Priority Transport

[OVeractiveBrain]

This is a common theme amongst prehospital providers, and is a recent source of debate. In particular, the call for non-emergent transport for patients manageable prehospitally (most of them) has been strong, especially in Connecticut. I hope to give some insight into reasoning and leave this open for discussion.

Note: "hot", "code 3", "priority 1", and "lights and sirens" are synonymous

Note: "cold", "priority 2", "flow of traffic", and "no lights or sirens" are synonymous

Priority responses both to and from the hospital are reminiscent of an older EMS system; the so-called "grab'n'go" era. Many providers, even new ones, maintain the need for priority transport to the hospital. Still, other systems attempt to activate only the necessary resources via EMD (for example, dispatching the medical engine hot, and the transporting ambulance cold until advised by the engine). I unfortunately have no actual data on the efficacy of systems. I know that at one of my services, a project of electronic data acquisition is to demonstrate that the central medical dispatching unit SHOULD be dispatching us priority 1, where they do not, since we are often upgraded by the FD. If anyone has preliminary data on response times and outcomes, Id love to see it. Since there are so many variables, I find it difficult to rely on any one source.

Personally, I lean towards the side of priority to the call, flow of traffic from the call. In my system we have a wealth of resources including an engine and an ambulance, sometimes another first responding paramedic, and the PD if we need it. I practice in an urban and suburban environment. We have the resources should we need them, we have the interventions and authority to use them via standing order, and the greatest response time is approximately 20 minutes. Unless there are some extenuating circumstances of the day or traffic, its not hard to get to any of our hospitals. I believe that I have the skill and diagnosing prowess to define a problem and fix it. Thusly, patients I can manage (nearly all of them) I take in flow of traffic. Until I cannot manage a patient, that is.

The exception to this rule is clear-cut CVA and trauma. In my service area we have both stroke alerts and trauma alerts. If I think some one is a candidate for fibrinolytics, I’m on a one. If I know the hospital will, trauma-team some one, I’m on a one. The only other cases are point by point; an ACS with hypotension (difficult to manage), pre-activated cath lab per MD order (even that im on the edge with), ROSC s/p Cardiac Arrest with complications, the patient is borderline stable and traffic is bad, etc. This is my own personal view on my patients, not a rule I suggest everyone follow.

A brief digression I feel is warranted. People sometimes associate "priority 1" with "blow through stop lights and annihilate anyone in their path." Priority responses merely ask for the right of way. My EMT partners are aware that priority means "drive the way you usually do, except now you can go around cars and through intersections." At American Medical Response (one of my services) we are required to stop at all red lights (including on priority) and the FOB limits dramatic forces on the vehicle. Priority 1 for me and my partners is not an insane bounce-a-thon to the hospital; rather it is an acceleration of the patient to the hospital. A 20 minute trans time can be reduced to a 10 minute trans time, or a 15 to a 10, or even a 5 to a 2, and safely. There is NO CIRCUMSTANCE which I can justify putting myself, the patient or my partner at risk by driving crazy. While lights and sirens may induce a heightened state of anxiety, a trained professional driver need not succumb to that anxiety. I note an anecdotal story of one of my friends, looking for me in every ambulance that passed, stating “all I saw was two guys not you, lights and sirens, looking so bored”. I consider that crew, experienced.

That said, there are obvious risks associated with priority transports. Even a hypervigilant driver puts the crew at a greater risk priority 1 over priority 2 responses. While a good driver can reduce the risk, it is ever present. I have seen minor MVAs be caused as a result of cars obeying the law and pulling to the right and stopping (into each other) or as a result of crossing the double yellow lines. The major reason to NOT go priority 1 is the risk of safety, or the inability to manage a patient as a result of being thrown around.

Different systems can influence decisions made. In a rural setting, with few cars in opposing traffic and usual long distance transports, priority one can be made without much risk. The access to a helicopter may not always be available, and speed is necessity. The counter argument is, however, that in a rural setting priority one may not be necessary if there are so few obstructions. A rural setting provides more obstacles: frequent traffic lights, heavy traffic, limited access to large or multi-laned roads, etc. This increases the risk of and need for priority transport.

Id like to hear people’s opinion on the subject, in particular their own personal beliefs towards priority transport. Im sure there will be many debates over the individual points ive made. Since they aren’t backed by anything but anecdotal evidence, they aren’t terribly believeable. In addition to people’s own view on priority transport (and why they feel that way), if anyone has any data on patient improvement or crew/public safety, id also love to see that as well.

Discuss.

Overactive

[BEorP]

My opinion is that, at least in the service where I did my field placement, over uses priority responses. (Although technically they do not tell you whether or not to use L&S, but if the calls is dispatched at one of the two highest priorities you will be expected to.) As far as I understand, the way that the dispatchers ask if the person is breathing alright is, "are they breathing normally?" Unfortunately this leaves open the option of someone who has the flu and a sore throat or cough, who is really not breathing normally answering "no" to this question. By answering "no" they will then get a response that includes the fire department (not standard on all calls here) and will include an ambulance running L&S.

