ALS using Lights and Sirens back to the hospital

[VentMedic]

Why, even with all the protocols in place, new technology to monitor with and the availablity of hospital Stoke Teams and Chest Pain Centers, are lights and sirens (Code 3) still used for almost every "priority patient" going to the hosptal?

This is true especially for Cardiac Arrest patients.

Paramedics have agrued and are correct that in many situations in the field they are doing everything that can be done initially for the patient. So why are they still in such a hurry to get to the ER?

The crew should have ACLS and protocols. For Chest Pain or Stroke, the appropriate hospital people and teams still have to be notified and respond to keep the interventions going that should already have started with the Paramedic. Even with immediate notification of the hospital, there will still be a short delay going to the cath lab or CT scanner regardless of those 2 - 3 minutes saved by the ambulance.

So why all the noise? I won't even mention speeding.

[Just Plain Ruff]

I spend a lot of time in Jacksonville and my office is between Baptist hospital (quite a good hospital with almost every service you can imagine for adults and peds) and St. Vincent's Hospital with nearly the same facilities. Neither are trauma facilities.

What I see is a lot of transfer services (Century and others) that run l&S many times. I have seen BLS Century ambulances running hot on the highway which I just don't understand because Century has a lot of ALS ambulances I believe.

I have close relationships with some ER Staff at St. Vincent's as well as St. Luke's hospital here in Jacksonville as a matter of my job duties. None of those contacts I have say that Century and others have critical patients as often as I see them running hot.

Heck, St. Vincent's has their own critical care transport units I believe so I'm not sure what the requirement for running hot is down here.

I could be getting erroneous information but today I sat around my office day dreaming(should have been working) and saw no fewer than 10 ambulances of differing services from Jacksonville Fire to century to ASI(that's all I could read on the side they were goin so fast) that were running hot on the stretch of highway I can see.

I have worked in nearly 11 different ambulance services and never have I seen so many ambulances (transfer ambulances I believe) running hot and this is a day to day occurrence.

What am I missing here? Am I seeing things or is there truth to this?

Is it just that the transfer crews are so incompetent or unsure of their job that any cardiac transfer gets lights and sirens or is it deeper or more problematic?

[zmedic]

I think emergent response is still indicated for events such as suspected stroke or MI, where even a five minute difference can be a big difference (MI you lose 1% of infarcted area per minute) I’ve also had patients that in the course of the ten minute ambulance ride went from being awake and alert to unconscious. In most urban situations emergent driving saves very little time, though on long transports the savings in time may be more dramatic (I’ve had 45min emergency transports where I probably saved ten minutes from slower traffic pulling over for me.) But I will agree with you that 90% of emergent transports are unnecessary. They put our lives at risk and risk the live of our patients and people on the road. I also think it's sorta funny that a lot of these patients who come in emergent then sit on the pram for 15min while the nurse triages and looks for a bed.

[Just Plain Ruff]

To further this discussion:

I've spent 6 months in Miami at the busiest trauma center in the country(some would argue that statment but the hospital is who says it) and every patient that I saw bringing a patient in woudl come in hot. I watched them many times and the patient was no-where near critical enough to warrant L&S.

I spent 1 year in Tampa at Bayfront Hospital and 1 in 100 or so ambulances came in hot.

In Queens New York at the New York Hospital Queens every ambulance came in hot, even the ones coming in to get grandma for a transfer to the NH. I think it might be a New York thing.

In Patterson New Jersey, at St. Josephs Hospital they all came in hot it seems but that might be because it was so unsafe anywhere in Patterson that they wanted to be a moving target.

In Colorado Springs, AMR is king there. Limited L&S.

Olathe, KS - Olathe Medical Center - limited L&S too.

Detroit Michigan(11 months assignment) limited L&S but these were smaller hospitals and not actually in the downtown area of Detroit.

Dubuque Iowa - 1 week assignment - limited L&S

So what are these statments saying, Why in some areas they run hot all the time and others they rarely use it? I do not know that info.

I think this is a good topic to discuss.

[akroeze]

Where I went to school we would go L&S all the time but where I got a job we would rarely run L&S.

[Just Plain Ruff]

I guess what I'm asking is why is it so different around the country?

