Quick decision at a MVC

[Just Plain Ruff]

Let me ask this.

Does anyone see anything wrong with some of the responses of load the patient up with medications and then send them BLS?

Here is one of the quotes Under the suspicion of cerebral edema, if the medic could give him a dextrose solution, osmotic diuretic and corticosteroid like Dex it would in my opinon prolong the stability of the patients vital signs.

What are the thoughts of the group of loading medications on a patient and then dropping him down to BLS status?

I know that we have a out of the box scenario but is it appropriate to give medications of an osmotic diuretc and corticosteroids to a patient and then put them in a BLS ambulance with no medic.

Or am I reading that out of context and way off base?

[Vorenus]

Man, that`s a real great discussion.

Too many posts to answer to, so just the short version.

Pat. 3 gets a blanket, as said.

When it comes to the decision between 1 and 2, I`d propably say pat. 1 gets ALS, while 2 gets BLS.

Pat. 1 needs to get intubated, since GCS is below 9 and the respiratory rate over 29 - both indicators for an intubation in Trauma. Maybe I read over it, but how is BP on Pat. 1? Osmotic diuresis is no option in a pre-hospital enviroment, we don`t even carry the drugs. HyperHaes might be an option, though. We want to have that Pat. normotensive, in a normocapnia and normoventilated.

As for Pat. 2. He gets analgesia, predni, and fluids, then of with BLS as long as there`s no change in vitals.

The two trucks stay together while en route to hospital, so medic can re-evaluate and possibly swap if a change of the situation occurs.

[Just Plain Ruff]

But isn't that putting patient number 2 in the bls truck at significant risk. Giving ALS medications and then dumping him on the bls crew?

It's damned if you do or damned if you don't. I was always taught and drilled in the head that if you give medications or ALS interventions to a patient then you DO NOT leave that patient or put him in a lower level ambulance since you have provided ALS Meds.

What if both patients crash at the same time. YOu can't just drop the first patient to go take care of 2nd patient.

It just seems that you decide which critical patient you take care of and give the other to BLS to hoof it to the hospital. Once you begin ALS procedures on patient 1 and then drop him into the laps of the bls boys, isn't that a recipe for disaster? I seem to believe it is.

There is no real right or wrong answer to this scenario but I think the truly wrong answer is the one where you give ALS level medications to a patient and then put him in the hands of a bls crew to "do the best they can and please try not to let him die!"

[Kiwiology]

Problem is that "BLS" means so many different things - for example a "BLS" person in Australia can do more than an "ALS" person in the UK, a "BLS" person here has more high-value interventions than an AEMT in the US.

These patients need to go to a tertiary referral centre; the quickest way for that to happen is by air so while the plane is on its way we are taking them to the small hospital having pre-alerted them.

Intubated bloke goes with the ALS crew and the other fella can do with the "BLS" people after we give him some fluid.

[Vorenus]

If we stay in this scenario, where we have to transport 2 ALS pat. in one ALS and one BLS truck, there are not much alternatives.

I don`t think starting ALS on one pat. (the one you transport) and doing nothing on the second (the one you don`t transport) sounds any better at the end of the day. Yes, it`s a pretty bad situation.

I called out to transport Pat. 1 `cause he would get the most aggressive ALS treatment, while unless there`s some change of the situation, the predni and analgesia (I`m not talking about knocking him off) could be handled by BLS.

[Just Plain Ruff]

Problem is that "BLS" means so many different things - for example a "BLS" person in Australia can do more than an "ALS" person in the UK, a "BLS" person here has more high-value interventions than an AEMT in the US.

These patients need to go to a tertiary referral centre; the quickest way for that to happen is by air so while the plane is on its way we are taking them to the small hospital having pre-alerted them.

Intubated bloke goes with the ALS crew and the other fella can do with the "BLS" people after we give him some fluid.

Very true Kiwi. But in the USA is where my question is focused.

[systemet]

What are the thoughts of the group of loading medications on a patient and then dropping him down to BLS status?

I wouldn't feel comfortable with doing this in most situations. I could see potentially administering a small amount of analgesia, and placing a patient in a BLS ambulance, if I knew I was going to be following them. Granted, they should be able to manage any respiratory depression that occurs, but I'm not sure that they're best equipped to identify an early anaphylaxis presentation or deal with it effectively, even if IM epi / nebulised ventolin are options for them.

Of course, this is (technically) an MCI situation. There's inadequate resources to match the number of victims present and their severity. So some compromises may have to be made. I think in most of those situations the risk / benefit is going to fall on the side of withholding pharmacology if there's not going to be an ALS provider present for transport.

[mobey]

I am with Sys on this one. Legally I can administer a med, continue care for 15min then pass off to a BLS provider.

In this scenario there is not 15min to spare so it would not happen.

Risk/benefit is huge in this instance, and a little analgesia for anyone is waaay down low on the priority list.

[HellsBells]

Legally I can administer a med, continue care for 15min then pass off to a BLS provider.

Where did you get this legal opinion from mobey? My understanding, per ACP is that if any ALS drugs are given, ALS must monitor them for the duration of transport. Furthermore, what meds specifically are you referring to? Now I know that in actual practice, we do in fact hand off pts who have had analgesics, antiemetics, etc. to BLS crews. Particularly in situations where hospitals will send pts out for BLS transfers, who have recently had morphine or other pain control. However, I think if we are actually following the law to the letter, it is technically not sanctioned.

[flamingemt2011]

I vote, both patients in a single ambulance with one EMT from second truck and Mobey as the medic, other EMT drives the second ambulance to wherever.If one EMT is good enough for patient #2, then two EMTs and one Medic should be good enough for both. Althoug I agree with Mobey that patient number one has little chance of walking out of the hospital, I would not give a lower standard of care based on those odds. I have transported two criticals with my partner in the back and a FF driving several times.

Edited November 8, 2011 by flamingemt2011