They put the "BS" in BLS

Don't go jumping to conclusions based on the title of this post. Yes, the BS stands for exactly what you think. I however, am not a disgruntle burnt out medic, aiming to complain. Not yet at least.

My agency prioritizes calls into three categories. Priority 1, which would be an unstable ALS patient, priority 2, which is a stable ALS patient, and priority 3, a BLS patient. Many of us have added a fourth category, priority 4, sometimes referred to as priority 5. Priority 4 patients don't quite meet the BLS criteria by our standards so they might be considered BS patients.

These patients seem to want to call us at the best time amongst our 24 hour shift, around 3am. There chief complaints range from a variety of medical emergencies, here are a few:
  • Cut finger
  • Can't sleep
  • Can't poop
  • Tired
  • Lonely
  • Scared
  • Can't find my car keys
  • Barrack Obama is going to win the election
  • I've had a headache since 10 o'clock
Yes, these are all real complaints. I also realize that a few of them could be symptoms of a truly emergent medical condition. Sometimes it is something that the patient will deal with all day, just until the point where they can't sleep. Once they can't sleep it becomes an emergency, and who wants to use one of the 3 cars in the driveway, at 2am, to drive them to the ER? So if they can't sleep, why should we?

Just in case you don't believe that these are all real 911 calls, watch this:

Here is a pretty good news story:

This dispatcher has had enough, watch this:

Here is a transcript from a story NBC ran on our system. I had the luxury of escorting a reporter in our ambulance, wish I had the video.

LEE COUNTY: For 3 months, NBC2 Investigators have been working with emergency services collecting calls and riding with paramedics. We discovered a large number of calls coming into 911 are for anything but an emergency, which puts your safety at risk.

911 operator: What is the address of your emergency?
Caller: We are at the corner of Edison and Cleveland-- 3 car accident at least with injuries

It's Friday night and multiple calls are coming into the 911.

But this story isn't about people who call 911 for a real emergency. This story is about the 40 percent of calls that aren't for an emergency at all.

Some examples:

911: What's your emergency?
Caller: Um, yes I locked my two keys in the car.

Caller: I'm depressed because [expletive deleted] Obama's going to get the thing
911: What's going to happen? Obama's going to get what?
Caller: He's going to get elected.

Caller: She needs to go to the hospital because she has a toothache

Caller: Yeah I ran out of gas.

Caller: I'm at the Chik Fil A on Colonial and I'm trying to get an ambulance to move and they won't move. I'm parked here in the heat, I'm about to need an ambulance myself.
911: So, you are not having a real medical emergency right now?
Caller: It will be if I sit here in this heat any longer!

The four days we rode along with EMS, only 2 cases were truly life threatening emergencies.

"Typically 911 is the first thing people think of, and it's the easiest thing because it's guaranteed," said Paramedic Robert Bertulli.

When people call 911 unnecessarily, it puts a strain on the system and puts your safety at risk.

"It happens all the time," said Bertulli.

When crews are tied up on a call for a stubbed toe or nosebleed, EMS must shuffle ambulances and your ambulance could be coming from farther away.

"Inevitably someone's going to suffer as a result of calls made that are unnecessary," said Bertulli.

Only 20-percent of the calls that come into 911 are truly life threatening emergencies - like heart attacks.

Forty-percent of calls are emergencies – not life threatening, but serious enough you shouldn't be driving to a hospital.

The remaining 40-percent of calls are not emergencies at all.[...]
I have a strong belief regarding these calls. I believe the most extreme are a little ridiculous. I think calls like these add to bad attitudes and burnt out personnel. I also thank God for some of them, because I wouldn't have a job if all we ran were true emergencies. I don't mind holding a hand here or there, if it means I can still have a job. Our agency would be able to cut our resources in half, if it wasn't for the priority 3 and "priority 4" calls. We are paid by Joe Citizen, so I am willing to respond for whatever he needs. I will do my job, and I will explain when not to call 911 to someone who apparently has no clue, but I'm not going to become disgruntle over it.

These calls also create this sense of "everything is bullshit" amongst some providers. On the way to a call I will notice some partners complaining before we get there. "This is going to be BS". I think this is dangerous because it puts you a step behind if it's a true emergency.

