Re: transport of patients to hospital using red lights and siren

July 9, 2009

From Pennsylvania:

Table 1- Medical criteria for emergent lights and siren transport

1. Vital signs (patients >8 years old)

1. Systolic BP <90 mmHg with possibly related disease or trauma

2. Respiratory rate >36/min with patient as relaxed as possible

3. Respiratory rate <10/min

2. Airway

1. Inability to establish or maintain a patent airway

2. Upper airway stridor

3. Respiratory

1. Severe respiratory distress unresponsive to BLS/ALS treatment

4. Cardiovascular

1. Cardiac arrest

2. Severe, uncontrolled hemorrhage of any cause

5. Trauma

1. Penetrating wound to head, chest, or abdomen except for

obviously superficial wounds

2. Two or more suspected proximal long-bone fractures

3. Major amputation including two fingers, three toes, or above

wrist or ankle

4. Penetrating or blunt neck trauma except obviously mild or

superficial injury

5. Neurovascular compromise of an extremity

6. Neurologic

1. Glasgow Coma Scale score <13, only if acute change of any cause

2. Seizure activity not controlled by BLS/ALS treatment

7. Obstetric

1. Intrapartum emergencies including, but not limited to, cord

prolapse, premature labor, and arrested delivery

8. Pediatric

1. Upper airway stridor

2. All patients <8 years of age individually based on the mechanism

of injury, degree of distress, and the EMS personnelï¿½s experience with

patients of this age; when in doubt, seek advice from medical command and/or

transport emergently

9. Other

a. Emergent transport should be used in any situation which the most highly

trained EMS provider believes that the patient's condition could be worsened

by delay equivalent to the time that could be gained by emergent transport.

In all cases using this option, documentation of the reason for this on the

trip must be recorded.

>

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> does anyone have a P&P regarding the use of lights and siren to

> transport a patient to the hospital ..specifically..what types of

> conditions suggest this response..thanks for sharing ht

> - --

> H.T. FILLINGIM B.S. CCEMT-LP

> FISHER COUNTY HSOPITAL DISTRICT EMS

> ROTAN, TEXAS 79546

>

July 9, 2009

Oh my! I can't let this go by without comment. This hits a nerve with

me, and I have to speak out.

RANT WARNING! If you're not interested in some politically incorrect

statements and some criticism of our profession, hit the delete key.

Now, I recognize that HT asked for some guidelines about Code 3 transport,

and obliged by posting the Pennsylvania policy. So what I'm writing

has NOTHING to do with HT or . Whether this is the STATE OF

PENNSYLVANIA policy I don't know, but since I now live in a state that has STATE

MANDATED policies and protocols, I am able to accept that this egregious policy

is probably the one promulgated by the State of Pennsylvania. If I'm

wrong, correct me. I have a real prejudice against state mandated policies, so

I admit that right up front.

This " policy " speaks volumes about how we deceive ourselves in EMS about

what we do. This also speaks volumes about how BAD medical direction is in

EMS. I don't seriously think that doctors write most of this crap. Most

of the time medical directors glance at these things and just sign them.

Yep. That's the ticket. Of course there are exceptions. I know some

great medical directors, but there are many more that are nothing but drones,

who have no real knowledge or understanding of emergency medicine, let alone

prehospital emergency medicine, and they help perpetuate the sort of crap

that's institutionalized by this " Pennsylvania " policy. Don't think that

there are not equally egregious policies in place in Texas. Please read down

for my comments, which I warn you are somewhat disrespectful of those who

wrote this policy. If you disagree, then I welcome your thoughts IF you can be

rational and reasonable. I may not be right about all of it, but I think

I'm right about most of it. And NONE of my comments are aimed at

Bledsoe. He only passed this along to us, and thank you, , for doing it.

So, if you are interested in my not politically correct comments, read

down.

GG

>

> From Pennsylvania:

>

> Table 1- Medical criteria for emergent lights and siren transport

>

> 1. Vital signs (patients >8 years old)

>

> 1. Systolic BP <90 mmHg with possibly related disease or trauma

> 2. Respiratory rate >36/min with patient as relaxed as possible

> 3. Respiratory rate <10/min

>

GG: UMMM. I thought that basic EMTs could assist ventilation when

respiratory rates were outside the fences. I also thought that EMT-Inte

rmediates and Paramedics could do some things to help with hypotension. Yes,

there

are some times when it's clear that the patient needs to be in the OR NOW,

but the criterion does nothing to address those cases. So medics are

assumed to have no judgment, verdad? BTW, WTF does " Respiratory rate >36/min

with patient as relaxed as possible " mean? Should we employ aroma therapy?

