ALS Intercepts

[uglyEMT]

Great Topic

Let me preface this reply with the fact I live in a rural area with a 35 to 45 minute travel time to an ED, 1hr + to a Level 1 Trauma, over 1 1/2hrs to a burn center and in my system all ALS is hospital based.

I believe in our case ALS intercepts are needed. Usually ALS gets dispatched along with BLS for certain calls and it is up to BLS to cancel ALS. We usually meet enroute either closer to the dispatch or about half way to the ED (around 15 minutes from dispatched time, roughly 20 minutes to ED), We have predetermined meeting points that ALS will stage at if they get there before us OR line of sight meetings if we or they have passed the staging points. Again all communicated between BLS and ALS. Sometimes ALS will meet us on scene if they are in the area (not often but does happen).

I feel with our travel times this kind of intercept is a good thing especially in the cases of MI and severe respitory distress/ failure. I dont have figures for all calls where ALS has been involved but from the ones where I have been on the rig the outcomes have been positive. With the few MI's I have been on the patient was stabilized enroute to the ED (one wasn't unfortunatly). Two allergic reactions the patients were begining to reverse symptoms by the time they got to the ED. One OD patient was helped and had near normal vitals (down from HR 200+ RR 40) by the time we got to the ED.

Now depending on the system sometimes I feel ALS intercepts are not required do to the quick travel times to an ED. Other systems have ALS onboard or are all ALS providers so intercepts are not required.

In this fractured system we have in the US where every state, county, sometimes municipality has different protocols and / or ALS/BLS combinations everyone is different and what works for some does not work for others. Hopefully one day in the future we will have a more uniform system where things are nearly the same throughout (yes in some areas it will have to be different but majority speaking).

[HERBIE1]

Too many variables to make a blanket statement. Is the area rural or urban? What are transport times? What are the capabilities of the hospitals in the area? What is the problem with the patient? What type of ETA do you have for an ALS backup?

I think in large part, many of our protocols are litigation driven- as is too much of medical care in general. In essence, we are practicing defensive medicine by proxy. That's just how it is. Docs need to order multiple unnecessary tests to "confirm" that a person has a cold, and not some virulent new strain of flu that has been imported from the Congo.

I agree with the comment that many times, the IV we establish is merely a convenience for the ER staff, and these days, with how busy they are, it's probably a good thing.

Many times we need to wait so long to get a bed for a patient that I will either push more analgesic, another albuterol, etc until we arrive at an ER. I have also carried a pocket full of albuterol to continue an nebulizer treatment while waiting for a bed. On several occasions I have guilted the staff into finding a bed for us when I say- well, our patient is still in a lot of pain, and I just happen to have some morphine in my pocket, how about if I give the person a bit more while we are waiting? Similarly, I have asked- LOUDLY for someone to find me a portable O2 tank because we have drained ours waiting for a bed, or a portable monitor because we have drained our batter pacing and/or monitoring our patient. That usually gets someone moving.

[Kiwiology]

I am biased coming from a system where advanced life support by Intensive Care Paramedics is reserved for really sick or severely traumatically injured people.

The notion that you need ALS for a bit of morphine or adrenaline, or a BGL check, or some fluid is a wee bit out dated if you ask me.

Personally I would consider time to appropriate hospital vs. calling for Intensive Care especially if moving towards hospital is moving away from backup.

The sorts of patients I would personally call for Intensive Care are:

- Looks really sick and I don't know what is going on

- Cardiac or respiratory arrest or near arrest

- Severe respiratory compromise (asthma / croup / epiglottitis)

- STEMI on 12 lead ECG

- Severe new presentation cardiac chest pain with good story (sweaty, nausea, SOB etc)

- Poorly perfused haemodynamically compromised arrythmia

- Severely SOB/sick pulmonary edema/CHF

- Seizures not responding to midazolam

- Pain not significantly relieved by or unlikely to be significantly relieved by IV analgesia

- Altered or unconscious with GCS less than 12

- Severely anaphylactic patient who needs steriods

Anything else I think can safely be treated and transported by the Ambulance Paramedic.

[spenac]

I am biased coming from a system where advanced life support by Intensive Care Paramedics is reserved for really sick or severely traumatically injured people.

The notion that you need ALS for a bit of morphine or adrenaline, or a BGL check, or some fluid is a wee bit out dated if you ask me.

Personally I would consider time to appropriate hospital vs. calling for Intensive Care especially if moving towards hospital is moving away from backup.

