# When will we stop running code?



## NomadicMedic (Oct 13, 2012)

I read a post in another thread that said, when referring to a city's BLS ambulance response, "you must be excited, you get to run code to everything". 

When are we going to stop endangering ourselves and the public, by driving recklessly, with lights and sirens, to calls that are simply not emergent. 

In the instance mentioned above, it should be recognized that the ambulance responding code has been requested by fire department EMTs on scene who have made contact and evaluated the patient, determining that ALS interventions are not needed and the patient can be safely transported to the ED via a BLS unit. Yet, due to contracted response time requirements, they respond with lights and sirens. 

Headache? Lights and sirens.
Stubbed toe? Lights and sirens.

Need to go to the hospital because you just don't feel well? 

Lights and sirens.

It's unnecessary and put providers and the public at risk. 

I'll be honest, I'm nervous every time I respond to a call hot.


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## Cup of Joe (Oct 13, 2012)

"but when people call us, they expect us to use the lights and sirens to take them to the hospital, thats why they called." :glare: (don't worry, I smacked that person upside the head for you already)

I agree with you.  They have very limited benefits, if any.

As for responding to a call, we are basically required to here.  The public around here feels like they're getting ripped off if we don't pull up with the lights on.  For transporting, it will be no lights or sirens majority of the time when I'm in charge.


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## TransportJockey (Oct 13, 2012)

I hate that. And one of the reasons I very rarely run code at all (the other being long straight strectches of endless back roads)


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## Chief Complaint (Oct 14, 2012)

We don't respond code to calls such as headaches and stubbed toes.  If dispatch provides us with enough info to determine that its a "nuisance" call we just drive like regular folk.


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## EpiEMS (Oct 14, 2012)

Only life threats and unknowns deserve a code response. Isn't that just common sense?


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## NomadicMedic (Oct 14, 2012)

I wish it was as simple as "what I think is a priority call gets lights and sirens"

We respond hot to Charlie, Delta and Echo level calls. (For those of you not familiar with Priority Medical Dispatch cards, here's a link. http://wiki.radioreference.com/index.php/Medical_Priority_Dispatch_System)

Most of the Charlie/Delta calls are really non emergent, but I can't decide that... It's a response criteria set by the agency.


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## DesertMedic66 (Oct 14, 2012)

Any 911 call gets a code 3 response by ambulance and fire department for my area. I've been dispatched out literally for a "toe pain". When we got on scene the patient is in full arrest. Also vise versa. I don't see my system ever going code 2 (normal driving) to 911 calls anytime in the near or far future. 

People who call 911 are usually not realible. So we have no way of knowing what is actually going on. It's to the point now where we just get an adress of the call and either "unknown medical aid" or "traffic collision" when we are dispatched.


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## Shepard (Oct 14, 2012)

Here you run Code 3 to everything unless determined to be Code 2 response by EMD. I believe that running code is necessary because you have no idea what your really going to. Transport is always Code 2 except in a few circumstance as dictacted by state law.


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## rescue1 (Oct 14, 2012)

We go hot to calls dispatched as "ALS", which includes unknowns. We also go hot to accidents with confirmed injury. Anything thing else is cold. I'd say I go no lights and sirens about 50% of the time.
That being said, everyone has probably been bit in the *** by a misleading dispatch complaint, so I can sort of understand running hot to calls. My pet peeve is transporting emergently.

There are only a few patients that truely benefit from the saved minutes of L/S, mainly severe trauma. Yet you still see units transporting hot for simple fractures, complaints of "feeling sick", and similar calls. Even better are calls with 30 minute on scene times spent assessing the patient, followed by L/S transport. 
There is nothing that those saved minutes will do for that patient except endanger them.

Luckily, where I work we transport with lights very rarely.


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## Medic Tim (Oct 14, 2012)

rescue1 said:


> Even better are calls with 30 minute on scene times spent assessing the patient, followed by L/S transport.



And then spend 5+ minutes before unloading the pt once at the hospital.

We have priority dispatch. We run hot to about 60% of our calls. Most of them do not require a hot responce. I can count on one hand the number of times I have gone to the hospital hot this year. We have some crews that go hot for just about everything. It has been my experience that ppl who run code for everything are not comfortable in their assessment/skills or are new.


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## leoemt (Oct 14, 2012)

n7lxi said:


> I read a post in another thread that said, when referring to a city's BLS ambulance response, "you must be excited, you get to run code to everything".
> 
> When are we going to stop endangering ourselves and the public, by driving recklessly, with lights and sirens, to calls that are simply not emergent.
> 
> ...



I don't think the issue is running code too much, rather I think its lack of training and experience. I am probably one of the safest drivers out there when it comes to driving code. Then again, I have a "real" EVOC course under my belt at the WSP Academy. 

Recently, I had a 40 mile long code run and when the call was done my partner looked at me and said "that was by far the safest driving I have seen."