Perhaps soft music and poetry? If you don't attend to your patient's

ventilatory status, he'll be AS RELAXED AS POSSIBLE before you know it!!! He

may even STAY relaxed for hours afterward, until rigor sets in. After that,

they relax again until embalming.

>

> 2. Airway

>

> 1. Inability to establish or maintain a patent airway

>

GG: Wouldn't one have to know what the tools available were? How many

times are we completely unable to establish a patient airway? If we can't,

do we REALLY THINK that running an anoxic patient Code 3 to a hospital is

going to be the solution? Something here does not compute. Airway is

probably the MOST important thing that we attend to, and we devote a pittance of

training to it. Stop and think about your EMT and Paramedic courses. How

much time was actually devoted to the " difficult airway? "

>

> 2. Upper airway stridor

>

GG: Gee. What is that thing attached to the wall with a plastic

flower pot hung under it and a bunch of tubing running out of it for? Anybody

here know how to use that thing? Oh, I guess not. Hit the Lights and

Siren and put the Pedal to the Metal.

>

> 3. Respiratory

>

> 1. Severe respiratory distress unresponsive to BLS/ALS treatment

>

GG: I guess if you can't ventilate your patient using all the bells and

whistles you OUGHT TO HAVE BUT DON'T in most services, then your next choice

is try to get somewhere there's a competent airway manager and hope your

patient survives the trip. " Respiratory distress unresponsive to BLS/ALS

treatment covers miles of ground. " Are we talking about mechanical

obstruction? Neuromuscular problems? Reactive airway disease? Chronic

airway

disease? What? Of course, if you can't get your patient ventilated, then I

guess you make a run for the border. Bottom line, you're transporting a

dead patient Code 3.

>

> 4. Cardiovascular

>

> 1. Cardiac arrest

>

GG: Oh yeah. If we have been working them for 20 minutes in the field

and they haven't got up and tap danced yet, all we need to do is expose them

to the wonderful sound of a Whelen and a rock-and-roll trip to the ER where

the nursies and docs will work their magic and bring them back

instantaneously. They can do SO MANY THINGS THAT WE CANNOT DO IN THE FIELD!!

And on

the way, the medics in the back will get a free agility practice and test to

see how many compressions a minute they can do while bouncing off the walls

and ceiling. Videos of this are very popular on YouTube. Chiropractors

promote this policy because they get so many medics as patients after a good

Code 3 while doing CPR trip.

It also makes the medics feel REALLY good afterward, in spite of the fact

that their patient was dead when they started the trip and probably, just

like and Abraham Lincoln, remain dead to this very moment.

They DID SOMETHING and it got their adrenaline going like nothing except a

good snort of coke. Hey, it's really about us, isn't it?

Maybe it's time that we in EMS recognized that our adrenaline rush doesn't

usually do our patients any good.

> 2. Severe, uncontrolled hemorrhage of any cause

>

GG: This is legit I suppose, although unless the hospital is really on

the ball, the few minutes saved, if any, by Code 3, will be lost while the

poor souls at the hospital, who are NOT ready for this, try to get things

together. It ain't like you see on TV except at a VERY FEW places like Taub

and

so forth. Most of the time they don't have surgeons standing by, the OR

staff is NOT set up to do a craniotomy, and so forth. How many are able

and willing to crack a chest or a belly in the ER? Few, I suggest. Unless

where you're going is a Level I or II, you can probably forget getting any

sort of time-wise definitive treatment. So why risk running over granny,

the kids, and being broadsided by a semi while you're kidding yourself about

what you're doing? Oh, sorry. Because it makes US feel so good.

>

> 5. Trauma

>

> 1. Penetrating wound to head, chest, or abdomen except for

> obviously superficial wounds

>

GG: Again, will any time saved by Code 3 be effective in outcome? I

doubt it very much. Cite a study that shows it. I would love to know about

it. Think about what happens when you get to the ER. You transfer them

to the ER gurney and they are swarmed by ER folks. Who basically do the

same things you should have done, i.e, assure an airway, ventilate, start IVs,

give fluids, do an ECG, and so forth. How often do you go in the doors and

they say, " Take him right to surgery? " Not often. Wouldn't it be better

if you gave them a good heads up as to what you were bringing, did all the

stuff enroute, and when you got there, they actually DID go directly to

surgery?

