fenwayfrankee

I have been doing EMS for the better part of a decade in Mass and have never heard of the sticky test...

The head trauma surgeon at one of the major teaching hospitals here is Boston was big on permissive hypotension. He did not give us an actual systolic BP to work from but rather he wanted their BP as low as possible while still mentating. Reguardless of the BP, if they are mentating they don't get fluid.

In the late 1980s, the idea was tested by the NYC EMS, but borne of necessity: Due to a managerial problem, over half the EMS fleet was mechanically "down" for repair. Until that issue was corrected, and the Chief of EMS fired, we had EMTs in Command cars (Supervisor's vehicles), with radio designations like "T" for "Triage" cars, that would respond to calls to at least start patient care, until an ambulance could arrive to effect transport. If the Command car was manned by Paramedics, the designation was "U" for "Union", and same concept involved. Then EMS Station 41 had a lot of their transports done with 41-Union assisted by 94-Larry, also known as Peninsula Volunteer Ambulance Corps.

Part of the problem was, the "specs" for the ambulances were incredibly complicated, to the point that at least one manufacturer or vendor went out of buisiness trying to supply NYC EMS with the ambulances.

Another problem was, Central Repair Service was running Monday through Friday, daylight tour only. To get the fleet back up, EMS farmed out the busted down ambulances to the NYPD and Department of Sanitation CRS facilities, just down the street, and a few more to "Red Square", the FDNY CRS a few miles away. A few also got sent to private venders for servicing.

FDNY CRS was called "Red Square" because they could, on any day, have more (pumper) engine and (hook and ladder) truck vehicles in and around the building for repair, preventive maintenance, or new vehicle final preparation, than some countries have fire service vehicles within their borders, and, of course, the vehicles are "fire engine red", hence the name.

The department purchased a bunch of ambulances that didn't have to be matched to a "spec book" that reportedly was a yard thick, hired a civilian to run the EMS, fired the chief, and got away from Triage or Union cars as the new ambulances got assigned to stations, and then to crews, and started Monday through Friday around the clock mechanic schedules, and daylight on Saturdays. There are also Roadside Repair crewman and vehicles assigned full time for any vehicle breakdowns

After the FDNY/EMS merger, the FDNY tried going back to using something like the televised LACoFD "Squad 51", manned by one Paramedic, and one Paramedic Lieutenant, who would bring the start of "definitive care" to a patient, and also do field supervisor duties. The teams were called "PRUs", for Paramedic Response Units, and kind of looked like the iconic Dodge truck from the "EMERGENCY!" series.

It didn't work, as the Lieutenants also had to do duties in the stations, so they had to decide if they were more useful in the field or the stations.

They eventually took the concept, and the PRUs, off the road, reassigned the Paramedics to Paramedic ambulances, with a partner of course, and turned the former PRU vehicles over to the Roadside Repair crews from FDNY EMS CRS.

And, again, I mention we keep turning down the use of the concept of "Mensa Medics" (single field Paramedics) in favor of a "Pair-A-Medics".

So, fenwayfrankee, take this as one system's attempt to use non transporting ALS, and list it as a concept failure.

Thanks for the info. I never knew NYC*EMS tried that.

Wow... you guys are about as helpful as tits on a bull..... :shock:

Hey Fen....look into Chester County and Delaware Couny EMS in Pennsylvania. I know some of these counties have chase cars.

Uhhhh, why the question, BTW?? 8) And where are you located?

Thanks fo rthe help.

Yes I do.

Would you care to share?

Does any one know of any Urban systems that use non-transporting ALS. Or any large systems that use it? Thanks.

AAA

In our system LTs and CAPTs are EMTs. Deputy superintendents and higher are paramedics. There are 2 LTs on per shift and 1 D/S. Being a tiered system there are far more BLS trucks than ALS. There is somewhat of a mantra here: "EMTs answer to bars, and MEDICs answer to stars". The LTs enforce the operational side of things, as well as clinical supervision of the EMTs. So unless they are telling an ALS to wash a truck or something like that, their supervision is non-existent. The paramedics are in a sense clinical supervisors of the BLS, not for disciplinary purposes but to promote patient care.

As far as the BLS crew taking off, I am not sure we know all the facts, and we were not there so its hard to judge. If it was a misunderstaning on whether the ALS was there then it is a horrible ACCIDENT. If it was intentional then there is a problem. Working as an EMT is my system I have left a scene with a potentially worthy ALS patient with a private ALS onscene. Not all MEDICs are created equally, which is quite evident in this area. On the flip side, if the patient is an acute medical pt (not trauma), I would let them in. The potential discipline from OEMS is not worth the risk. If they want to get in back and screw around its their perogative. And I am not going to get involved. They can get in and do everything they want on the way to the hospital because we are leaving. So in this case I would let them in.

As far as the supervisor being onscene, why didn't he/she get in the back of the BLS truck. This is definitely a case that needs 2 sets of hands in back. Everyones goal should be patient care so ditch the supervisor SUV, it will still be there when you get back. And if its not, there is a fleet of them that look just like it.