Lights and sirens REQUEST the right-of -way, they don't guarantee it. Once providers get that through their heads and stop driving like there a race car then we can minimize crashes.

My biggest pet peeve is the videos on youtube of ambulances running code and they approach a controlled intersection and have a red light. Instead of going around traffic, or waiting for the light to change they get right behind the motorists and start blasting airhorns and sirens until said motorist pulls into the intersection against the light.


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## DrParasite (Oct 14, 2012)

n7lxi said:


> Yet, due to contracted response time requirements, they respond with lights and sirens.


This is probably the #1 reason why managers write policies that say every response must have lights and sirens.  The public insists on a rapid response when they call 911, they want shorter run numbers, and they want the ambulance to show up with it's L&S on, so they know they came quickly

The #1 reason providers want to go L&S is similar to why every patients needs ALS (or at least an ALS assessment), your headache might be a stroke, and your stubbed toe might actually be referred cardiac pain for a diabetic (or so it was told to me by someone online).  what you are dispatched to and what you really have can be two different things (911 callers are rarely accurate, and garbage in/ garbage out).

I must say, I do think we should be responding to all calls with an illness or injury L&S.  Been burned too many times by inaccurate dispatches, as well as having patients and family say "you took forever to get here!!!"

Now transporting emergently, that's a different story altogether, and should be avoided except the patient is experiencing a time critical medical emergency that cannot be resolved in the field.


leoemt said:


> My biggest pet peeve is the videos on youtube of ambulances running code and they approach a controlled intersection and have a red light. Instead of going around traffic, or waiting for the light to change they get right behind the motorists and start blasting airhorns and sirens until said motorist pulls into the intersection against the light.


Fire trucks are the absolute biggest offenders of this, usually with a guy in the front seat of the truck doing the recording.  I've also seen PD go L&S to routine calls, speeding up the road and pushing people out of their way.  So it's not a problem that is limited to EMS people.


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## Veneficus (Oct 14, 2012)

*The emperor's new cloths*

There really isn't a need for a lights and siren response or transport.

But, for decades, since the very inception of EMS, in order to sell our services to the public, we tricked them by telling them how important response times are.

It was an easy metric for them to follow and the call volumes were low enough that a response based system actually worked. 

It was probably your boss that sold the public on paying your salary with response times. (Just like the special fabric that only the worthy could see) 

Now we simply have to perpetuate our own lie. 

If you look at the NFPA recommendations as well as the common fire service mantra of a goal of 8:59, anyone with a CPR card knows this will never work. 

With brain death in an arrest in 6-8 minutes, 8:59 90% simply will not be fast enough. We know and preach that bystander CPR will make the difference between life and death in SCA.

Now somebody else will probably talk about other "life threatening" emergencies, but it was the Canadian's often quoted sudy that shows ALS makes minimal difference in mortality, but reduces length of hospital stay.

So what does a BLS response actually do for these same people? They either transport or babysit waiting for the mythical ALS to show up perform some voodoo and...Wait for it...transport.

Imagine the public outcry of a disatcher who said "we'll get to you in due time." People would be calling for heads.

Many years ago now I did some research for a safety committee where I worked. I had statistics from the insurance institute of America, I had medical research and opinions on time sensitive conditions, I had the combined experience of hundreds of EMS workers of all levels who identified most calls were simply not emergencies.

Driving code is purely psychological for responders and patients. It carries no benefit and as you identified, carries significant risk. (when I did my research on it, the insurance people claimed it statistically raised the chances of a collision 300%, and traffic has probably increased exponentially since then.)

As call volume increases beyond our financial and physical capability to actually respond to calls in the recommended time, what will we do then? Logicially we will increase the time we say should be the benchmark.

Do you know where that 8:59 benchmark came from?
It was what the average professional FD in the US could reasonably get 90% of the time. It is a standard based off of the average performance now 30 years ago.

If it was so important, with fire calls decreasing and EMS calls increasing, if response time mattered so much, wouldn't it have been logical to close engine companies and replace them with 1 or 2 ambulances per station?

Didn't see that happen did you?
(I better not get started on NFPA though, it is complete BS in itscurrent form, just look at the minimum manning recommendations for fire apparatus, anyone who has tried fire suppression other than standing there and watching the building burn knows it is not enough. You don't see major city FDs with unit staffing that low. Wonder why?)

Back on point, if you stopped responding lights and sirens, the negative public perception and backlash would be devastating to EMS.

Do not start that fight my friend, it is a loser. 

What will change it is when we realize we cannot be a response agency and need to be proactive, only then will EMS have the interaction and public relations, and documented numbers to start changing public opinion slowly. 

We must move away from the easy metric of response time. But it is hard to do when it is so often used. We created this monster and now it is out of control. 

In the meanwhile, you have discovered the naked truth.