This won't happen because there is NO effective coordination between EMS

and hospitals. Hospitals get notified that a patient's coming, but they pay

no attention to what EMS tells them. Whatever assessment has been done

will be repeated in the ER, and it will just waste time.

No matter what EMS tells the hospital enroute, assessment and treatment

begins again in the ER.

> 2. Two or more suspected proximal long-bone fractures

>

GG: Unless these are filling the potential space up with blood, this

makes no sense. Unless you're going to a Level I there won't be any orthopods

waiting, and even if you are, the time saved is negligible. They'll lie in

the bay in the ER for a long time while they pour in liquids just like you

could have in the field. It's a myth that they always have Type O hanging

and ready to administer.

> 3. Major amputation including two fingers, three toes, or above

> wrist or ankle

>

GG: I think this depends upon possibility of reattachment. Even then, I

doubt the little time saved will make a difference. What's the window?

Take a little time and learn this. Then fashion your responses to reality,

not fantasy. What's different about one finger or two? Are toes more

valuable than fingers? Where do these things comes from? Anybody able to

cite

a study to support that?

> 4. Penetrating or blunt neck trauma except obviously mild or

> superficial injury

>

GG: So, what is this saying? Airway? If you can't establish an airway

in the field, your patient is going to die during your Code 3 transport.

So why are you doing this?

Now, if they're bleeding out into the throat, by all means get them there.

It may or may not help. If you're adequately trained in surgical

airways, then you'll be able to do exactly what the ER doc will do when you get

them there. So why wait? If you're not. Do not pass GO. Go directly to

jail. Do not collect $200 dollars. If that's not the problem, it's

extremely unlikely that unless you're at a Level I or II with trauma surgeons

waiting, that they'll be able to fix the problem any better than you could.

So the time for fixing this is where YOU are, not in the ER. I hate to be

so pessimistic about this, but my experience in 30+ years as a medic is that

these folks do not profit by arrival at the ER. They are dead, and they

remain dead.

> 5. Neurovascular compromise of an extremity

>

GG: This might be legit, but it depends on what extremity and to what

extent it's compromised and how much time is involved. Will 10 minutes saved

make a difference? I sincerely doubt it. When docs work on a wrist fx,

for example, they often blow up a cuff that cuts the circulation off for up

to an hour. I've seen it.

>

> 6. Neurologic

>

> 1. Glasgow Coma Scale score <13, only if acute change of any cause

>

GG: Unless it's < 8, there is probably no advantage in rapid transport,

and even then, unless the hospital is ready and waiting to take said patient

directly to surgery, nothing is gained.

> 2. Seizure activity not controlled by BLS/ALS treatment

>

GG: Maybe. But EMS should have more than one toy to use. I know ONE

EMS service in West Texas that carries NO anti-epileptic drugs. NONE.

So, I guess if you have nothing in your box to treat the patient, the siren

and lights are your only intervention.

OTOH, if you have at least two anti-epileptics, then you may have a better

chance of breaking the seizure. If not, then I suppose Code 3 might make

sense if you can't maintain ventilation. Does it provide an advantage?

Maybe, maybe not.

>

> 7. Obstetric

>

> 1. Intrapartum emergencies including, but not limited to, cord

> prolapse, premature labor, and arrested delivery

>

GG: I agree with this.

>

> 8. Pediatric

>

> 1. Upper airway stridor

>

GG: I don't get this. We should be able to manage almost all these

patients in the field.

> 2. All patients <8 years of age individually based on the mechanism

> of injury, degree of distress, and the EMS personnel¢®s experience with

> patients of this age; when in doubt, seek advice from medical command

> and/or

> transport emergently

>

GG: Well, we all know that MOI is worthless as a predictor of injury or

outcomes, but there are still many PHYSICIANS IN EMS, as in medical directors,

so-called trauma nurses, and paramedics who should know better, in emergency

care who continue to worship at the alter of MOI. All this does is give

those who want to put us down ammo to say that we cannot assess a patient,

and, let's face it. Many of us cannot. Code 3 transport of a patient who

was in a rollover where another person died, and who was up and walking

around at the scene, does NOT need Code transport most of the time.

