I'm part of a rural BLS fire based volunteer service. We always have ALS in route to us for chest pain. And anytime we feel it's necessary we can call for them. And if it turns out we don't need them, we can also call them off. So other than suspected cardiac problems, it's pretty much up to who ever is on the call.
Our county is all ALS, but assists other counties that are BLS. I don't specifically remember the PA state BLS protocols on what they say about this, in this area the BLS provider typically makes the call based on their feeling of whether the pt. needs ALS intercept. Personally, I would say anytime the pt. needs something ALS can provide, call for it. Sounds over-simplified, but it tends to work in our area. Usually, when BLS calls for ALS, they need it. It's few and far between that they don't call and should have, although it does happen.
The dispatch center should be screening the calls for information to decide at that point if als is needed, if you are dispatched for a bls run and you arrive on scene and feel als is needed it is your decision at that point. the one thing i think that you need to keep in mind is your distance to the er and the distance that als will be coming from. the main issue is the patient care if you can arrive at the er before als arrives go enroute and if possible try to rendevous, if you cant than you are getting the patient where they need to be
The county in Washington State where I spent the last 19+ years as an EMT-B has a two-tiered EMS system. Calls are dispatched using a criteria-based Emergency Medical Dispatching system. If it's an ALS call, the local agency BLS crew is dispatched, along with one of the county's ALS units. If it's a BLS call, then the responding agency EMTs are all that's dispatched. The EMTs operate under a pretty comprehensive protocol system that includes, among other things, specific ALS upgrade criteria. They can also upgrade based on experience or a "gut feeling." The protocols also allow them to downgrade an ALS call after assessing the patient, sending a short report to the incoming ALS unit, and getting their concurrence.
The last two replies is pretty much how our system works around here. Our dispatch follows their protocal in asking questions to the caller and if it fits the ALS or BLS criteria. Once on scene and we assess the pt., we can always recall them w/out any problem. When in doubt, keep them rolling. In our area which is rural, we have 4 different directions we can go with a pt. . Any direction we travel we are talking 20-30 minutes to the nearest ER. Alot depends on which end of our district we are at, and the nature of the call. We are a Volunteer Ambulance Association that covers 450 square miles in our district.
PA protocols do say when calls should include ALS from what I remember. However, I used to dispatch and live outside of Philly and now am in central PA and our dispatchers screen calls to include ALS if the calls necessitate. Most, if not all, of the dispatchers are EMD certified and can make that decision. That being said, depending on the circumstances of the call, we can call for ALS if we think it's warrented. All cardiac arrests, resp. distress, SOB, and chest pains get ALS. Depending on the trauma call, they also go out for that. But, say the caller panics and calls 9-11 and says their ( i don't know say. . .) grandma has belly pain and hangs up. BLS would just be dispatched. Say BLS gets there and grandma is puking up blood, I'd call for ALS to meet us somewhere and high-tail it to the nearest ER. With that being said, say ALS gets dispatched with us for a fall victim. Say we get there and ALS isn't there yet. In speaking with the pt, they tripped down one stair have left toe pain and want to go to the hospital. I would call off ALS in this case. If I had to call med command for this I would. As you get more and more experience, I believe it makes it easier to judge when you need ALS and when you don't. However, it can also make you more complacent that you might be able to care for something that might be over your head.
I would get ALS on its way when the dispatch that came over described a situation that was contra-indicated in my protocol(IE drugs, IV, Pneumo-thorax. etc etc etc or any other event listed in my protocol.
I always think ABC ABC ABC and. having the experience of being able to quickly assess the patient helps a lot in keeping the Pt within the golden ten minutes. A good Pt assessment followed up by accurate radio communication with the ALS unit works wonders for the care of the PT.
I would request paramedics for any airway, breathing, circulation issues, undifferentiated AMS (if you are 99% sure it's a stroke and can definitively rule out low glucose, then you may not need paramedics). Considering on transport time, you may also want to consider paramedics for pain control measures. Also remember, just because one part of a patient presentation may not indicate a need for paramedics does not mean that another part of the presentation may indicate paramedics. Also remember that just because a patient may have a DNR order doesn't mean that they won't benefit from paramedics.