The sorts of patients I would personally call for Intensive Care are:

- Looks really sick and I don't know what is going on

- Cardiac or respiratory arrest or near arrest

- Severe respiratory compromise (asthma / croup / epiglottitis)

- STEMI on 12 lead ECG

- Severe new presentation cardiac chest pain with good story (sweaty, nausea, SOB etc)

- Poorly perfused haemodynamically compromised arrythmia

- Severely SOB/sick pulmonary edema/CHF

- Seizures not responding to midazolam

- Pain not significantly relieved by or unlikely to be significantly relieved by IV analgesia

- Altered or unconscious with GCS less than 12

- Severely anaphylactic patient who needs steriods

Anything else I think can safely be treated and transported by the Ambulance Paramedic.

But your BLS is more than just a boy scout first aid class like the emt basic course is in the states.

[Richard B the EMT]

But your BLS is more than just a boy scout first aid class like the emt basic course is in the states.

While I would not say it in that manner, the statement is, unfortunately, accurate.

[zippyRN]

While I would not say it in that manner, the statement is, unfortunately, accurate.

there are a number of factors which drive the needs for and utility of 'ALS intercepts'

one factor in USA type models is the fact that EMT-Bs really are BASIC and in international terms the USDOT core

curriculum for EMT-Bs is at a level somewhat lower than volunteer and/or 'middle tier' crews elsewhere in the world ,

the other main factor is time to definitive care - in a urban or suburban setting unless the ALS unit that will intercept is very close by it will be quicker to pre-alert the recieving ED and make your way in at whatever level of driving authorisation the crew has. - if you are 10 minutes from the ED and the response time for your ALS support is going to be much more than 5 minutes is it worth waiting at the side of the road ?

Edited July 10, 2010 by zippyRN

[fiznat]

The notion that you need ALS for a bit of morphine or adrenaline, or a BGL check, or some fluid is a wee bit out dated if you ask me.

I disagree. Epinephrine is a powerful drug that we use for our sickest patients, and I think you'd be surprised to see the profound effect just 0.3 mg of the stuff can do for bad asthma or anaphalyxis. Just 1 mg in 1000 cc of fluid is a potent treatment for hypotension, better than dopamine in some cases. Same thing for morphine. There is absolutely no reason why a patient should have to wait to get to the hospital to receive analgesia when we can provide it in the field. Too many people focus on "saving lives" instead of "providing comfort and relief." Both are our responsibility, and I think ALS intercepts for these purposes are absolutely necessary.

[rat115]

Interesting topic. Doublly interesting for me since my EMS Director has a copy of the COEMS "EMS Star" out for all of our service to read about the old ALS vs BLS argument in the area titled "EMS Skeptic".

Living in a rural area, we only have 2 ALS providers with our county ambulance service. Our ALS intercepts are called as soon as we know there's a chance we may need them. This includes calling to put flights en route. Normally, we get the pt into the ER before the flights get to us.

For our local ALS, we have them come out either POV or in our county suburban. I've only seen a few times that our ALS were able to do alot for a pt and only because the pt or family caught an AMI right away.

Flight intercepts are a regular occurance for us getting out critically injured or ill pts to higher level of care from our level 4 ER. This has saved many lives for us.

[Kiwiology]

I disagree. Epinephrine is a powerful drug that we use for our sickest patients, and I think you'd be surprised to see the profound effect just 0.3 mg of the stuff can do for bad asthma or anaphalyxis. Just 1 mg in 1000 cc of fluid is a potent treatment for hypotension, better than dopamine in some cases. Same thing for morphine. There is absolutely no reason why a patient should have to wait to get to the hospital to receive analgesia when we can provide it in the field. Too many people focus on "saving lives" instead of "providing comfort and relief." Both are our responsibility, and I think ALS intercepts for these purposes are absolutely necessary.

In Australia every Ambulance Paramedic (non ALS) can give adrenaline and IV analgesia.

In New Zealand from 2012 every Paramedic (non ALS) will be able to give adrenaline and morphine, and many already can.

In Canada every Primary Care Paramedic can give IM adrenaline.

Perhaps we are doing something wrong?

[BushyFromOz]

Same thing for morphine. There is absolutely no reason why a patient should have to wait to get to the hospital to receive analgesia when we can provide it in the field. Too many people focus on "saving lives" instead of "providing comfort and relief." Both are our responsibility, and I think ALS intercepts for these purposes are absolutely necessary.

Here Here!

Boggles my mind to know that the majority of ambulances in the US are incapable of providing something as basic as pain relief!