ALS Intercepts

[Just Plain Ruff]

There was an article on the EMS Professional email that I get. It's about ALS intercepts and a study that was done. Here's the link

http://www.jems.com/article/administration-and-leadership/paramedic-intercepts-bls-study?utm_source=Go+Forward+Media+eMail%2C+Powered+by+Bronto&utm_medium=email&utm_term=Paramedic+Intercepts+with+BLS+Study&utm_content=ruffems%40gmail.com&utm_campaign=JEMS+eNews+07-08-10

I hope that works.

What are your thoughts on ALS intercepts? Do they do more harm than good?

My opinion is fractured if you ask me. Often times the BLS crew calling realize they are going down the road to the patient gettting sicker and they call. Other times they call because they think the patient needs ALS. Both reasons I do not disagree with.

What my fractured thinking is how long did this ALS intercept delay definitive care? The reason why I ask this is that my experience in ALS intercepts are the bls crew calls me less than 10 minutes outside the hospital I've been based at. We get in route and we pick a location where we can safely get off the road and get me into their ambulance. This costs valuable time for the patient. By the time we are back on the road, it's been 2-5 minutes or more because I like to get my own exam done and that takes time. I like to hear lung sounds and heart tones and all that. I like to get a non-bumpy ride twelve lead. If I need to intubate I prefer to be sitting still rather than moving down our counties roads.

This all takes time.

By the time all that is done, that BLS ambulance could have been at my hospital with the patient. The really good EMT crews I've worked with realize when they are out of their depth and call when they depart the scene. Others don't.

What are some of this groups experiences with ALS intercepts. Does it waste valuable time or is it beneficial?

The study showed that 76% of the time the patient got a monitor and an IV. 24% of the time the patient got more advanced stuff. Not sure what the outcomes for these aptients were, they didn't say.

Of the past 10 ALS intercepts and that's over the period of a year, I think I've done more invasive and Higher level care than an IV and Monitor in maybe 2 of those intercepts, both of those patients had very poor outcomes due to one having a huge MI and the other in cardiac arrest.

My experiences may differ from yours.

Discuss

[spenac]

I think it is hard to truly say. Factors such as how fast they will be seen and treated in the ER and how aggressive your protocols are. For example if the patient needs thrombolytics and your service carries and say odds are the patient will have to wait 30 minutes in the ER to get them you stopping them on the street in front of the hospital saves 25 minutes. So you benefited patient. Now if all you are going to be able to do is start an IV then by all means just let the basics take them on in. In most cases I would think unless intercept is done at least 10 minutes out the basics should probably just finish the transport. Wow I am talking in circles now. Wow Ruff thinks for frying my brain.

[mobey]

I really think it is time to stop thinking in terms of what the patients "Need".

Unless there is a problem with ABC, the reality is, patients just NEED a safe ride to the hospital.

ALS care (to me) is not just about giving the patient what they need (in fact, that is a very small part of it) ALS care is about relieving stress from the ER, and providing symptom relief to the patient sooner.

I would like to see a study not only on patient mortality, but also on psycological trauma, and comfort, as well as ER treatment that could be witheld because it was given onscene.

I have no problem with ALS intercepts delaying definitive care if that does not add to morbidity/mortality.

This monitor & IV nonsence is a joke. Since those are both in the EMT scope here, MOST patients get that regardless of the responding level of service. I would like to see the percentage of patients that recieved pain control, breathing treatments, and benzo's.

[Aussieaid]

"Although it's clear ALS procedures were utilized in a significant percentage of patients, the authors didn't examine the medical records to determine whether they made a clinical difference. What was the impact on patient survival from cardiac arrest? I suspect there was none."

So what the good Doctor is saying is that what is the point of ALS in cardiac arrest at all? Just transport them to the hospital fast? And if you are going to start training the BLS providers to do 12 leads without the ability to treat them then why not just make them all ALS providers instead?

[mobey]

So what the good Doctor is saying is that what is the point of ALS in cardiac arrest at all? Just transport them to the hospital fast?

Why transport them?

What does the ER do? Exactly the same thing as we (ALS) do. The difference is, there is science in good quality CPR. You cannot provide good CPR uninterupted if you are trying to load, and unload a patient.