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## Melclin (Oct 14, 2012)

Similar to other posts, we go L/S to many jobs based on MPDS, but transport very very few people that way.

I feel L/S has its place. Done properly, its pretty safe, its just a matter of doing it properly. I feel that there are jobs that are time critical to the extent that minutes will make a difference. Cardiac arrest, major trauma, choking/apnea. While the benefit may be small and infrequent, many of the benefits we provide could be described similarly. Especially in the city, you could knock of 10 or 15 mins or more in peak hour. I think it would be absurd to be sitting their at an empty intersection waiting for a long light cycle on the way to an arrest. 

This is all predicated on the idea that L/S driving is safe and that is reasonably true here. I'm aware of only 3 fatalities in the past thirty years, state wide. Serious injury is more common but still very rare. I may be wrong but I have been told that our accident rate on L/S drives is no different to non-L/S and the fatality/injury rate at least in ambulances (fly cars are another matter) is not any different to the general population who of course are not driving L/S. We have a pretty strong culture of safe L/S driving (although safe is a relative term) and widespread recognition of the idea that minutes and seconds make very little difference in the majority of cases. A week of driver training (I think it might now be two weeks) based on a model of low risk driving was part of my induction into the service. You don't drive L/S during your first 6 months, after which you are instructed and signed off in L/S driving by in our in house facilitators. 

RE public perception, we make a point of turning the lights and bells off before getting near the pt (unless there is an obvious need for the beacons eg MVAs). I've been told it has to do with trying to maintain a sense of calm (similar to one of the reasons we don't run at jobs), but I'm not exactly sure of the origin of that culture.

Also, I feel at least for myself, driving L/S to more jobs than is strictly necessary helps maintain the skill of that kind of driving. I'd suggest the possibility that the very occasional L/S drive may present more dangers that doing it more regularly.


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## mycrofft (Oct 14, 2012)

Lights and siren while driving the safe speed limit can save time for longer distances and through medium to light urban traffic. Whether the time is effective varies from pt to pt, but if thirty seconds' or two minutes' time will make the difference in a pt's outcome, they are probably too damaged to survive the ride to definitive care.

What lights and siren do as well as make the drive a little safer and smoother (for a driver who is patient and competent!!!) is to add another layer of the social glue we call "expectation to be rescued". As in , "I can calmly drive to the freeway, drive eighty MPH while curling my eyelashes and talking on the cell phone, and get to my work, every day, because if something goes awry those nice young men and women in the ambulance will rush to my aid. Like Jack Webb said".

If I hear the term "Code 2" again I'm going to have a hair transplant so I can rip it out (again). Either you are prudently driving without warning devices activated, or you are driving prudently but sometimes exceptionally (using legally sanctioned *exceptions* to the law like using the shoulder, using turnarounds on the freeway, etc.) WITH warning devices, or you are driving foolishly. The true concept of "Code 2" is driving with alacrity (which you should always prudently do) but WITHOUT warning devices...which should be the basic level of performance, not a "special code". 

MANY are given to understand Code 2 means drive _*fast and exceptionally*_, but *without warning devices*. (Why, so you don't interfere with people on their cell phones?). It is NEVER defensible, and is just silly/dangerous, to drive in any  manner other than an efficient common motorist might when you are not using your sanctioned warning devices.


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## triemal04 (Oct 14, 2012)

Shepard said:


> I believe that running code is necessary because you have no idea what your really going to. Transport is always Code 2 except in a few circumstance as dictacted by state law.


So?  You take the information you have at hand and what can reasonably be assumed to go along with that and run with it.  Thinking it's a good idea to respond emergently because the "twisted ankle" might actually be someone who has a life threatening and time sensistive problem is silly.

Unless you have a very different definition of what "code 2" is, that is completely ridiculous.  Generally the only people I know that use/say that are cops, both when they're calling for cover, and responding to such a call or certain other types.  Basically they drive near emergently, without any warning devices (other than maybe at intersections) because it's only an "urgent" call, not "emergent" and to lower their profile.  No reason to do that in an ambulance, and damn sure not with a patient in the back.


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## triemal04 (Oct 14, 2012)

DrParasite said:


> The #1 reason providers want to go L&S is similar to why every patients needs ALS.


No, probably the real reason that most people, if they are being honest, want to drive emergently is because they thinks it's fun/sexy/cool/something like that.  Excuses like "we don't know what is really wrong" "I've been burned before" "callers aren't reliable" are excuses.  While there may be truth to it, there isn't enough to necessitate a mandatory emergent responce to all calls.  Plus, when you look at how much time is actually saved, and the very few conditions where that small amount would actually make a real difference, it becomes even less neccasary.


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## Tigger (Oct 14, 2012)

Shepard said:


> Here you run Code 3 to everything unless determined to be Code 2 response by EMD. I believe that running code is necessary because you have no idea what your really going to. Transport is always Code 2 except in a few circumstance as dictacted by state law.



