When to call ALS?

[DesertEMT]

I am preparing for a test with an ambulance company in the next coming weeks, this will be my second try, I only have to complete one test which is the trauma scenario and so I am trying to study up on everything I did wrong last time. One of my mistakes was not calling ALS back-up, so my question to you Emtcity is "when is it necessary to call for ALS assistance as an ILS provider?"

[Kiwiology]

There is no easy answer to this question really as it depends on a multiplicity of factors e.g. what the patient actually needs, what you can do, the patient status, distance from an appropriate hospital (not necessarily the nearest hospital) and distance from back up.

An extremely over simplified answer would be "when you cannot provide immediately necessary time-critical intervention that ALS can provide significantly faster than the patient is able to be delivered to an appropriate hospital"

[Chief1C]

Look over your ILS protocols, it will probably tell you when to call ALS. But if you're assessing your patient, you can always use ALS going by mechanism. Won't hurt to give a true trauma patient, the full court press.

[HellsBells]

I would assume that in most cases your "scenario" would be serious enough for ALS back up to be called. At least thats how its always been in every test or exam scenario I've ever done. Very rarely do you get one with minor injury or benign medical compliants.

[systemet]

I am preparing for a test with an ambulance company in the next coming weeks, this will be my second try, I only have to complete one test which is the trauma scenario and so I am trying to study up on everything I did wrong last time. One of my mistakes was not calling ALS back-up, so my question to you Emtcity is "when is it necessary to call for ALS assistance as an ILS provider?"

Can you expand a little more on what your scope is? ILS is a confusing level.

I guess the trite answer would be any time the patient may potentially benefit from an intervention or assessment that ALS can use that you can't?

For what it's worth, I've never had an issue backing anyone up. I'd rather have a BLS crew call for assistance and have it be an overreaction / waste of time, than to have them not call when the patient needed help for fear of "upsetting the paramedics".

[island emt]

What are the things that an ALS provider can do that are above your scope of practice?

Most likely airway and procedures such as chest decompression and surgical cric. Probably pain medications and other interventions that are limited to Paramedic level only.

If a serious trauma pt needs help then you want all the help you can get to be on that call.

What does your medical director want you to do?

Some places want a Paramedic on any call beyond a stubbed toenail .

Not saying thats right or wrong , just what the decision makers want.

Edited February 24, 2012 by island emt

[DesertEMT]

From my understanding the difference between ILS and ALS where I was taught is; medication (cardiac and pain), endotracheal intubation, and EKG and Defibrilation (with the exception of an AED) are all out of my scope. It is easy for me to determine when ALS is needed during a medical call but trauma is a bit of a weak point with me when I can't actually see a patient.

[Kiwiology]

For a trauma patient there is most likely little benefit in calling for ALS outside of pain relief and chest decompression

[runswithneedles]

Regardless if its a test or in the field your gut is your best guide. If you sense that the scenario has a possibility of going south or you cannot manage the patient because whats needed is out of your scope.Call for ALS. Working with paramedics as a basic. Ive learned that by understanding what a paramedic can do helped me determine if I needed a paramedic with me or if the crew could be BLS only

[Kiwiology]

Here are some general guidelines we use when calling for back up and hopefully they can be of help to you

1. Only call for back up if the patient requires or is very likely to require an intervention you cannot provide

Calling for back up because the patient looks "unwell" or "they have tachycardia" is probably a waste of time. What does your patient need that you cannot provide? If your patient is "unwell" is it because they have a cold for which your back up has nothing or is it because they have decompensated septic shock and need fluid, inotrope and antibiotics? If your patient has "tachycardia" is it because they're a bit upset for which your back up has nothing or is it because they have monomorphic ventricular tachycardia for which they require cardioversion and antiarrythmatics?

2. Meet back up en route unless the patient is unmovable or moving toward hospital will move you further away from back up

Begin moving the patient toward hospital rather than staying at the scene. Only wait at the scene if you cannot extricate and transport the patient (for example pain is making move them impossible or they are trapped) or your backup is coming from the opposite direction to hospital

3. Only call for back up if they can locate you significantly faster than you can deliver the patient to an appropriate hospital

If it is going to be significantly faster to deliver the patient to an appropriate hospital vs waiting for backup then transport the patient unless you can't begin to transport your patient because e.g. they are trapped or require pain relief

4. Helicopters take time, call a helicopter only if the patient one hour or more from hospital by road and is time-critical

Helicopters are over-rated and over-used. There is little evidence that helicopters make a difference in determining positive outcome on morbidity and mortality. Helicopters also take time and in many cases transporting by road is faster.

Here are some examples

i) A patient fell from a roof and had a GCS of 6 with poor airway and breathing. The scene was 30 minutes by road to hospital and the crew called for a helicopter. The helicopter located at the scene 18 minutes after dispatch, was on scene for 15 minutes and took another 15 minutes to fly back to the hospital. The patient arrived in hospital 48 minutes after helicopter dispatch and 18 minutes later than if taken by road.

ii) A patient was found unconscious as home, 25 minutes by road to hospital. A PRIME Ambulance Doctor was already on scene. The patient arrived in hospital one hour and forty minutes after helicopter dispatch and one hour fifteen minutes later than if taken by road.

iii) A patient had been shot and was 25 minutes by road to hospital. A helicopter was dispatched and arrived 26 minutes later, was on scene for 24 minutes and took 11 minutes to fly back to the hospital. The patient arrived in hospital forty minutes later than if taken by road.

In all the above cases the decision to use helicopter transport significantly increased the total transport time to hospital. Our audit process is revealing a number of cases where this happens. Note that in general: you need to be more than sixty minutes from a hospital before helicopter transport will significantly reduce the total time it takes to transport the patient to hospital, unless a helicopter has already been dispatched or extrication is going to be very prolonged.

Edited February 25, 2012 by kiwimedic