Would Waiting For ALS Be In A Pt's Best Interest?

[Guest]

I need to preface what I'm about to say by admitting that I am not a medic. I recently completed an EMT-I course, but I am still a lowly Basic. I am well aware that New York State emphasizes never to delay transport in order for ALS to arrive on the scene.

I'm going to pose a question to the medics reading this thread. Here's the situation: a BLS ambulance is on the scene of a medical emergency and, if they leave now, it will take them 15 minutes to get to a hospital. Meanwhile, there is an ALS flycar which they are in radio contact with, advising of an ETA of less than, let's say, 5 minutes. Is there really no scenario where it would not be in the best interest of the patient for the EMS crew to wait on scene for those extra few minutes? (For the sake of argument, let's say that the flycar is coming from the opposite direction from the hospital; in other words, the EMS crew needs to decide whether to wait for the flycar or just transport the patient BLS.)

With this question, I'm not interested in hearing a lecture about New York EMT protocols. I want an honest answer about whether waiting for a medic would be in the best interests for a pt.

Here are a few situations that I could think of where it seems to be that it would be worth waiting for the medic, rather than loading and going. Here are a few that I can think of off the top of my head:

- Exacerbated Asthma that doesn't respond to Albuterol

- Cardiac Arrest that can't be shocked with an AED

- Severe Pneumothorax

I completely agree that, in most cases, the correct course of action is to start toward the hospital instead of waiting for the medic. But, I would be surprised if this is the correct method for every medical scenario. But, maybe I'm wrong. If so, please enlighten me.

Edited April 25, 2006 by bennybomb

[grumpyff 1,159]

Let me start by saying my EMT expired back in 1997, and at that time we were just starting to get ALS fly cars. Before that it was stabilize, scoop and run. For the scenario, I think I would wait. During that 5 minute eta, I would reassess/ retake vitals, switch over to onboard O2, etc. If need be I would instruct to driver to start responding to the hospital slowly, allowing the medic to catch up.

[mikeinet 37]

Speaking from a basic level...

In this senario, I'd wait it out - 5min vs 15min... flycar is your closest ALS facility.

But, lets say the medic was 10min out and hospital is 15min out... medic gets on scene, gathers his/her equipment... gets to the pt... gets your report, begins to do their eval... begins to do their ALS interventions... how much time has passed? Was it worth the wait where you'll have to transport (15min eta to hospital) and then transfer care again... Where's the point where it's best to get the pt in their "final care provider" (hospital) and let them do the interventions and just take over?

I know medics will always say ALS EMS interventions are just as good as hospital interventions... not debating that I know they are - but I feel there is a somewhat bias. At a hospital, you can do all you can as a medic, and much more. If you need a cat scan, you've got it - need an xray, just around the corner...

It's one of those split second decisions depending the case IMHO. If you can be sure the patient won't flatline on you in the time it takes for the medic to get there (say in the severe asthma case) then wait up... but if you've got a pt that can't be shocked with the AED, waiting 5min for the medic, then having a 15min transport ahead of you... you need to look and really think the odds of getting that pt out of vib and whether its best to wait an extra 5min for the medic or just start for the hospital and pray the medic can catch up to you. You're pt is brain dead after a few minutes without air... think about what would be best for your pt knowing that every second counts.

It's a tough call either way you look at it... really depends the situation and the circumstances. . . . What about traffic? Is it rush hour that you have to fight?? Much to consider.

Don't forget too... if you're sitting there waiting for ALS... as a basic you can retake vitals... be doing CPR (if applicable)... giving o2... what else? Not much. Think about the pt's family sitting over your shoulder with them in arrest... screaming at you "why are you just sitting here?" - you're going to lose a lot of credibility with the family if they don't get the sense you're doing anything. . . . 'arn't you going to do something????' - then when your call goes to court and the family throws neglect... haaaaaaa, oh boy.

Edited April 25, 2006 by mikeinet

[Guest alsfirefighter]

There is no right or wrong answer to the question. The answer lies in what the overall patient condition is, the ability of the EMT on board to provide proper treatment and what the ETA of the ALS provider is. The best course of action is never get out of the mindset to keep the patient moving toward the hospital, whether its how to get them to the stretcher, the stretcher in the bus and the bus enroute to the hospital. Most Paramedis will say that timely transport even when they are on scene is important, and scene management overall is a sign of a competent Paramedic. Can we provide important critical care...obviously yes. Can we as ALS providers start interventions that do not gain immediate effect or improvement on a patient, yes, however we can get it started and reduce the door to door time and the overall speed and effectiveness of patient improvement. I do not have the thought or kid myself that many of the intervention I have are the same or equal to what a ER can provide. We are limited in many areas, the only one that is definately the same or equal to is that of Cardiac Arrest. The only good outcomes statistically come from early CPR, early defib and rapid ACLS administration. There is nothing in a cardiac arrest setting that the ER will do that a Paramedic will not. This includes pronouncement, but with us its without transport.