Degree of distress means exactly what? I have had many patients who would

scream when I took the IV cath out of the package. Is that distress? At

least the criterion mentions " in passing " that the experience of EMS

personnel plays a role. Now, of course, when you can't figure out what to do,

or

when you work in a " Mother, May I? " system, you call somebody on the other

end of a radio who can't see your patient, is completely dependent upon what

you tell her/him about what's going on with the patient, doesn't know you

or how good you are and whether or not you could assess a dead mule or not,

and who attempts to " second guess " you by looking into a crystal ball that

they keep by the telemetry box. He or she will, 9 out of 10 times, say, just

transport. How this helps a patient I have no idea. However, it makes

all of us in EMS feel really good about the " systems " we have in place.

>

> 9. Other

>

> a. Emergent transport should be used in any situation which the most

> highly

> trained EMS provider believes that the patient's condition could be

> worsened

> by delay equivalent to the time that could be gained by emergent

> transport.

> In all cases using this option, documentation of the reason for this on

> the

> trip must be recorded.

>

GG: This is actually the only thing that makes sense about this whole

piece of written fecal matter.

I'm sure that I have offended many by this rant. Well, live with it. We

need to begin to think like medical professionals, not hotshot ambulance

drivers. Sure, I love running RL&S. What a sense of power! What a rush!

Is it legit? Nope, not most of the time. Does it help the patient?

Nope, not most of the time.

And if we can't tell the difference, what does that say about us? And if

we have to abide by a policy such as Pennsylvania's, what does that say

about EMS in general?

Now, I have made a bunch of statements that I cannot back up with research.

But neither can the other side. I plead for common sense. I plead for

the end to self delusion that we in EMS indulge in. Let's get real about

what we can do and what we can't, and let's take a real look at Code 3.

Running dead people to a hospital Code 3 helps nobody. Most of the other

Code 3 transports also make no sense.

If you feel differently, cite some studies. I always want to learn.

The Plaintiff rests.

GG

>

> >

> > -----BEGIN PGP SIGNED MESSAGE-----

> > Hash: SHA1

> >

> > does anyone have a P&P regarding the use of lights and siren to

> > transport a patient to the hospital ..specifically. transport a p

> > conditions suggest this response..thanks for sharing ht

> > - --

> > H.T. FILLINGIM B.S. CCEMT-LP

> > FISHER COUNTY HSOPITAL DISTRICT EMS

> > ROTAN, TEXAS 79546

> >

>

July 9, 2009

Gene,

GREAT WORDS!!!Â

When do we transport emergency?Â Since 78% of EMS Vehicle accident fatalities

occur while running lights and sirens....I say NEVER.Â The risk of killing the

patient, in my opinion, far outweighs any potential benefit of saving a few

seconds at the ED...especially when the first couple of minutes is filled with

statements like " why did you come here? " or " were we the closest facility? " or

" why didn't y'all fly them to a different hospital? " Â

My agency is located in a suburban environment with moderate traffic most of the

daylight hours and a few periods of heavy traffic congestion.Â A few years

back, I began following my crews to hospitals on emergency transportsÂ They

would use the lights and siren and I would follow them abiding by all traffic

laws, not speeding,Â waiting at all traffic lights, traffic tie ups and stop

signs.. Over the course of 75 transports, the fastest my crew ever beat me to

the hospital was by 45 SECONDS.Â So, now, when talking to my crew about why

they made a decision to run emergency to the hospital, I ask them the same

question: " Was the time saved for the patient worth a large enough benefit that

you risked not going home to your family tomorrow morning " .Â If that answer is

yes, then you made a good decision...if it isn't...you need to re-evaluate your

decision making process regarding the use of lights and sirens.Â

I don't have the studies, but I do know rural studies show almost no benefit to

running emergency during transport...but in large urban environments time can be

saved when an ambulance doesn't have to sit through 3 or 4 cycles of a single

traffic light due to traffic congestion.Â Now, creative minds have been at work

and I know of at least one urban environment in the US (not in Texas) where they

have the " opticom " traffic light interrupters on the majority of

intersections...then they put filters on their opticom trigger lights...and

instead of running emergency to the hospital, they turn on their opticom

triggers and turn all their traffic signals green speeding up their transport.

HT, to answer your question, our emergency transport protocol is if the benefit

outweighs the risk...and we talk about a majority of these decisions after they

are made.Â

Dudley

Re: transport of patients to hospital using red lights and

siren