Can cite the laws applicable in these instances?


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## AnthonyM83 (Oct 14, 2012)

I know some people want to get ride of code 3 responses altogether. I have to warn that I can have a 40 minute non-emergent response to a call under 3 miles away in Los Angeles traffic. Adding lights/sirens cuts that down to 6 minutes. Has nothing to do with speeding, rather being able to oppose traffic. We have blocks and blocks of gridlock. I know of several specific blocks that takes about 15 minutes to get by (one block per 15 minutes!) 

And we're already saturated with ambulances...the calls just keep coming out. Five within that saturated 5 square mile area in 10 minutes. Then five more...


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## Shepard (Oct 14, 2012)

For the record: Code 2 in my area and as far as I know California in general is non emergent, non lights and sirens, follow all traffic laws and signals. California Ambulance Driver's Handbook says a few times thats Code 3 transport should be avoided except in the case of uncontrolled hemorrhage, stroke or complicated child birth.


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## Shepard (Oct 14, 2012)

Shepard said:


> I believe that running cod.e is necessary because you have no idea what your really going to.



While this may be true I should be more clear. Code 3 is used to oppose traffic and move through stop lights. I think EMD is necessary in order to determine a Code 2 response. For the majority of the time a twisted ankle will be bumped down and Ambulance and fire wont respond LNS.

I also agree with everythjng said. Everyone should be required to have full EVOC course and need to understand that Code 3 does not mean recklessness.


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## Shishkabob (Oct 14, 2012)

Happens as long as you rely on the uneducated public to relay medical signs to dispatch.


And there are plenty of abusers who know just the right words to say to get a quicker response.


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## Anonymous (Oct 14, 2012)

AnthonyM83 said:


> I know some people want to get ride of code 3 responses altogether. I have to warn that I can have a 40 minute non-emergent response to a call under 3 miles away in Los Angeles traffic. Adding lights/sirens cuts that down to 6 minutes. Has nothing to do with speeding, rather being able to oppose traffic. We have blocks and blocks of gridlock. I know of several specific blocks that takes about 15 minutes to get by (one block per 15 minutes!)
> 
> And we're already saturated with ambulances...the calls just keep coming out. Five within that saturated 5 square mile area in 10 minutes. Then five more...



This^

I was EOS 8 miles from station at 7:30 the other day, got to station at 8:20.


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## NomadicMedic (Oct 14, 2012)

You are all missing the point. Reread the original post. 

I specifically mention instances where the fire department EMTs are on scene (responding in an engine) and have determined that the patient is stable (that is, NON EMERGENT) and does not require an ALS level response and yet the BLS ambulance STILL responds hot to the call, after being requested by the fire EMTs on scene who have already assessed and began treating the patient. 

Anthony mentioned the difference between a 40 minutes vs 6 minutes with lights and sirens. If the call is truly BLS, chances are the patient can wait 40 minutes. If the patient can't wait for definitive care, a paramedic should make that call and treat and transport accordingly. 

Now I agree that there are ALS calls that may require a hot response (delta/echo priority), but a BLS transport only response should always be cold. And the transport should always be cold as well.


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## Brad Z (Oct 14, 2012)

n7lxi said:


> Anthony mentioned the difference between a 40 minutes vs 6 minutes with lights and sirens. If the call is truly BLS, chances are the patient can wait 40 minutes. If the patient can't wait for definitive care, a paramedic should make that call and treat and transport accordingly.
> 
> Now I agree that there are ALS calls that may require a hot response (delta/echo priority), but a BLS transport only response should always be cold. And the transport should always be cold as well.



But that's means two units (the Fire BLS folks and the responding BLS transport) will be out of service an additional 34 minutes.  A code 3 response gets everyone back in service and ready for the next call sooner.  Not saying that's a reason to go code 3 but certainly a consideration for some departments.


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## NomadicMedic (Oct 14, 2012)

Brad Z said:


> But that's means two units (the Fire BLS folks and the responding BLS transport) will be out of service an additional 34 minutes.  A code 3 response gets everyone back in service and ready for the next call sooner.  Not saying that's a reason to go code 3 but certainly a consideration for some departments.



Certainly not a reason to go code, ever. 

If an ambulance was responding to an "arm pain" non emergent call with L&S, and they were involved in a traffic collision, the press ad public outcry would be disastrous if the reason they were responding code was "to get back in service quicker". 

Sorry. Not a valid reason.


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## Achilles (Oct 14, 2012)

Brad Z said:


> But that's means two units (*the Fire BLS folks *and the responding BLS transport) will be out of service an additional 34 minutes.  A code 3 response gets everyone back in service and ready for the next call sooner.  Not saying that's a reason to go code 3 but certainly a consideration for some departments.



