Lights and Sirens Response/Transport

[systemet]

Since we are on the topic of L&S, I have a question for all. You are dispatched to a rural hospital for a confirmed STEMI going to the big academic center for a cath. VS are stable (don't worry about specifics). Do you respond to the sending facility with L&S?

If one of the mods wants to make this a new topic, feel free to do so.

Assuming I get to decide (and I'm not told by dispatch), it would depend a little on the distance to the rural hospital. If it's a few hundred meters from a rural ambulance station, probably not. If I'm coming from 45 minutes down the highway, I probably would.

It's also a little dependent on how rural we're talking about. If I'm going to be at an academic center in an hour cold, and I can save 10 minutes driving hot on a decent highway, I'd probably do it. If it's just "rural", and this is a 20 minute trip, not so much.

I remember there being quite a few studies a few years ago looking at transporting patients to "cardiac centers" versus non-PCI hospitals, and then doing secondary transfer (something in Denmark particularly, DANAMI? Wasn't there another around the same time in the states, CAPTIM?). They seemed to suggest that it wasn't that time-dependent. But I've also seen data from cardiologists showing that even for PCI, early revascularisation has much better outcomes. So I guess it depends a little on the patient, and how old this STEMI is. If it's already a few hours old, perhaps there's less benefit from a rapid response.

No one's going to bother telling me until I get to the hospital, but it would be interesting to know why they've chosen to go with PCI instead of 'lytics, if they're rural. I'm assuming there's no cardiogenic shock here, so maybe we've had recent surgery / trauma / prior CVA?

[Kiwiology]

You are dispatched to a rural hospital for a confirmed STEMI going to the big academic center for a cath. VS are stable (don't worry about specifics). Do you respond to the sending facility with L&S?

Um, duh, yes because I'm up front driving fast using the new steering-wheel mounted siren control because it's so important right?

More than likely not but at most I'd turn on the red lights and use the siren at intersections; which is overwhelmingly what we do here.

Now, while we're waiting for the latest Trop-T and CKmb to come back on this bloke and for the nurses to fight over which one is going to come with us I'm going to nick into the Resident Medical Officer's lounge and get something to gnaw on, I don't have any body fat so it's very hard for my adipose tissue to release stored triglycerides which don't exist for beta oxidation into pyruvate and eventually ATP when I get hungry .... you wouldn't want me flaking out halfway to Big Academia now would you?

Aw shit, that sounded a lot like basic science, we're going to have you in the corner aren't we ....

[triemal04]

Since we are on the topic of L&S, I have a question for all. You are dispatched to a rural hospital for a confirmed STEMI going to the big academic center for a cath. VS are stable (don't worry about specifics). Do you respond to the sending facility with L&S?

If one of the mods wants to make this a new topic, feel free to do so.

Depends. Is the patient actually ready to be transferred? I mean, can I go in, get report from the sending Doc and nurse, transfer the patient to my gurney and walk out, or are they still working on all the paperwork?

If they are ready, then yeah, I'll pop the lights on. Still won't be driving that fast, but it's useful to clear intersections and avoid having to stop. If they aren't ready, then no. What's the point of risking myself, my partner and the little old lady driving the '85 Caddy who can't see over the steering wheel when I'll just be waiting at the ER?

There was a recent study that looked specifically at STEMI treatement and outcomes (I think it was just STEMI's) and EMS and ER responce times. What they found was that what actually mattered was decreasing the time once the patient got into the ER. I still don't think that means we should dawdle on scene for some calls, but if the biggest delay is something we can't control or fix...

And to answer the original question, I won't say it's the only time, but the best time to be taking a patient to an ER emegently is when they need a time sensitive intervention that is not available in the field. I think that's about the only time where it's been shown that going with lights&sirens actually mattered.

[HellsBells]

Assuming I get to decide (and I'm not told by dispatch

Actually, I was going to comment on dispatch here. But, before I get started, I'm not trying to rip on dispatch in general, but relate some personal experiences.