[Aeromedic]

Out here in rural SK there are TONS of ALS intercepts, and they do work for us quite well. The big difference with our policies (at least in south/central) is that we never unload a patient. Through intercepts we also get ALS Care up to a half hour before a "hot and hope" sort of BLS transport. Most of the intercepts that I have done have involved Respiratory Compromise (needing steroids, lasix or vent/combi), Major Trauma where patient either already is or may become hemodynamically unstable and of course the assorted cardiac. I know that a lot that I have done have involved little more than an IV and a bit of watching, but on occasion it has gotten hairy and ALS has made a big difference.

My personal thought is that if the medics can pack well enough to be able to move just gear, rather than patient, it is a much more effective and efficient way of doing things rather than having to do a patient switch on a highway, etc...

[AnthonyM83]

I honestly didn't have time to read the entire article. But it should be mentioned that the fact that often patients don't receive much ALS care after the transfer, shouldn't invalidate the need ALS. ALS is often there for unstable patients IN CASE they crash, since they have a higher probability of 'crashing' than stable patients. A lot of times these patients just get BLS care with IV and cardiac monitoring. That's just fine....

[JPINFV]

By the time all that is done, that BLS ambulance could have been at my hospital with the patient. The really good EMT crews I've worked with realize when they are out of their depth and call when they depart the scene. Others don't.

I'd argue that that's too late. An EMT crew needs to request paramedics as soon as they realize that the patient needs a higher level of care. A perfect example is a patient in resp. distress secondary to acute pulmonary edema shouldn't need anything past a doorway assessment by an EMT crew to conclude that they need paramedics. The paramedics can be responding while the EMTs complete their initial assessment, treatment, packaging, and moving to the ambulance. Once in route, unless there's an excessive transport time, I see very little reason to request paramedics because a condition declines unless the paramedic base is between me and the hospital (however being at the hospital is generally not worth the paramedic response).

Edit: Something I realized that I should have added and something that Anthony touched on. One of the reason I will call paramedics if I have a reasonable belief that the patient might require paramedic intervention now or in the immediate future. If an EMT doesn't call when there is a reasonable belief that the patient will decline during transport because there isn't an appropriate paramedic intervention at this immediate time, then everyone would be complaining that the EMT should have called for paramedics. This ends up putting the EMT in a 'damned if you do, damned if you don't' situation because they can't divine the future.

Edited July 9, 2010 by JPINFV

[Lone Star]

Every ALS intercept I've ever run simply involved the medic transferring gear to my truck and taking over patient care. ALS was called for as soon as I got on scene and realized that the information that the dispatcher had to work with severely understated the patient condition.

The transfer of care only lasted about 30 seconds, as the medic that got on board started their own assessment. I wasn't offended by this, as they needed to fully ascertain the patient's condition and status after any treatments I've given.

I think that the whole key that decides whether an ALS intercept is successful is getting the EMT to realize that the patient's condition, not ego, is the deciding factor. The EMT HAS to realize that they're very limited in what they can do for the patient, and further has to admit that it's in the patient's best interest to call in the 'heavy guns'.

I've had medics bitch and whine about getting mobilized for a BLS call, only to find out that the patient is decompensating rapidly. I've never had a paramedic bitch because they got 'called out for nothing'.

[Richard B the EMT]

Once again, I remind the city that I work in a system where almost all calls are 15 minutes from an ER, once we start towards that hospital.

When I, and the other EMTs, make that determination that ALS is needed, we request it, continue our evaluations and treatments, "package" the patient, and move them to the ambulance. At that point, we again radio, this time requesting an ETA.

Determination now, of "stay and play" versus "load and go", depends on the ETA. Which is shorter, the time from your current location to the nearest appropriate ER, or the time until the ALS joins you at the location?

While I won't say it doesn't happen, mid route meet-ups (intercepts) seem rare within my operation.

I do recall one time we were 90 seconds from the location to the ER doors, with CPR in progress. Due to a heavy call volume, an ALS crew from another station a distance away was en route, and saw us pull away from the location while they were still 30 seconds away. We declined to stop, and continued to the ER, where they arrived in time to assist in the off loading of the patient. Then, they got nasty with us for not stopping to allow them to jump in and do their "Thang". The lieutenant arrived, having heard the 2 personnel, who were driving, arguing over the air as to "Stop!" "No!", and stated the delay would not have made any difference either way.

The patient was pronounced within 5 minutes of arrival.