I am not familiar with the interaction between FDNY EMS and the private providers. In our system when they are sent we have no radio contact with them. A call is given from the turret via phone to their dispatcher. And after that its a relay of info between the dispatchers. This by far is not the perfect system. Luckily this happens very infrequently. Private BLS is sent only on very minor illness/, and private ALS very, very infrequently is sent on anything. Especially to intercept our BLS. If a call is has been given to the privates and enroute has been modified to require an ALS response, the private is usually cancelled and our ALS/BLS units respond. If a private is onscene requesting ALS they get a ALS/BLS response.

start a car....PUSH THE CAR

I am a fan of the system that I work in. I do not believe that you have to be a paramedic to provide a quality assessment and treatment. I personally think that the way our system works due to the training we receive. In my system the dialysis patient that describe would have gone BLS because realistcally, nothing more was needed than BLS care. (o2 and a ride to the hospital) Without getting to much into the details, not everyone is going to be a fan of every system. It works fine for us and I am proud to say where I work. But from the other side of it, I am one of those folks who has their medic ticket but is working as a basic. Maybe I am a little more comfortable with this type of system because I know what needs to be done. If I was the medic on the call and was going to work it up, then I would keep the ALS coming. But if as a medic I was going to just BLS the call, then I am going to take the patient to the hospital and not have the medics come "just in case". Also I work in a system where we have a lot of advanced practices as basics, as well as a lot of leeway with medical control. Such as nasal narcan, glucometry, BLS albuterol, and pulse oximetry. So a lot of stuff we deal with more on our own. Not to mention we are never more than 10 minutes to the farthest hospital, so in a number of cases it is quicker and easier, as well as the patients best interest to just go to the hospital. I supposed my comfort level is due to my advanced certification, but I know plenty of good EMTs in this system that I would put against a lot of medics. As a whole, I feel that our system works this way due to the training that we recevive, I do not think this system would work everywhere. We make this system work. I would put 90% of our BLS against 90% of the private companies ALS in the area. There are definately things that I would change, the system is not perfect but overall I am proud of it.

Oh, I've never said that this type of system was good for patient care. It forces basics to treat patients that should never be BLS AND is way out of the scope and education for basics. I do not consider the decision to call ALS or transport easy, especially for the borderline patients. Simply calling ALS because a number is above or below a specific limit should not be the only justification for a reroute or for summoning prehospital ALS. A good physical exam and history, though, does. The skills and education that is required to obtain and interpret the results is very lacking for most EMT-Bs. Combine this with a system with no online medical control at the BLS level and you have a recipe for disaster. Add in IFT companies that are willing to transport anything called in and basics that want to treat dispatch as medical control (ex. one idiot at my company recently called dispatch to get ALS [we are supposed to just pick up the phone and dial 911] when he was less then 2 miles from the hospital [i.e. transport code 3 would be the correct transport plan]. Because he was too stupid or scared to make a decision, definitive care and ALS was delayed).

HTN was the chief complaint with their monitor reading over 200 prior to arrival. The patient was slightly altered, which was a combination of a possible psych Hx (dictated physical in the records that we recieved stated this) and just finishing a dialysis treatment. In my area, you only find ALS with the fire department, so all private emergency calls are dispatched BLS by a lack of choice. She was also complaining about SOB (not really showing it, though), but I believe it was psychosomatic based on the rest of her presentation (she still got a mask, which she held on to and used PRN). My unit had a 20-30 min ETA (first call of the day leaving from our base) and a less then 5 transport (just down the street from the hospital).

This is also why I believe that interfacility EMTs should be held to a higher standard then 911 EMTs in a system where all 911 calls get an ALS response (ALS can triage down to BLS in the field).

I guess we just have a differnece of opinions and leave it at that. That's what makes the world go round. I am not a fan of that type of system. But if works well for you, then good luck!

Calls are held because the system is stretched so thin. Its hard to send an ambulance to a call when you don't have one. Imagine how much thinner the system would be stretched if we were tying up additional ambulances on calls. Such as sending an ALS truck to a call that is only worthy of a BLS response, but because they are on dialysis, an ALS truck is sent for no reason other than the patients history. I am sure that the paramedics will be able to provide stellar care to the stubbed toe of the dialysis patient. And when a BLS is sent solo to a call, it is either because the call only warrants BLS care. Or there is no ALS to send. There would be a lot more "solo" responses if everyone that has some type of medical history is getting an ALS response based solely on their history and not the complaint.

Just out of curiosity, was your Dialysis patient with hypertension symptomatic? Such as with CP/SOB? Or was HTN the complaint?

If all starts with triaging the 911 calls when they come in. According to APCO standards, calls that are deemed ALS worthy are dispatched both ALS and BLS. So those situations which listed would get an ALS repsonse according to certain criteria. So when you are 50 years old and call saying you have SOB, you get a ALS response. When you call and say I am 50 years old and I have a headache, it gets a BLS response. The calls are evaluated before an ambulance is ever sent.

RichmondMedik

EMT City Freshman

ACTUALLY if you do a little research on Boston H&H you will find they are run by Boston University and are no longer under the city -- so technically they are a private service with a real big ego

Paul

Contrary to your belief RichmondMedik, Boston EMS is not run by Boston University. Boston EMS is a third service agency. The EMTs and Paramedics are city employees that fall under the umbrella of the Boston Public Health Commission. This happened when Boston "Health an Hospitals" was disbanded when Boston City Hospital was privatized and became Boston Medical Center. The affiliation between Boston EMS and Boston University is this: our medical direction comes from Boston Medical Center, and there is a deep training affiliation with BU where there are certain fellowships where they become part of the Boston EMS training division. This meaning that they provide alot of the continuing education and many studies are done using the service. At no point and time is it a private service, or was it a private service. As far as the ego's go. They are the best EMS system on the east cost, possibly the nation. So I guess the ego is deserved.