Our dispatchers are hired as laypersons (generally) and trained on the job. They use the medical priority dispatch system (MPDS). So obviously they have to follow the directions as predetermined by the card system. Now, this system is alright if the dispatcher can interpret the meaning of the cards adequately, but due to profound lack of any medical knowledge, they can't. Its amazing the sheer number of pts who are allegedly "not breathing normally" or are "clammy" as per dispatch, but have compliants completely unrelated to those 2 modifiers

Furthermore, we have a standing policy where a Fire Engine Co-responds on all Delta or Echo responses. This policy drives me crazy. In the vast majority of Delta calls the Fire Dept is sent away before, or seconds after they arrive on scene. This of course pads the Fire Depts stats and ensures funding, but puts all responders at increased risk by adding a Fire Engine to the L/S response.

Anyway, its to the point now where I will choose how to respond based on the notes written by dispatch on the call, not the bravo, charlie, delta, etc determination.

[DFIB]

I think that we all agree that L/S are a bad idea on a regular basis. But a couple of things come to mind for me...

First, I wonder if any of the studies have been done in areas where emergent transport triggers the the traffic signals ahead, clearing the intersections ahead of the emergency vehicles? I've ridden once, I can't remember where, maybe Denver, where they had this and it seemed to make a huge difference over L/S alone.

Also, in some of the places that I've worked, L/S had a larger impact on my ER response than on the traffic en route.

I'm not exactly sure of the dynamic, but I've called in with patients, for example, a gunshot wound (rural service), "This is Dwayne, I'm en route with a 22 year old male GSW, 90% traumatic amputation to left humerus secondary to 12 g gunshot wound, significant loss of blood prior to EMS arrival, pt has thoracic damage to effected side, unknown depth of those pellet wounds. Pt is unresponsive at this time, B/P 66/0, resps 36, intubation imminent, yadda yadda yadda..."

We arrive at the ER to...nothing. Wheel the pt inside to find two nurses hanging out by the radio, doc is in bed, RT/Xray haven't been notified, nothing. They see my pt covered in blood and freak out saying, "Why didn't you tell us that he was critical!!!" Really? That radio report failed because I didn't say the word 'critical'?

Do you work in my area? I hate running a basic unit with patients that definitely need ALS and have to go look for the Doc upon arrival. We started running lights and siren all the way to the door and leave it screaming until the patient was offloaded. This really and I mean really pissed in their post toasties. We still run the siren to the door so they know we are in a time sensitive situation but don't leave it on while we offload. Now when we run the siren to the door the Docs are usually up and waiting.

We most often run lights with no siren and just use the siren to get other vehicles to yield. Or drivers are some crazy SOB's. Poorly trained, rough as they come but avoid swapping paint. They scare me just about every run. I wear a helmet at all times in the ambulance because I got tired of cracking my head while tossed around in the back. My most common communication with the driver is "we are not in a hurry".

That said, traffic is horrible here and we frequently spread the traffic on two lane highway with no shoulders and drive through the middle. Lights and sirens save us a considerable amount of time but our driving conditions are weird compared to the US.

Our dispatchers are hired as laypersons (generally) and trained on the job. They use the medical priority dispatch system (MPDS). So obviously they have to follow the directions as predetermined by the card system. Now, this system is alright if the dispatcher can interpret the meaning of the cards adequately, but due to profound lack of any medical knowledge, they can't. Its amazing the sheer number of pts who are allegedly "not breathing normally" or are "clammy" as per dispatch, but have compliants completely unrelated to those 2 modifiers

We don't have a local dispatch. Most local 911 calls come in directly to the station and the person receiving the call is the same person going on the call so we don't spend a lot of time on the phone. We get a lot off calls where a cab driver stops by the station to inform us there has been a collision. Imagine what that does to our ETA on the scene. Occasionally we will get dispatched from the state capitol because someone called them instead of us.