What do we think the reasons for one area going L&S all the time and another area being very limited on this?

Is it lack of training?

Is it that the ones going L&S all the time just have not been in a significant accident to where it requires them to re-evaluate their position on this?

Lots of questions in my mind.

My opinion, of course you know you were going to get it, is that there are very limited reasons for us to go L&S. It's proven to not save time, or just save a minute or two.

It's proven to be a liability and dangerous.

What about the services who use the lights but not the sirens. Can you say dangerous.

One thing that really always made me chuckle is the fire departments.

I called in a trash fire in an isolated dumpster at 3am(don't ask why I was up so late and driving around). About 100 feet from any building and the top doors that cover the dumpster were closed so all you saw was smoke and not fire.

The fire department responded with Lights and sirens and their station was 3 blocks away. I had to laugh.

The fire departme

[VentMedic]

One of the reasons we started our own Adult (already had the Neo and Pedi) inter-facility ground transport team was the L/S issue. We would call for ALS transport maybe just because of a medicated drip. The patient is either being transferred for specialized services at one of our affiliate hospitals or for insurance reasons. The patient is stable on release from the our hosptial, but we notice the ambulance leaving our driveway Code 3. We weren't sure who authorizes the L/S, why and where the liability might fall if something happened. When we inquired to the ALS ambulances services; "Paramedic's judgement to call for L/S if he/she thinks the patient is unstable". That left us with more questions about the competency of these crews and how they determined our patients were unstable.

So, my question is why?

With all of the improved technology, skills, protocols and "trust"granted to the paramedic, why are L/S still used so much going to the hospital (or another hospital)?

What is the rational for turning on L/S if you are ALS?

I will comment on some of the busy Florida BLS teams and L/S because I am not shy about asking a crew about this that is coming in to pick up a routine transfer like the devil is chasing them. They are told to "expedite". This is perceived by some as permission to run Code 3.

[AnthonyM83]

I'd say 99.5% of LACoFD's ALS calls transport code 3...occasionally it's an "easy code 3". I think the main reason is to get the paramedic squad back in service for the next call (some areas are seriously overworked)...even though CA ambulance handbook specifically recommends not going code 3 for certain conditions, like cardiac as to not aggravate condition.

In the area I work, depending on time of day, going code 3 will SIGNIFICANTLY reduce transport times, especially when they're already extended due to hospital diversions.

Of course, if the ambulance crashes, it's the employee's and ambulance company's headache...the fire/medics just jump on a different ambulance, continue on with their shift, and don't have to think twice about it.

Some of the smaller departments in the area will actually make legitimate LS or no LS decisions. Refreshing....and ummm more legal.

[JPINFV]

My old company offered ALS services [RN, RT, or RN and RT trips were considered ALS]. Out of all the ALS transports I did, I transported a whopping 2 code 3 over 2 years. One was a patient who was paced [implanted pacemaker failed in the AM. He had a transvenious pacemaker put in and was being transfered to have surgery to fix/replace his implanted one] and the transferring hospital had done just about everything to screw up the transvenous pacer [they had it turned all the way up to maintain capture]. While we were prepping the patient [RN getting information, getting the patient hooked up to our monitor, etc], the hospital's RN ended up bumping the pace maker wiring causing it to come unplugged.

The second was an RT transport for a possible leaking trach. We got about halfway to the original destination when the RT noticed that the destination was changed in the RN notes. As we were getting off the freeway to call the transferring SNF, the patient desated. Of course, the EMT in the back with the RT "didn't feel comfortable" bagging the patient if he needed to.

[Traumaking07]

You can say that the ems uses lights and sirens for the most b/s reasons like the drunk parked is butt on the sidewalk that you know is going to be a fun and BUMPY ride to the hospital.But when you say lights and sirens about fire department using llights and siren at three am for a stupid dumpster fire 100 ft from and building ,well I have to say we as a responding unit to that b/s fire call dont realize what it is until the first unit gets on scene so yes even three am light and siren down the road due to the civilian the just reported that stupid fire is prob trying to get to dunkin donuts to buy coffee and not paying attention to the fire truck or ambulance responding to that bullshit call that it was just dispatched too.