1. Trauma patients entrapped with required extrication.
2. Patients with compromised or obstructed airways.
3. Full arrest cases.
4. Patients exhibiting signs of hypoxemia (respiratory distress, restlessness, cyanosis, altered LOC).
5. Unstable cardiac rhythms.
6. Chest pain unresolved.
7. Chest pain resolved prior to arrival; upon arrival; or resolved when on-scene of BLS/ILS
8. Patient exhibiting signs of decompensating shock (B/P < 100, diaphoresis, altered LOC, tachyphnea).
9. Unconscious patients.
10. Any case deemed by the responding agency or Medical Control as beneficial to patient outcome.
11. Pediatric cases with any of the conditions listed above.

1. If the primary response area (**) is covered by any combination of BLS, ILS or ALS, the highest level of service shall be utilized for any patient whose condition warrants advanced level care as indicated in item A, 1-11, listed above.
2. When determining need for assistance from an advanced secondary or tertiary provider, consideration should be given to the following.

a. Transport time to hospital
b. Rendezvous site
c. Availability of resources
d. Interventions needed (i.e., defibrillation, airway, drugs)
e. Transport of the patient should not be unreasonably delayed for transfer of care.
f. Decisions for or against requesting advanced assistance should be based on the patient's best interest. "Err on the side of the patient."

3. Regardless of response jurisdiction, if two different agencies with differing levels of care are dispatched to and arrive on the scene of an emergency, the agency with the highest licensure level shall assume control of the patient(s).

C. Transfer of care

1. Safety will be emphasized throughout the intercept and transfer of care.
2. Patient transport should not be delayed.
3. Neither the assessment nor the transfer of care can be initiated if it would appear to jeopardize the patient's condition.
4. The transfer of care must occur under the immediate direction of on-line Medical Control.
5. Ambulances should rendezvous at the site predetermined by operating procedures or unit-to-unit radio contact.
6. Rendezvous should not take place on heavily traveled roadways. Sites considered for rendezvous should be parking lots, safe shoulders or side streets.
7. Patients should not be transferred from ambulance-to-ambulance. The higher-level personnel, with proper portable equipment, shall board the transporting vehicle and oversee patient care with the assistance of the requesting agency's personnel.
8. The higher-level personnel which have boarded the transporting ambulance will determine the transport code for the remainder of patient transport (i.e., Code 3 = emergency transport with lights and siren in operation; Code 1 = transport with all normal traffic laws observed and no operation of lights and siren).
9. Pertinent patient information should be transmitted to the intercepting ambulance prior to rendezvous (i.e., nature of problem, need for intubation, defibrillation, drugs, etc.).

* "In-Field Service Level Upgrades" as referred to in this policy imply services above the level of care provide by the initial responding agency.

** "Primary Response Area" is the immediate coverage area of an agency.

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