I would like to point something out. Not all firefighters are BLS, in fact a lot of departments require medic to get on the department.


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## NomadicMedic (Oct 14, 2012)

Allow me to clarify further. The original post was regarding EMS response in Seattle and King County.

In both Seattle and King County the firefighters are required to be EMTs. A paramedic does not respond on an engine or in a paramedic unit unless they are specifically dispatched or requested by the EMTs that arrive on the engine. This is the way the King County medic one system was designed. Firefighters are the first responders. Once the firefighters have determined the need for transport, they call dispatch and request an ambulance. In Seattle BLS transport is provided by AMR. In South King County BLS transport is provided by TriMed.  In many instances these private ambulance companies will respond code in order to meet the "response time guidelines" set forth in the contract.

They don't respond code because they have an emergency patient. They don't respond code because they need to get the fire unit back in service, they respond code because the contract requires a certain timeframe be met otherwise the private company pays a fine to the city.

Now tell me, is that a valid reason to endanger providers and the public?


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## Brad Z (Oct 14, 2012)

n7lxi said:


> Certainly not a reason to go code, ever.
> 
> If an ambulance was responding to an "arm pain" non emergent call with L&S, and they were involved in a traffic collision, the press ad public outcry would be disastrous if the reason they were responding code was "to get back in service quicker".
> 
> Sorry. Not a valid reason.



No department is ever going to say they they run L&S for unit availability.  They don't need to.  I'm just saying it's certainly a consideration, particularily in areas where a 40 minute response time can be shaved down to 6.

I'm not personally advocating L&S for stubbed toes.  But certainly response time affects the total call time, which determines staffing levels.  Every unit sitting in traffic heading to a non-critical call is unavailable for a critical call.  That means either more units in service or longer response times. 



Achilles said:


> I would like to point something out. Not all firefighters are BLS, in fact a lot of departments require medic to get on the department.



Understood, but that seemed to be the case in the original scenario.


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## Shepard (Oct 14, 2012)

n7lxi said:


> Allow me to clarify further. The original post was regarding EMS response in Seattle and King County.
> 
> In both Seattle and King County the firefighters are required to be EMTs. A paramedic does not respond on an engine or in a paramedic unit unless they are specifically dispatched or requested by the EMTs that arrive on the engine. This is the way the King County medic one system was designed. Firefighters are the first responders. Once the firefighters have determined the need for transport, they call dispatch and request an ambulance. In Seattle BLS transport is provided by AMR. In South King County BLS transport is provided by TriMed.  In many instances these private ambulance companies will respond code in order to meet the "response time guidelines" set forth in the contract.
> 
> ...



No. It is not. FD should request a non emergent ambulance. Running Code 3 to a non emergent call is unecessary and dangerous.


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## DrParasite (Oct 14, 2012)

n7lxi said:


> they respond code because the contract requires a certain timeframe be met otherwise the private company pays a fine to the city.
> 
> Now tell me, is that a valid reason to endanger providers and the public?


absolutely.  the city requires it.  if the city were to drop the response timeframe, then would the company still respond code?

The city wants it.  whether or not it's valid isn't the point, the city (AHJ) wants it this way.  

Using your logic, if the city cared about the public and providers, they wouldn't encourage this unsafe behavior.  Since they obviously do, you can draw your own conclusions.


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## Shishkabob (Oct 14, 2012)

n7lxi said:


> I specifically mention instances where the fire department EMTs are on scene (responding in an engine) and have determined that the patient is stable (that is, NON EMERGENT) and does not require an ALS level response



Since everyone is thinking it, I'll be the first to say it:  I don't always trust all my BLS first responders to make that determination, they're only marginally better than the lay person in recognizing sick, and they are just as apathetic when it comes to providing medical care.

No, no.  They might view things as 'urgent' that an experienced Paramedic wouldn't, whilst they might view something as benign that the moment an experienced Paramedic lays eyes on the patient goes "We need to go, now".  And some are just plain lazy and want ALS on scene as quickly as possible so they can toss it aside.









(Yup, I made gross generalizations in this post, "everyone is different", "there are good first responders", etc etc)


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## Jambi (Oct 14, 2012)

Linuss said:


> Since everyone is thinking it, I'll be the first to say it:  I don't always trust all my BLS first responders to make that determination, they're only marginally better than the lay person in recognizing sick, and they are just as apathetic when it comes to providing medical care.
> 
> No, no.  They might view things as 'urgent' that an experienced Paramedic wouldn't, whilst they might view something as benign that the moment an experienced Paramedic lays eyes on the patient goes "We need to go, now".  And some are just plain lazy and want ALS on scene as quickly as possible so they can toss it aside.
> 
> ...