[Medic137 6]

keep the patient moving toward the hospital, whether its how to get them to the stretcher, the stretcher in the bus and the bus enroute to the hospital. 

←

Now that BLS ambulances carry AEDs, Albuterol, and Epi pens, you've probably done all the things I can do quickly. If they haven't worked the odds are I'm not going to make a big difference either. (yes, there are some exceptions) Get the bus moving to the hospital. Medics get lost, and flycars break down. When you see my lights in your rear view mirror you can pull over. Until then, keep moving!

[Guest cya69]

I will make an assumption here that the medic is coming from the direction of the hospital because this may make a difference in a transport decision. If the medic is en route from the direction of the hospital then under no circumstance should transport be delayed. If the medic is coming from the opposite direction of the hospital the transport decision would be base upon patient presentation. In your scenarios of exacerbated respiratory problems not responding to intial treatment and cardiac arrest you would wait the five minutes as opposed to a 10 minute transport without any additional intervention. A pneumothorax is either just that or it's a tension pneumo which requires intervention and was this spontaneous or was is traumatically induced? which may also make a diffence in the hospital you will be transporting to. Bottom line is the need for strong BLS making decisions based on fact and presentation and not panic.

[WAS967 97]

I'm with ALSff on this one....there is no easy answer to this. Th ebest answer is use your best clinical judegment. That comes with experience.

For traumas I'd get moving to the hospital. People with severe trauma need one thing - a surgeon. Most traumas come down to immobilization, hemmorage and airway control. Most can be done on the BLS level - intubating aside.

I run into similar situtations where I work from time to time. We have outlying areas where a lot of times we used to have the BLS agency get on scene, they would scoop and run to the ER. Average response for me to the far reaches of that areas is about 12 minutes and I'd be coming from opposite the direction of the hospital. But the hospital is about 15 minutes down the road. Obviously if they are about to transport and I'm 2 minutes away, waiting can be justified. Maybe moreso for time if the patient is stable. But they also have the option of transporting and calling for an intercept from the recieving hospital so they kind of have the best of both worlds if push comes to shove.

In the end, this is one case where we truly, as ALS providers, rely on good clinical judgement from our EMT partners in the field. If you take the best interest of the patient in mind, you really can't go wrong.

Edited April 27, 2006 by WAS967

[IzzyEng4 427]

Two words

ALS INTERCEPT!

We do it all the time up here in New Haven County. If there is no medic available in the area, one is sent out. If they do not get on scene we can meet them enroute. I rather get my patient to a hospital rather to wait on scene for a medic. Yes there are times where you need to wait for a medic but you can always meet up with them along the way.

There are plenty of times to scoot and boot and it doesn't matter how far / close the hospital is. I've had to BLS cardiacs and traumas to a hospital several times. You have to make that split decision. I rather get enroute to the hospital and meet the medic along the way than wait on scene, waiting cuts into that golden hour!

[firemoose827 324]

I guess the same question could be applied to helicopter intercepts. We seem to have an overabundance of EMT's who love to call for Life-Net at every MVA we get, than they wait on scene for it to arrive sometimes for up to 15 minutes!! We are in between two regional trauma facilities; Albany Med 45 minutes to the east and Cooperstown Hospital 35 minutes to the west. We have a small community hospital here in Cobleskill but it is just that; SMALL, and worthless.

We had a 2 car MVA last week with two critical PT's and they called for two birds. But the thing is the one was laying in the driveway, they were assesed and packaged in 5 minutes and the bird had an eta of 12 minutes. I would have gone the short trip to Cooperstown and would have been there by the time the bird landed, they assessed the patient and transferred him to their stretcher and than finaly took off. But the EMT chose to wait and was in the back of the ambulance for 15 minutes waiting for the bird to land. Than it was another 15-20 minutes before they were airborne again. Sometimes people fail to make the proper judgements. That PT should have been in the trauma unit long before he was actually even in the bird. I try and tell them, if you have an extended extrication time and the PT is bad THAN you call the bird. If you can easily package and drive to the hospital than do it...remember the golden hour?