[Richard B the EMT]

FDNY EMS EMD uses a MPDS type system developed in-house, but as I see it, comparable to Dr. Clawson's. We have at least 50 call types, and 9 different priorities pre-assigned to them. High Priority calls always get full L&S responses. Cardiac Arrests, obviously, are Priority 1, L&S response, 3 teams (Certified First Responder-Defibrillator Engine, BLS and ALS ambulances) and an EMS supervisor. A flat tire is a Priority 9, NO L&S, actually placing the ambulance off service until either a spare ambulance Can be brought to them, or the tire mechanic's truck arrives to change the flat tire.

I don't know if it is a New York City or NY State "thang", but we're taught that when we arrive, technically, the "Emergency" is over. Calls that had, due to their type and priority, an L&S response would have the crew's decision as to using L&S to bring the patient to the hospital, on the reverse, if no L&S on response, no need for them during transport.

I'll personally shoot someone responding to a crew with a flat using L&S, unless the first crew has a critical patient on board. Edited for spelling

Edited February 9, 2012 by Richard B the EMT

[jonas salk]

We have Ontario's DPCI 2 system. The call taker asks a few questions and then assigns a priority, code 3 or code 4 for 911 calls. Code 4 is L&S, code 3 is not. One of the questions the call taker asks is "is the person breathing normally". A surprisingly enough the majority of people will usually answer no. This makes the call an automatic code 4 SOB, and with it fire gets tiered.

We don't really have much option, if a call is classified as a code 4 we are supposed to drive L&S. Personally I hate driving code 4 for BS calls and will typically leave them off as long as possible. I'll also turn them off as soon as I get on side streets.

[Richard B the EMT]

I'm not exactly sure of the dynamic, but I've called in with patients, for example, a gunshot wound (rural service), "This is Dwayne, I'm en route with a 22 year old male GSW, 90% traumatic amputation to left humerus secondary to 12 g gunshot wound, significant loss of blood prior to EMS arrival, pt has thoracic damage to effected side, unknown depth of those pellet wounds. Pt is unresponsive at this time, B/P 66/0, resps 36, intubation imminent, yadda yadda yadda..."

We arrive at the ER to...nothing. Wheel the pt inside to find two nurses hanging out by the radio, doc is in bed, RT/Xray haven't been notified, nothing. They see my pt covered in blood and freak out saying, "Why didn't you tell us that he was critical!!!" Really? That radio report failed because I didn't say the word 'critical'?

Did you give them an ETA, or arrive several minutes prior to the given ETA?

My region doesn't usually have direct contact between field crews and the ERs, unless someone direct dials with their cell phones, as this is usually handled by dispatchers doing the "note" (notification). I had one expeience where, while making a "note" call to the ER, the person I spoke with was adamant I give her the patient's blood pressure. In and of itself, probably not unusual.

What made it noteworthy here, is that I was calling in: "Patient is a 65 year old female in full arrest, CPR is in progress, and we have an ETA of 7 minutes"

"What is the patient's pulse rate and BP?"

"I say again, the patient is in full arrest with CPR in progress, ETA now 6 and a half minutes."

"But what is the pulse rate and BP?"

"Full Arrest, CPR being done?"

"Pulse rate? BP?"

I gave up.

"Pulse rate zero, BP zero over zero."

"Thank you."

(On radio) "Base to unit 5, uncertain of the note, as person I spoke with insisted on vital signs. You may be coming in cold to them."

"5 to base: is a copy, we'll attempt to handle on our end on 81 (arrival at hospital)."

I think they finally moved that person off the ER "hot" line.

On a historical note, if I was told correctly, it was only when a crew was bringing in a critical, that they were allowed to blast the siren within a block of the ER, back when buildings were nowhere as well insulated against outside sounds. It may have only been a half minute warning, but it has to have been better than the door opening, and hearing "a little help here!" cold.