This


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## Joe (Oct 15, 2012)

I read enough of this thread to decide that you guys always have to find something to complain about. Dont like running code? Go run ift dialysis calls. Or work for ups. The public expects us to. You all make it sound like every time we run l&s someone gets injured. I can count on 1 hand how many rigs ive seen crashed during emergent runs on one hand (1). Actually ive head of more crashed when not running code (6 or so) keep in mind we are dispatched to over 4k calls a month in my city


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## NomadicMedic (Oct 15, 2012)

Linuss said:


> Since everyone is thinking it, I'll be the first to say it:  I don't always trust all my BLS first responders to make that determination, they're only marginally better than the lay person in recognizing sick, and they are just as apathetic when it comes to providing medical care.
> 
> No, no.  They might view things as 'urgent' that an experienced Paramedic wouldn't, whilst they might view something as benign that the moment an experienced Paramedic lays eyes on the patient goes "We need to go, now".  And some are just plain lazy and want ALS on scene as quickly as possible so they can toss it aside.
> 
> ...




Remember, they're not calling for a paramedic ambulance, they're EMTs on a fire engine calling for EMTs on an ambulance. No ALS response unless requested. If its an ALS call, the medic one paramedics transport and the private ambulance does nothing. 

Here's the order of response. 

911 call.
Fire engine with EMTs. 
Patient contact. 
If a BLS call, fire requests a private BLS ambulance. 
If an ALS call, fire requests paramedics. 
If ALS arrive and downgrades to BLS they request a private ambulance.


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## rescue1 (Oct 15, 2012)

Joe said:


> I read enough of this thread to decide that you guys always have to find something to complain about. Dont like running code? Go run ift dialysis calls. Or work for ups. The public expects us to.



Since when is "The public expects us to" an acceptable reason for us to do something? The public as a whole has no knowledge of medicine or what it entails and their expectations should not determine operational procedure.


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## Tigger (Oct 15, 2012)

Joe said:


> I read enough of this thread to decide that you guys always have to find something to complain about. Dont like running code? Go run ift dialysis calls. Or work for ups. The public expects us to. You all make it sound like every time we run l&s someone gets injured. I can count on 1 hand how many rigs ive seen crashed during emergent runs on one hand (1). Actually ive head of more crashed when not running code (6 or so) keep in mind we are dispatched to over 4k calls a month in my city



And this is the attitude that will prevent any substantive change from happening in EMS. If the workforce will neither embrace nor seek change, it is not likely to happen. 

Also, considering that most days trucks run non emergent far more often than emergent, it is not a stretch to have more trucks crash during non-emergent operations. I'm not sure many statistics exist showing how many accidents occur between other vehicles not including the ambulance as a result of emergent vehicle operations.


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## NomadicMedic (Oct 15, 2012)

Joe said:


> I read enough of this thread to decide that you guys always have to find something to complain about. Dont like running code? Go run ift dialysis calls. Or work for ups. The public expects us to. You all make it sound like every time we run l&s someone gets injured. I can count on 1 hand how many rigs ive seen crashed during emergent runs on one hand (1). Actually ive head of more crashed when not running code (6 or so) keep in mind we are dispatched to over 4k calls a month in my city



Really. How about a little research to back that up?

Emergency Medicine International
Volume 2010 (2010), Article ID 525979, 7 pages
doi:10.1155/2010/525979
Research Article
Ambulance Crash Characteristics in the US Defined by the Popular Press: A Retrospective Analysis
Teri L. Sanddal,1 Nels D. Sanddal,1 Nicolas Ward,2 and Laura Stanley2


"The ... essential issue that is verified in the analysis of these data is the fact that the use of lights or lights and sirens often places the responding ambulance and the civilian population at risk."

http://www.hindawi.com/journals/emi/2010/525979/


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## DrParasite (Oct 15, 2012)

Joe said:


> I can count on 1 hand how many rigs ive seen crashed during emergent runs on one hand (1). Actually ive head of more crashed when not running code (6 or so) keep in mind we are dispatched to over 4k calls a month in my city


the numbers you give don't matter.  out of all the emergency runs, how many result in crashes?  vs out of all the non-emergent runs, how many results in crashes?

to be even clearer on ratios, if you have 100 emergency runs, and the ambulance crashes on 1 of them, you have a 1% crash problem.  if you have 1000 non-emergency runs (since most calls are non-emergencies), and 6 crash, then you have a 0.6% crash problem, which is less than the emergency rate, despite more crashes

statistically you have a higher chance of crashing with lights and sirens than without.  that's just how the numbers are.


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## Tigger (Oct 15, 2012)

n7lxi said:


> Really. How about a little research to back that up?
> 
> Emergency Medicine International
> Volume 2010 (2010), Article ID 525979, 7 pages
> ...



Never mind the research, the public wants us to do it!


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## Veneficus (Oct 15, 2012)

rescue1 said:


> Since when is "The public expects us to" an acceptable reason for us to do something? The public as a whole has no knowledge of medicine or what it entails and their expectations should not determine operational procedure.