Think about it, if you are expecting a patient to be drunk and end up with a cardiac arrest, how much gear changing do you have to do? I like to expect the worst and be relieved when I get there. It's hard sometimes to do, but it works for me.

Also, think about how much you can do by just holding a patient's hand and reassuring them. How many lives you can save without having to do CPR. What I mean by that is, education. Maybe you can catch a suicidal teenager in their teachable moment. That means that they might be a little more receptive at the exact moment you are there. You could save their life and never even know it; or do you need a pin for your shirt collar?

Cartoons found at

There are good points on both sides of this discussion. Feel free to share your views.

****Update May 4, 2009****

Sure enough, after writing this, I have the greatest example of a shift. We work 24 hour shifts here, and I just ran six calls during my shift, and had zero transports. Here are what my calls consisted of:
  • The first call of the day was for a drunk lady that had a family that was sick and tired of her. They were stating that she couldn't drink anymore or she was going to kill her liver. The patient adamantly didn't want to go to the hospital, and this doesn't count as being a threat to yourself or others. Refusal #1.
  • Next we we responded to a possible man down at the boat ramp. We had no idea what we were even looking for. The dispatch notes stated that a man was dropped off by a boat at the boat ramp. The man's wife called through onstar, and she was not on scene. We ended up actually finding the guy, who was sitting on a bench waiting for his wife to give him a ride. Apparently his phone died and his wife was scared when she couldn't get ahold of him. Refusal #2.
  • Next up, a fender bender. Not much explaining needed here, no injuries to anyone on scene. Refusal #3.
  • Next was a pedestrian hit by a vehicle. This wasn't as bad as it sounds, the car was backing out of a parking space and knocked someone off their bike. The patient was a a law enforcement substation with a laceration on his elbow. He just wanted to get checked out. He knew he didn't want to go to the hospital. Thank you LE for having us dispatched for a bandage! Refusal #4.
  • Next up, another bicycle accident. Patient had a recent history of stroke, with unilateral deficits. The patient decided he wanted to get back on his bike. The bike didn't think it was time yet, and threw him off. The patient had some small lacerations to his ankle from the sprocket. He didn't want to go to the ER. Refusal #5.
  • Finally, epistaxis at 3am. Mild hypertension, nothing much else to explain here. He went POV. Refusal #6.
This isn't a regular shift, just thought I'd share it since it's so relevant.


Here is something I found on PubMed. It's a research survey on the geographical differential of ambulance use. Appropriateness is emphasized.

American Journal of Emergency Medicine, Feb. 2009.
Nordic School of Public Health, SE 402 42 Göteborg, Sweden.
AIM: The aim of this study was to analyze possible differences in the use of ambulance service between densely and sparsely populated areas. METHODS: This study was designed as a 2-step consecutive study that included the ambulance service in 4 different areas with different geographical characteristics. A specific questionnaire was distributed to the enrolled ambulance services. Completion of one questionnaire was required for each ambulance mission, that is, 1 per patient, during the study periods. For calculations of P values, geographic area was treated as a 4-graded ordered variable, from the most densely populated to the most sparsely populated (ie, urban-suburban-rural-remote rural area). Statistical tests used were Mann-Whitney U test and Spearman rank statistic, when appropriate. All P values are 2 tailed and considered significant if below .01. RESULTS: The medical status of the patients in the prehospital care situation was more often severe in the sparsely populated areas. In addition, drugs were more often used in the ambulances in these areas. In the sparsely populated areas, ambulance use was more frequently judged as the appropriate mode of transportation compared with the more densely populated areas. CONCLUSIONS: Our study suggests that the appropriateness of the use of ambulance is not optimal. Furthermore, our data suggest that geographical factors, that is, population density, is related to inappropriate use. Thus, strategies to improve the appropriateness of ambulance use should probably take geographical aspects into consideration.
*****End Update*****


Shaggy said...

