ALS or BLS? Help me decide...

[benanzo]

Hi, I am new to this forum but have been active in other ems forums. I am an EMT-B in (I'll say the Greater Puget Sound Area (Seattle-ish) so as not to be pinned down by the locals I am bashing.) The system is set up so that city bls FD is primary resp on all 911 calls. If needed they request ALS, also city FD. After evals, if pt determined to be BLS tx, they call private AMB. But SNFs call private AMB directly most of the time without using 911. So, pretend you are the private BLS AMB called by SNF to tx pt to ER:

80 y/o male STH decreasing LOC/increasing SOB x 2 hrs. RN @ SNF states pt normally A&O x 3/3, active motor able to support self in wheelchair. Hx NIDDM, A-FIB, HTN, Arthritis, pneumonia 2 mo. ago

Pt presents lying 45 degrees in bed, pale/hot/diaphoretic, barely responsive to px, very congested upper resp., RR 40 very labored, HR 90-120, BP 140/80, sats initially 79% RA, 88% after 5 min highflow NRB. There is no pedal edema, temp 102.0, glucose 160, full code. You call for the FD medics to come but will they take him?

You decide.

What is this guy's underlying problem and what ALS Rx could he benefit from?

I already have my opinion but I want it to be confirmed un-biased first.

Thanks a lot!!

[akflightmedic]

Well based on that information, its not hard to figure out who you work for and who the other agencies are. Anyways, this guy sounds septic. Could he use ALS intervention? Sure he could. Would it make an immediate difference..I dont think so. Could BLS run him to the ER which is only a few minutes away? Sure they could. Should BLS do this? I don't think so, since a higher level of care can and should be provided when possible. Should the RNs at the SNF stop skipping the process that is established in order to ensure quality care to all residents regardless of the condition. I think so. They should not be circumventing the system that is in place. That leads to problems and questions such as this one.

[wizchip]

I would have to agree that a BLS transport would be appropriate if the ER is with in a short distance. However ALS would be preferable because the patient is a full code. I used to work for one of the major private ambulance services. Many of the facilities in the area had standing orders to call on a private service instead of FD. Granted we we also the primary ems for the city on all levels, but still unless the patient was coding the would call for a non emergent response on everything. Many of these facilities I have been to have less ability to respond to patient needs than any BLS crew would. Many times we would send BLS and ALS to a facility on a call just for that reason, you never got the true story from the staff. In many areas this isn't possible. In my area it was because we always had a minimum of 5 ALS crews and 7 BLS on a shift. But those are my expereiences

[AZCEP]

Echoing the others, if the transport is short, BLS should begin the transport to the closest receiving facility. Cardiac monitor and vascular access would be nice, but they aren't going to make a huge difference in the end.

[hammerpcp]

That sounds like a very difficult system to work within. As if our jobs are not already enough of a gray area, you have interagency/interfacility politics and complicated procedures do deal with. Not knowing the legalities etc. of your system I will just have to go with the common sense answer. This pt does sound septic but he is not decompensating, so a quick trip to the ER with a BLS crew will not be detrimental to him, and ALS could not do any real interventions for him anyway.

[Nate]

I think that in order for a private ambulance service to hold a contract with anyone, they should be able to at least meet or exceed the ability of the local FD. If they can't afford to become an ALS provider and they are the only provider around (or better then the alternative company that runs ALS), then maybe the private service should calling FD for assistance when a call like this comes in. That way if the patient is bad, or does code between the initial call and your arrival, at least ALS is already enroute, or there with you. I mean, if it turns out to be a true BLS call then FD can go back in service and the private company can transport.

I think instead of this municipal vs. private war going on that some people like to start, we should start looking at ways to integrate the two. Contrary to some EMS personnel's belief, there are private services that actually are more capable then municipal services. Last time I checked, I was the same paramedic whether I was working at the city or at my second job on the private ambulance.

[JakeEMTP]

I think instead of this municipal vs. private war going on that some people like to start, we should start looking at ways to integrate the two. Contrary to some EMS personnel's belief, there are private services that actually are more capable then municipal services. Last time I checked, I was the same paramedic whether I was working at the city or at my second job on the private ambulance.

Excellent point Nate. Where I am is by no means Houston, but we still have the GF & R vs Private here. Most ALS outside of Greenville are volly, but there is still the " we're better than you " BS. It is high time this mentally was put to bed and pt care became paramount. In class, the instructor won't let the fire guys wear their uniforms. We are all equal and there to learn the same curriculum. When we complete the class, we will all be Paramedics, regardless of what colour our shirt is.

[Nate]

Yeah, around here if you get MCI (which happens more then you think down here) you will usually see five to six different Fire/EMS services, plus the chemical plants fire/EMS, and then you get the private services that mutual aid for transport, so what happens is you end up with paramedics from one service on another services BLS ambulance, etc.

[akflightmedic]

While you guys make valid points, it just doesnt hold water with this particular area. If I am not mistaking, this may or may not be referencing to Seattles Medic1 which happens to be one of the top services in the nation. Their medic ambulances do not run BLS calls, only ALS. They have very rigourous hiring and training programs and in return you get a nice salary and schedule and are guarenteed to run only ALS calls. How sweet is that? I would have worked for them but I can not go through paramedic school again as is required by their hiring agreement. They dont care who you are or how long you have done it, you will redo their medic program for 10 months. They do pay you but it is only 3k a month while in school. Their program also has very low turnover, no big surprise there.

So, to make a long story short, please do not start the private vs municipal argument because it is irrelevant with this particular system. Read up on Medic 1, good stuff...

[Nate]

So is Medic1 the private service or the FD based service? Because if it is the private service that has only ALS rigs, why was a BLS crew from them on a call if they don't have BLS rigs?