I think you missed the point.

*We* Have told them for years that response times mattered.

*We* Have told them the metric of good EMS is response times.

After a few decades of us spouting this BS. They believe it and expect it.

*We* are responsible for this.


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## Shishkabob (Oct 15, 2012)

And it doesn't help when the firefighters unions are still pushing "quicker responses", while actual medically proficient agencies are pushing "better patient outcomes not solely based on response time"


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## WuLabsWuTecH (Oct 15, 2012)

First unit in and First ALS unit here go code.  Unless it's a potential for multiple patients (like MVCs) where first 2 transport units will go code, or unresponsive/arrest/critical patients, where first unit + first 2 ALS units will go code.

The rationale is until we get medically trained eyes on scene, we simply don't know what we have.  How many times has that lift assist turned into an arrest?  Or that leg pain turned into an MI?

But yes, if there are already units on scene, and it's not a life threat, then there is no reason to go code.  Our response times are measured based on first unit on scene.  If there is a downgrade, there is no statistic that keeps track of how long it takes other units to get there.


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## VFlutter (Oct 15, 2012)

The public's expectations should not dictate our practice. But running code is so engrained into the culture of EMS that it will be hard, if not impossible, to convince the majority to change. 

Family members often get frustrated when they see the code team walking. They expect them to be running down the halls with loaded Epi syringes dogging wheelchairs and hurdling stretchers as if that will make everything better. 


Except I have to admit its a little annoying when Anethesia gingerly strolls down the hall eating an apple while you bag the patient.


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## Shishkabob (Oct 15, 2012)

I guess the public would be just as angry when they find out we eat, sleep and joke on the way to calls.... all at the same time, backwards, while blindfolded.


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## Veneficus (Oct 15, 2012)

ChaseZ33 said:


> Except I have to admit its a little annoying when Anethesia gingerly strolls down the hall eating an apple while you bag the patient.



You make that sound bad...

It was an apple, not a candy bar


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## WuLabsWuTecH (Oct 15, 2012)

ChaseZ33 said:


> The public's expectations should not dictate our practice. But running code is so engrained into the culture of EMS that it will be hard, if not impossible, to convince the majority to change.
> 
> Family members often get frustrated when they see the code team walking. They expect them to be running down the halls with loaded Epi syringes dogging wheelchairs and hurdling stretchers as if that will make everything better.
> 
> ...



Except that the public's expectations do need to be taken into account.  The taxpayers are the ones that sign your paycheck at the end of the day.  It's our job to educate them to change their expectation, but if after all is said and done, the public wants something from their public services, THEY are going to get it.  You upset the public, and suddenly the prospects of that replacement levy getting passed don't look so hot anymore...


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## Trashtruck (Oct 15, 2012)

L/S are good when the pt smells, the pt is annoying, you're tired of making small talk and could care less about what they think is 'wrong' with them, you are hungry and the food you just heated up/bought is now cooling on the front dash, you ordered to-go and need to get back before they close, you have to go to the bathroom, your RN crush of the week is getting off of work soon, you are trying to get off of work on time, oh, and if it's rush hour and the pt is actually critical.

I'd add the emoticon 'smiley face' if I knew how...


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## AnthonyM83 (Oct 15, 2012)

If this is what we want, then we're probably going to need additional funding from the city in order to vastly increase the number of units out there. OR we can also just have people wait an hour or more for a BLS response (because of that one 40 minutes away is on a call, you fall back on the one an hour away, and so on). Maybe this would discourage people from calling BUT also consider, those first responders are stuck on scene with her for that hour. Really?

An additional way to look at this problem is asking: Why are these units running hot? There's a difference between going code 3 and actually getting there urgently. Most of my code 3 responses feel like code 2 responses. Only difference is I'll occasionally be opposing traffic. And stop light waits get reduced to stop sign waits. Still dangerous, but not nearly as dangerous as "rushing" to get there.


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## Achilles (Oct 15, 2012)

Trashtruck said:


> L/S are good when the pt smells, the pt is annoying, you're tired of making small talk and could care less about what they think is 'wrong' with them, you are hungry and the food you just heated up/bought is now cooling on the front dash, you ordered to-go and need to get back before they close, you have to go to the bathroom, *your RN crush of the week is getting off of work soon*, you are trying to get off of work on time, oh, and if it's rush hour and the pt is actually critical.
> 
> I'd add the emoticon 'smiley face' if I knew how...


:rofl::rofl:


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## RanchoEMT (Oct 16, 2012)

*All Ready Do...*

On top of Code 3 responses my system also provides code 2 responses with non-emergent BLS calls or patients deemed stable by an on scene care provider with a response time frame twice that of our normal 10 minute 911 response.  Once on scene we can upgrade(from code2) or Downgrade(from code3) as we see fit.  Not all of our transports go code 3(lights and sirens) to the ER... Good System.


