ALS or BLS? Help me decide...

[akflightmedic]

They did not neglect to respond to anyone....The nurses skipped the system in place and called the private service direct. The nurses are the ones that screwed up the system.

The original poster works for the private service and he was questioning whether or not this was an ALS call and should he have called for them and would they have come. Basically, I assume he is second guessing himself and doubting whether or not he did the right thing.

[Dustdevil]

Sorry I didn't make myself clear. I wasn't talking about this incident in particular. I was referring simply to the practice of screening calls to decide who does and does not require ALS. It has gotten more than a couple of agencies in major legal heat, and a few people decertified in the process. Again, the quality of the care in that system is irrelevant if they never make the scene, or do so only after BLS has made the scene.

[mamamo899]

I am also new to this forum, but not to the world of ems. First of all, although I will get to the point and agree that the patient sounds septic, how about lung sounds? While I agree that the patient should be transported als (ie: iv in place, cardiac monitoring and possibly a breathing tx or other tx for not mentioned lung sounds) there is not much else that can be done in the field by ALS (ie:iv antiobiotics) along w/rehydration which is what this patient probably needs.

As for the private call, MANY nursing facilities in the area where I am do this ALL the time. I am not really sure why. However, when I worked for a private service, our dispatchers where told to tell the facility to hang up and dial 911 (think that was something they had w/the FD).

Lastly, as for the tiered EMS system, in theory it is great, however, reality often dictated and realized the loopholes that come along w/great ideas!

[UMSTUDENT]

Impressive system. King County Medic 1 is pretty well known and they get some press. I actually saw them mentioned, although not directly, in a video game once.

I've also heard that in Seattle you have to be certified in CPR to vote. Is this correct?

[Dustdevil]

I've also heard that in Seattle you have to be certified in CPR to vote. Is this correct?

Great idea!

Unconstitutional, but still a great idea. :wink:

[UMSTUDENT]

Great idea!

Unconstitutional, but still a great idea. :wink:

Would make sense wouldn't it? It's kind of a no brainer that something like that couldn't be applied to national elections regarding Congress or the office of the presidency, but I'm not sure how King County may define voter eligibility for county elections. Could see it being interpreted as a Jim Crow law; however, AHA CPR is conveniently not fail-able. It'd almost be no different than requiring someone to take the time to fill out their voter registration card.

[benanzo]

I seem to have stirred up quite a debate here over Medic One. (No, you don't have to be cert. CPR to vote here.)

The city of Seattle is contracted with AMR to do all BLS transports. AMR does not operate ALS ambulances in king county. (Besides Critical Care Transport rigs for ALS interfacility calls - when they respond to 911 calls, they operate as BLS.) When someone calls 911 in seattle, the first sick/not sick decision is made by the call taker-let's say they think the person is Not Sick. So, they dispatch 1 BLS Engine or AID car (which never transports). The Engine then makes the same determination of the pt when they arrive. Let's say they think the person is Sick. They call for ALS Medic 1 (Also part of the fire dept.) Medic 1 arrives and decides the person is not sick. The engine then calls for 1 AMR ambulance for transport. Then the AMR transports routine to the hospital. The theory is great...

The problems arise in the fact that you have entirely too many people involved in a single call. What happens over time, and I have been witness to it mult. times, is that when a BLS crew (fire or AMR) sees the ALS unit make a not sick call in a grey area, that pushes the ALS indicators up further for those people. Example being a 2 y/o first time febrile seizure, status seizures. By King Co. protocol there are 2 ALS indicators there (first time seizure, status seizures) regardless of the fact that the seizure is febrile which is common in kids. In my experience, Medic One has never taken that pt. based solely on those two indicators, and fire sees this, so when they encounter that the next time, they don't call medics, they just call AMR, which puts AMR in a tight spot over whether or not they should call medics. AMR new-hires have a sit-down with the Seattle Fire liason when they start and are told never to question the Fire Dept. crews (ALS or BLS.) It is even worse when there are clear indications of a sick pt which has already been cleared for BLS by medics (who have since left the scene and can't give comment or rationale to the transporting AMR just arriving.) The BLS fire engines and aid cars are at a huge disadvantage to the AMR crews when it comes to EMS because they never see the end result of transfering care to the ED. They never see how that pt was received by the ED staff because they only saw them on scene. There is so much more to learn about the patients and their conditions once you get them to the ED than can be found on scene or during the medic's eval. This gives them less scope of experience to decide Sick/Not Sick unless you base those decisions purely off protocol, which I already said has gotten distorted over time. It is almost faux pas to request the Medic back for a second eval even if the pt's condition has changed during fire's transfer to AMR. This situation, though not acceptible, happens all the time and is purely caused by the fact that there are too many people involved. My opinion is that Medic One should do all transports, ALS or BLS, to minimize the risk of distorting the perception of Sick/Not Sick based entirely on what you have seen the medics transport in the past. Unfortunalely AMR crews and the fire dept crews are not in good communication with each other which makes second guessing and doubt about a transport decision off limits. So, to say that King County Medic One is stellar is true, especially in their training and innovation for ALS pts. However, the entire system is bogged down by the continuous sick/not sick decisions made by multiple parties for a single pt. Some may say that that only enhances the chances that the pt will have the right decision made about their condition, but I say that's not true simply because second guessing is taboo here. When AMR is called, they're called to transport, not question. Fire is very protective of their own, even if the BLS fire crew secretly disagrees with the medics, they'll never allow AMR to question the decision once they arrive. Another problem is that AMR, the transporting unit, is infinitely disadvantaged by the fact that they were not present during the entire eval of their pt. Fire does not have a good habit of divulging all necessary info to the transporting AMR crew, and quickly become impatient when they are "grilled" for info. They might only get a chief complaint and a general idea of what is going on, which leaves the AMR crew to start back at square with SAMPLE and OPQRST etc, all during the transport to the hospital which is no longer than 10 minutes anywhere here. This often leaves AMR with only the most basic info and nothing more, which can be frustrating.