I do not have the road experience to back this up, but I think that a couple more questions could help to identify the need for a priority response in this situation. If the person calls because they are short of breath then sure, make it a priority response. But if the person calls because of feeling generally unwell then I think it needs to be clarified more as to whether or not they (or the person calling for them) would actually say that they are having trouble catching their breath (figure out how best to phrase it so that we can get the appropriate answer as to whether or not someone is truly short of breath).

Most likely the reason that this system has not been changed is a CYA thing. Better to make a big deal out of the flu 500 times in one year rather than miss a priority response on a single person who is really short of breath.

[strippel]

I see very little reason to go to the hospital with lights and siren on.

In my full time system, we have priority dispatching (Clauson via county government dispatchers). Callers are questioned, and calls are given a nature code of 1,2, or 3. One is an ALS emergency Chest pain, overdose, diff breathing, unconscious), and we CAN respond lights and siren. Class 2 is BLS emergency, (vehicle accident, fall victim) and we CAN respond lights and siren. A class 3 call is non-emergent in nature, and no lights and siren are to be used. If the class one call is severe in nature, our supervisor, or an engine company may also be dispatched. Many will respond non-emergent to priority calls. We are a city/suburban service.

That said, I can count on one hand the number of times I have an emergency response to the hospital in the last few years. Our facilities are pretty close, and patient care will not be effected by the few extra moments.

My part time is somewhat different. All calls are dispatched the same way, and most providers like to respond with lights and sirens. There is a movement to "slow" responses", but nothing organized. It is just a group of tenured providers with common sense.

Transporting to the hospital is different. The area covered is very large, with heavy traffic. There are only two hospital in county, out of county are much farther away. Many providers will use lights and sirens, as it can easily save a few minutes. This is a suburban/rural service.

I can't easily see the time savings (in safety and patient care), but some of my partners think they can.

[vs-eh?]

As always this is a fairly subjective issue in my opinion, and based on your crew's system...

Generally speaking a (subjectively urgent) trauma should get to an appropriate facility urgently. A query CVA (based on your systems guidelines and that meets your systems guidelines of urgent transport) should get there as well. I would also add "urgent pregnancy" like say breach or meconium present or something...There are other cases as well...

Generally speaking it (again) is up to the crew and what they feel comfortable with treating en route. It is not "break neck" speed to the appropriate hospital....It is getting to a hospital more quickly than following normal traffic would.

[1EMT-P]

I think it all depends on the patient's condition. If you have a critical patient ( AMI, CVA or Trauma ), then yes lights & siren maybe indicated.

[fiznat]

I agree with you Dustyn in that NO response to or from the hospital is worth risking injury to the crew or other drivers on the road. Priority one responses, all of them, should be very controlled, minimum-necessary types of drives.

With that said, I will play devil's advocate a little bit here.

How well are we equipped to absolutely diagnose etiology on a majority of our critical patients? I understand that there are a large number of cases where we are pretty damn sure what is going on, and fairly well versed on what it is that the hospital will have to offer that patient. Still though, I wonder if some of us might employ a bit of humility in this respect, and - in accordance with our level of education and equipment available - defer to the ED a little more often.

I'm as realistic as the next guy, though. I understand that 5 or 10 minutes added to transport time will, for 95% of our patients, really make very little difference. Still though, it might be a little bit arrogant to assume that we, with our limited resources, will be able to clearly define the line between those for who it will matter and those for who it will not. If the rule is always to err on the side of the patient, why is it not the same in this case? ...Especially if we concede that "priority one" is always to be driven in a responsible manner.

Types of presentations that I imagine might go priority one:

Trauma

CVA (with a reasonably recent onset)

AMI

Shock

Refractory or unknown AMS

Refractory SOB (asthma, anaphylaxis, etc)

Non-narcotic, significant overdoses

Newborn in distress

Uncontrollable hemorrhages (internal or external)

Failed airway

Routine calls near shift change/lunch time

etc

[JPINFV]

Routine calls near shift change/lunch time

Just wondering, does this depend solely on time of day, or the menu at the destination?

yes, I get the sarcasm.

[frontcrawl]

Good point, in fact NO EMS personnel should EVER not be making such important, critical decisions.

We should send a helicopter, nay, a V-22 Osprey to each and every call, just in case.

What exactly are the limits to this so called rule that says we must always err on the side of the patient?

What about cases where we come to the conclusion that the scene is unsafe? What if... What if...

Or where resuscitation efforts are terminated? What if... What if...

[mediccjh]

The only times I prefer transporting a patient lights and sirens:

CVA with <6hr onset (per the UMDNJ Brain Attack Team Guidelines)

Trauma (only a surgeon can save them)

AMI (They need a cath lab ASAP..I may be able to control the pain, but I can't Roto-Rooter their vessels)

Failed/Uncontrollable Airway

[Dustdevil]

Minus 5 for posting in an inappropriate forum.