All ALS all the time?

There are those who believe that the idea of "all ALS all the time" is the best policy for providing EMS to the masses, and believe it or not, I'm not here to debate that fact even though I am a BLS provider myself. There are also those ALS providers out there who believe that BLS providers should not be able to make a determination about whether a patient needs ALS care. Surprisingly, I'm not here to talk about that either. Rather, let me tell you a story:

We're called for a 27 y/o female having an asthma attack. Our crew is fast today, and everyone is assembled and we're off in the ambulance in record time: 4 minutes after the initial call marks our arrival on scene. Walking into the lobby of the building, I find the patient sitting in a chair, barely moving any air; she states (barely) that she has a previously diagnosed case of childhood asthma, but doesn't have an albuterol inhaler. A quick listen to the lungs, and she has wheezes on the exhale; also a tinge of cyanosis to her lips. This is not a healthy person. My partner starts a more detailed workup, and I get on the phone to medical control for a request to administer nebulized albuterol, which we carry on board. The request is approved and we begin administration of the medication and start prepping her for transport.

My next call is for ALS backup. Stair chairing and getting her out the door has already run us through a couple minutes and the 1st dose of albuterol is almost already run dry to no relief to the patient. I'm back on the phone to Med Control and get an order for "continuous albuterol administration -- no dosage maximum," which is technically not in protocol, but I'll worry about my two unit dose maximum when I get there. Move onto the stretcher and loading into the back of the ambulance, I see a FDNY rig quickly approaching from down the street, "Good," I think, my ALS has arrived. The two guys from the FDNY rig get out and walk up. Judging from the confused look on their faces, I know the question to ask them.

"You guys ALS?"

"No.... what's up?"

"Asthma.... bad. You guys know if they have ALS en route?"

"I don't think so."

I hesitate a second, thinking, and my thoughts reach the same conclusion as the FDNY EMT's who urges: "you guys just go, don't wait."

My thoughts exactly. Already a third of the way through the second dose of albuterol, and no change in the patient's status. She's still struggling valiantly for breath. 'This is probably my second worst asthma case I've ever done,' I think. The worst one ended with the patient intubated... luckily for the patient, I suppose, she won't, and can't be subjected to that today... at least not in the field.

I'm driving so I hop into the cab of the bus. I take a second to bring up the hospital notification number on the phone, hit the SEND button, hit the sirens, put the truck into DRIVE and we're off. I tell the ER what we're bringing them. Conveniently, we're only three minutes out. Arrival in the ER brings our rush into the trauma room and the "Green team" descends on our patient. Finally, quickly, she gets some advanced treatment and interventions. A happy ending to a frantic twenty-minute procedure of getting the struggling patient to the hospital, quickly and alive.

By the way, at the end of it, when my crew of three were bringing in another patient a little while later, a now freely-breathing young women in hospital gown gave us all hugs and thanks. Guess BLS isn't so bad after all. But the conclusion of the story is, this is the second time in a month when I thought I needed ALS and didn't get it. All ALS all the time is well and good, but how about all ALS when you need it, all the time? In a city like New York, you'd think that ALS would be available when needed. The facts of the matter are that FDNY*EMS does not use EMD dispatch, and does not work with the voluntary and volunteer organizations operating in the City limits. How many lives have been lost because advanced care was not sent where it was needed? How many patients received ALS for whom an accurate determination of need was not established by the dispatcher? How does the public allow shabby, poorly-run systems to continue to exist?