By the way, as for my scenario earlier, the medics have never taken that pt from me. I have been in that exact scenario multiple times with no change in transport decision. So, I began thinking that I was reading the pt all wrong...nope. I was right on the money each time based on protocol. There are SEVERAL ALS indicators (per King Co. protocol) given for that patient. I will continue to call the medics out each time simply because it is inappropriate for me to base my decision on what decisions I have seen the medics make in the past. Protocol is the only safe way to do business here, and anywhere really. ---- The first thing the ED does when they get that pt is deep suction to clear his airway (ALS skill) and ask me (with a surprised look) if he was eval'd by medics.

[Ridryder 911]

I have to admit King County has a great reputation. Yes, they are a forefather in EMS, but just like another EMS system, they too have problems. There are good EMS systems out there that may never get the publicity or notability such as King County. They have been fortunate to have a progressive physician and emergency medicine teaching to help make them have a great system.

I always forewarn all medics that every system has its advantages and disadvantages... each should be careful and evaluate when seeking employment.

I really do not like the BLS vs. ALS and call screening. There are too many variables that causes problems. If the patient requires transport, then why should the patient wait and then receive potential bills ? Again, we have not addressed our systems problems...

Be safe,

R/R 911

[benanzo]

I am not well informed as to the inner-workings of the Medic One program, but I can offer extensive critiques of the overall system here. It seems that there is a general conception that King County has a perfectly effecient and overwhelmingly effective EMS system, which is simply not true. Again, Seattle and it's surrounding areas suffers from too many ALS/BLS decisions being made by too many different people who aren't working very closely with each other. It seems to me that if the 911 dispatcher takes a call they believe to be BLS, then they should send a BLS AMBULANCE, not a fire engine, or worse, a ladder truck (what are they going to do that a transporting unit can't do?) I am not all for AMR taking over as primary BLS response. I am entirely unopinionated as to WHO does the response, just that it just needs to be a BLS AMBULANCE. The fire engine does nothing but add a layer that should be removed to maximize system efficiency. Frankly, it is only a matter of time before every system becomes privatized given the increasing operational costs and unwillingness of people to pay for services they don't use. If you need it you pay for it, just like anything else. That goes for here too. I was not surprised when I recently started seeing commercials about how the Medic One Foundation's funding is scarce and needs donations.

[Dustdevil]

Protocol is the only safe way to do business here, and anywhere really.

That is the only thing you have said that I disagree with.

Protocol is the firemonkey way to do business. The best and safest way to do business is to get a comprehensive and meaningful education and use your intelligence and experience to see the total patient picture and then arrive at clinical decisions based upon them. The human body is not a book. And medicine is not one big flow chart. Protocols should be a framework from which to base your clinical evaluation and care decisions, not an instruction manual.

So how long do these gods of paramedicine in Seattle go to school to learn to walk on water anyhow? What can we learn about Seattle that makes them so much better than anybody else, clinically speaking? Protocols? Psssshhhh, whatever. Protocols don't make the medic. And it has already been established here that their operational procedures suck turd. So, I want to know what makes the medics themselves so special. What I have read here makes me much less impressed with the system than I was before the discussion began. Reputation only takes you so far in the real world. After that, you have to prove yourself. I remain unimpressed.