Questions From a Reader Part Three.

This one comes via the comments on a previous entry:

"Is the decision to send ALS or BLS always made at the scene, or sometimes according to the information received from the call? Also, seems as if sheer availability might be the factor."

Once again our intrepid reader had provided an excellent question for us!

Decision made by the Government:
The decision on whether to send ALS or BLS are made on several levels. Some jurisdictions have all ALS response so, that decision is made on the governmental level or whoever had decided how their Pre-hospital EMS system is structured. (some areas have quasi-governmental "ambulance trusts")

Other jurisdictions have what is called a "tiered" system where BLS units, ALS units or both are sent to a call based on criteria. These criteria, if you remember from the last entry, are detailed in the medical protocols and set forth by the medical director of that jurisdiction.

Ok, as I keep repeating, each jurisdiction is different. I'll describe my understanding of how my jurisdiction works.

First off, let's get in our heads the concept of the process of an EMS event: First, someone gets sick or injured. They, a bystander or a family member calls 911. This is the first point where someone makes contact with the emergency medical system. This person speaks with an Emergency Medical Dispatcher (EMD), a person who is specially trained in telephone triage or interrogation techniques.

Decision made by the EMD:
Based on the questions they ask and what the patient or reporting person tells them, they make a decision to dispatch a BLS unit, an ALS unit or both. Of course, they have algorithms to help them make these decisions, just as EMT-Bs and paramedics do to help with theirs. Some calls have a requirement to dispatch ALS. Chest pain, trouble breathing and falls of greater than 25 feet are a few examples of calls that would get a Medic unit along with the ambulance.

Now, the Emergency Medical Dispatcher has made a decision as to whether the patient receives the services of ALS or BLS. Let's assume they send only BLS. That means somebody like me goes to this call.

Decision made by the EMT-B:
Now, let's assume the call is "Injured leg after a fall" and once I get there, I discover the 65 year old patient is having chest pain and shortness of breath consistent with heart attack as a result of all the excitement.

What do I do? Yep! You guessed it! I grab the radio:

"Ambulance XXX to Communications, Request ALS our scene or meet en-route"

Here are examples of how the decisions are made to send ALS. Sometimes the dispatcher makes decisions to send BLS only. Sometimes, BLS units will determine that the ALS, or Medic, unit are not needed and the call them off. I've seen other EMT-Bs do this when they get to a call and decide that the patient is not in need of a paramedic.

Me? Here's what I think (and do): If a Medic unit has been dispatched to my scene, I'm not going to call them off until they see the patient and make that decision themselves. I figure, if a patient has chest pain, they're MUCH more qualified to decide it's only muscle pain than I am. I figure, they're already on the road, it makes little or no difference if they turn around on the highway and I'd much rather they come to the scene and look at the patient.

Decision made by the Paramedic:
In a tiered system, the Paramedic has the opportunity to "downgrade" the patient to BLS. They can decide the patient doesn't need ALS care and leave it to clowns like me to transport to the hospital. In a tiered system, there are less ALS units per capital than one that is all ALS. This decision allows the Medic unit to be available for the next call. Of course, in an all-ALS system, everyone rides with a Medic.

Ok! I hope that answers the first part of your question. As to the second part, whether dispatch decisions are made based on availability. Well, I'm not privy to the decisions made by the EMS supervisors in my jurisdiction but I have experienced situations when dispatch tells me that "no medic available" or "ETA (estimated time of arrival) is 30 minutes" on a busy night. I've also heard from friends and associates that work in less populated areas that citizens are lucky to get a BLS unit let alone a paramedic.

Any of you other readers have opinions or stories? Hit the comments link below or send me an email.

I hope this answers your question. Thanks for reading!

--maddog