As far as ALS intercepts, I used to be an EMT-CC and i'm just a basic now sow I've experienced both sides. I wont wait for ALS, we assess, package, and respond to the nearest appropriate facility. If we can we will pick up a medic from the nearest town and go. Most of the time our county medics respond fast and are there with us or shortly after. On a few rare occaisions we had dispatch tone out 2 or 3 depts on our way to Albany Med and ask for any Medics to meet us enroute, and 98% of the time we get one pretty quick and transport is never delayed. Our county medics love this because they know that the best place for the PT is the ER. In a code situation we go to the local ER 5 minutes from just about anywhere in our district, stabilize, and the local paid EMS crew transports to Albany, Schenectady, or Cooperstown.

Jonesy

[Guest Rich DD]

I would not wait for the medics if they were 2 minutes away!!! If we are going to intersect, then go and meet them. If they are chasing my bus...... I cancel them... they are no good to me or my patient. Not when waiting 2 minutes for them, then by the time they talk to the EMT's on the bus, assess the patent, and start treatment, your looking at least 7 additional minutes.

If the hospital is 10 minutes away the patient doesn't see the Emergency Department for 19 additional minutes, (2 minute wait, 7 minute evaluation, 10 minute taxi ride to the hospital). If you dont' wait, then the patient is in the Emergency Department in 10 minutes.

If your patient needs advanced medications which are administered in a time focused treatment regiment, then waiting 19 minutes just killed your patient.

This is provided that your ALS cannot administer such meds. in the field.

Then again...... I still wouldn't wait.

Just my 2 cents.

[KML607 0]

Use your best judgement in the best interest of the patient!

[Guest]

ALSMEDIC (as always) hit thie nail on the head.

I've been a Medic now almost two years, and even going back to my EMT-B and EMT-I days, there is no one answer that bears more validity than the other. Having worked in Clinton County, where the majority of ALS interventions we done enroute because ALS came out of the 1 and only hospital in the county and could only intercept the BLS crew. Then you have BLS crews that wait for a medic no matter what. Prudent judgment and experience will guide you to the right answer on a call by call basis.

[paramedic441 0]

An additional two cents....

I've been in EMS for longer than I care to think about some days. When I started ALS was limited to a few Critical Care Techs. As a BLS provider (back then) you developed good critical decision making skills as well as the technical skills.

I've seen a shift over the years in BLS providers, and that is this: they're taught to call ALS for everything. The vast majority of our calls can be, and possibly should be brought in BLS.

The obvious exceptions would include airway management problems that cannot be corrected by an OPA or NPA, cardiac arrest, and medical patients that are truly circling the drain that would benefit from first line medications.

The biggest complication on traumas that I've witnessed over the years usually occur with multiple medics on the scene. Trauma is BLS with an occasional ALS trick.

IV's and saline locks are not treatments, but rather routes for treatments. If I don't anticipate giving a patient fluid or meds, no venipuncture. Too often Medics initiate this "treatment" because they can. Not because they should.

ALS has its place in the field, without a doubt. But so does good BLS. For the record, I'm a NYS CIC, and I've taught the Critical Care program for a number of years, and I've always attempted to instill into my students good clinical judgement, and to do the right thing for their patients.

I don't believe there is any cut and dried answer to this issue, it's going to be a case-by-case deal.

My best advise is to concentrate on doing quality patient assessments, treat the ABC's and above all, develop confidence in your skills as a provider.

[RU 911 0]

I agree with most is there a right answer to this question. The hospital is definitive care.

If you had to explain to an attorney why you delayed transport to the hospital. What would you say. 'Medic dependent'

Try this. Do the math the hospital is 15 min away.

If you wait 5 minutes for ALS the hospital is now 20 min away.

In many cases good BLS can accomplish lots.

[Guest alsfirefighter]

Good additional points by many. Only one I take exception to is the comment on IV's being done by medics as "treatment" because they can. I never start a line because I can...if I ALS a call it is because it is a ALS warranted call that needs immediate advanced intervention whether skill based or pharmalogical, or there is a possibility that advanced care can or will be needed before arrival at the hospital. That is why Paramedics start lines, if you ride it in ALS and your not next door regardless of medications or not, you start a line...why because its routine medical care which is always ALS protocol #1. Paramedicine is evolving into what it should be...making impacts on peoples lives through interaction and solid medical care. Its not just a make quick relief to get the hospital...we are definitive care, we are part of the care system. Effectively beginning treatments to stop a worsing conditions in its tracks, sometimes completely reversing them and reducing door to door time of patients which helps all, the patients by freeing up resources sooner and getting them back into their environment, us by reducing the chances of diversion by getting treatment acting faster and the hospital by freeing up resources they may need for other more sicker people.

Initiate appropriate BLS protocol.

Apply Oxygen

Apply EKG monitor

Establish IV access.