We have a shortage of practicing medics. we would not have to have a shortage of practicing medics if we addressed the BS calls. Paying to have a medic to handle mostly BS calls is not cost effective, but that seems to be the case in most cities. Yes, on very uncommon calls, the BS dispatched call turns out to be something serious. Even most of those could still have gone via POV or BLS without any detrimental effects to the patient.
Expecting medics to diagnose AMIs, CVAs, and treat cardiac arrests with post arrest care, and yet feel they are not competent to decide if a patient needs ambulance transport is ridiculous. Yes, we see the high profile cases of medics who screw up in this regard. How many do we know who screw up providing care and just have bad driving habbits that are dangerous to the patient? With effective QI, this could be addressed.

Adam Thompson, EMT-P said...


Thanks for your response. While I agree with most of your statements, I feel the need to clarify. I'm not an advocate of BS calls, but like I said, I might not be logistically required or financially allowed if these calls didn't exist. It does seem like people are calling 911 for more and more things thses days. I'm completely against the use of emergency services as primary care. I think paramedics should be allowed to medically clear a patient in certain circumstances but it's the medics that would abuse this that would ruin it.

QI is where the answer lies, unfortunately my system is behind the 8 ball on Qi/QA. We are just now starting BLS responses using priority dispatching. I hope this works but have heard some bad things about the system. We will see.

Thanks again for your response, I always like to hear other opinions.


Shaggy said...

Our system is not behind with QI. We just keep it weak to not scare off anyone. If the provider feels the service is picking on him/her, that provider will move on to another service, and the original service will be short a provider. Even if that provider is a liability, we know the laws of averages are in favor of not getting successfully sued for many reasons. Thereore, it is easier to keep the provider than pay out in OT and wear down the existing crews. The command facility uses kid gloves as they don't want to lose a service to a competing command hospital.

Still, just because a few medics will screw up doesn't mean it should not be done.Are we not hearing this debate on intubation? If a medic screws up a med, do we yank all meds off the trucks? Of course not, we deal the medic on a personal basis AND check to see if engineering controls would not help prevent future occurances.
Just my take on it after doing too many BS calls. BTW, I noticed most of them were in the poor income areas, and it was not because they had no access to health care. They did. Stupidity or low IQ seems to be the correlation.

Shaggy said...

Here is a link to a story of my City EMS system doing BS calls. . I hope it can still be accessed.

Shaggy said...

I forgot to add, call volume influences the attitudes of the EMS provider. I worked urban and suburban EMS, and when I came across a patient in the suburban setting who should be seen, but not immediately, but did not have a PCP, or did not need an ambulance, but should still be seen, we happily offered transport. We also did not do that many calls and were even happy to do non-emergency transports. In the urban setting, where you do back to back calls the whole shift, you seem very irritated with the same type of patient and almost make them feel guilty for calling EMS. Someone made the accusation of racism, but that had no bearing as regardless of race in either setting, the patients were treated the same in that given setting.
I wonder if you have noticed this as well.

Adam Thompson, EMT-P said...

"Still, just because a few medics will screw up doesn't mean it should not be done.Are we not hearing this debate on intubation? If a medic screws up a med, do we yank all meds off the trucks? Of course not, we deal the medic on a personal basis AND check to see if engineering controls would not help prevent future occurances"

You are correct, but I am just telling you the way it is. I have been told by my superiors that we have to cater to the bottom 5%. This is why some things that could be trusted in mine or your hands will never be granted.

Intubation might be taken away from us as well. It's not something I agree with, but the research is not benefiting the skill at the moment. Well it's not benefiting our use of the skill. It all boils down to that bottom 5%; the ones that fail to use ETCO2, or who's pride is more important than pulling a missed intubation.

"In the urban setting, where you do back to back calls the whole shift, you seem very irritated with the same type of patient and almost make them feel guilty for calling EMS"

Absolutely. The busier one of our trucks is, the worse the attituted of the medic on it(again, Im generalizing). It takes a lot to keep from saying "what are you thinking?", or "you called for this?". I do a pretty good job at it myself, I think, and sometimes I have to remind my partners.

I think sometimes we have to remember, it's not our emergency. We are more educated on the subject, so even though we know it's BS, they may not. It's not our job to judge them or criticize. It may, however, be our job to educate them, politely.

Good discussion Shaggy!