesome ambulance service. I'm sure they (and the paramedics who work for them) are very proud of this.

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KING County does NO BLS transports or calls. The private company AMR handles all BLS emergencies. If ALS is needed, then the Medic1 guys roll. You are correct. It is an awesome service and if I were younger or just getting started, I would give them very serious consideration.

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So is the company that serviced the SNF unit AMR or another company?

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He has pneumonia again, probably courtesy of the SNF unit. I do not agree that BLS should handle this, I think the SNF unit needs to learn how to activate an ALS response. This patient needs IV access, needs to be monitored, probably needs rehydration, and could possibly benefit from pharmacological interventions which a BLS unit cannot offer. I would have the ALS respond...................

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KING County does NO BLS transports or calls. The private company AMR handles all BLS emergencies.

So... if they get on the scene and find a BLS emergency, what do they do? Babysit the patient for fifteen to twenty minutes til a BLS unit shows up? Refuse and leave? Just seems like a lot of weird loopholes in that system.

Not to mention that any system that has basics evaluating whether or not patients need ALS is FAR from being a great system, no matter how smart their medics are.

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So... if they get on the scene and find a BLS emergency, what do they do? Babysit the patient for fifteen to twenty minutes til a BLS unit shows up? Refuse and leave? Just seems like a lot of weird loopholes in that system.

Not to mention that any system that has basics evaluating whether or not patients need ALS is FAR from being a great system, no matter how smart their medics are.

Any basic worth their weight can look at a patient through an assessment and determine what, if any ALS could be done, and determine from there. But, then again, we come from two different worlds, and I guess things are a bit different here.

BLS assessment, initiate ALS, start transport, treat enroute. Meet ALS if possible, if not, complete transport.

I must ask, what does the BLS transport do if the patient turns emergent?

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Posted · Report post

Let me correct my phrasology. They are not DISPATCHED to BLS emergencies, if they happen to roll up on one, they will transport.

There is no need for babysitting, the first responders do that. The guys on the engine or flycar, they babysit and call for ALS or BLS.

This is for Dust....as critical as you are of US EMS systems, this is one I think you should study before passing judgement. I am not saying they are the end all and be all but they have their act together, its been an excellent system for years and if we all followed their lead we would have the salaries and respect we deserve across the nation.

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I'm not passing judgment. But if they are picking and choosing their patients, there are very well established risks involved in that process, which does not speak well of their system.

They may be the most clinically sophisticated medics in the universe, but if they are neglecting to respond to patients who need them, they suck. Such is the risk of a tiered system.

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They did not neglect to respond to anyone....The nurses skipped the system in place and called the private service direct. The nurses are the ones that screwed up the system.

The original poster works for the private service and he was questioning whether or not this was an ALS call and should he have called for them and would they have come. Basically, I assume he is second guessing himself and doubting whether or not he did the right thing.

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Sorry I didn't make myself clear. I wasn't talking about this incident in particular. I was referring simply to the practice of screening calls to decide who does and does not require ALS. It has gotten more than a couple of agencies in major legal heat, and a few people decertified in the process. Again, the quality of the care in that system is irrelevant if they never make the scene, or do so only after BLS has made the scene.

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I am also new to this forum, but not to the world of ems. First of all, although I will get to the point and agree that the patient sounds septic, how about lung sounds? While I agree that the patient should be transported als (ie: iv in place, cardiac monitoring and possibly a breathing tx or other tx for not mentioned lung sounds) there is not much else that can be done in the field by ALS (ie:iv antiobiotics) along w/rehydration which is what this patient probably needs.

As for the private call, MANY nursing facilities in the area where I am do this ALL the time. I am not really sure why. However, when I worked for a private service, our dispatchers where told to tell the facility to hang up and dial 911 (think that was something they had w/the FD).

Lastly, as for the tiered EMS system, in theory it is great, however, reality often dictated and realized the loopholes that come along w/great ideas!

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Impressive system. King County Medic 1 is pretty well known and they get some press. I actually saw them mentioned, although not directly, in a video game once.

I've also heard that in Seattle you have to be certified in CPR to vote. Is this correct?

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I've also heard that in Seattle you have to be certified in CPR to vote. Is this correct?

Great idea!

Unconstitutional, but still a great idea. :wink:

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