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## triemal04 (Oct 16, 2012)

AnthonyM83 said:


> An additional way to look at this problem is asking: Why are these units running hot? There's a difference between going code 3 and actually getting there urgently. Most of my code 3 responses feel like code 2 responses. Only difference is I'll occasionally be opposing traffic. And stop light waits get reduced to stop sign waits. Still dangerous, but not nearly as dangerous as "rushing" to get there.


I guess that's really something to consider, and differentiate when you're talking about emergent driving.  When someone says to me "code 3" "hot" or whatever, I'm thinking of someone using lights, sirens, speeding, etc etc.  

I work in an area that, depending on the time of day can have hellish traffic; turning on the lights to get around traffic jambs while still driving the speed limit or under the posted limit is still more dangerous than normal driving, but I think less so than doing the same with a higher speed.  In the right setting I don't have much problem doing that and think it is appropriate.  In the right setting is where it get's sticky though.  

And really, most of the time saved in shorter trips doesn't come from how fast you are driving anyway.


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## mycrofft (Oct 16, 2012)

Lights, siren, and legal speed .


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## PNW EMT (Oct 18, 2012)

n7lxi said:


> Remember, they're not calling for a paramedic ambulance, they're EMTs on a fire engine calling for EMTs on an ambulance. No ALS response unless requested. If its an ALS call, the medic one paramedics transport and the private ambulance does nothing.
> 
> Here's the order of response.
> 
> ...



I am glad I am not the only one who feels the way you do. I work primarily in the county to the north of the one you mention however the culture there is quite similar. Unfortunately I think what it boils down to is no matter how many good reasons we come up with for why this practice is dangerous and unneccessary, the people who need to speak up about it to effect change are the private ambulance companies who won't because they don't want to rock the boat with their contracted cities/fire departments. My question is: If an ambulance crew crashes responding to a BS call because the company officer requested they respond red who's liable? The crew for responding code to a non-emergency call with EMTs on scene? The company for supporting the "FD is in charge, do what they say" mentality, or the FD/company officer for requesting a code red response for something ridiculous? Unfortunately I think until it happens it won't be addressed.


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## Brandon275 (Oct 30, 2012)

This is a touchy subject and one with no good solution.  Obviously we all know that going to calls hot is a danger and 95% of the time this level of response is not required.  We have all been sent hot to calls and gotten on scene and have found someone standing outside holding their bags and waiting for us to show up.  On the flip side we have all been sent alpha level response for the seemingly b/s complaint and found a train wreck.  Again, no easy solution here.


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## Veneficus (Oct 30, 2012)

Brandon275 said:


> This is a touchy subject and one with no good solution.  Obviously we all know that going to calls hot is a danger and 95% of the time this level of response is not required.  We have all been sent hot to calls and gotten on scene and have found someone standing outside holding their bags and waiting for us to show up.  On the flip side we have all been sent alpha level response for the seemingly b/s complaint and found a train wreck.  Again, no easy solution here.



I blame the dispatcher 

(que the upset dispatcher who can't take a joke flipping out on this post) 

Even when you find a trainwreck, their condition is almost never helped by the speed of response or transport.

Sure there may be the occasional penetrating trauma that will benefit from a 3 minute ride to a level 1 trauma center, but it boils down to risk/benefit. 

How many lives ad health are you going to risk in order to do it?

Consider not just the provider. But if a provider isfound criminally responsible for injury or death that will impact his/her family plus the family of whomever is injured or killed. Including in wake effect accidents.

For what? To save some time running the dialysis derby?

Responding to toe pain so the firefighters can get back to the station to watch tv, spoon, or workout while they wait for "the big one?"

So you can make it to the next toe pain in less than 8:59 90% of the time?

Maybe so you feel you saved a life giving somebody a ride to the hospital?

It is not reall a touchy topic, it is just another case of tradition overcoming reason and sanity.

Even the FD would be hard pressed to justify it for response times. It was developed when 8 minutes or less to water on a fire would save a structure. Modern construction has all but eliminated that possibility, and the inadequete intitial manpower responding to a working structure fire outside of big city or regional departments eliminates not only the need of an L&S response, it completely makes effecting a save (of life or property) hopeless. 

We drive code for 2 reasons.

1. We want to.
2. The public expects it because we tell them it matters.


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## RocketMedic (Oct 30, 2012)

My service responds L/S to everything and anything.


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## DarkStarr (Oct 30, 2012)

Rocketmedic40 said:


> My service responds L/S to everything and anything.



That's annoying.


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## MexDefender (Oct 30, 2012)

DarkStarr said:


> That's annoying.



We do the same. 

What's to be annoyed about?

As a kid you enjoyed it and as a newbie you did as well. Burnouts or just getting too old for it seems to be a common trend. That said I don't disagree with anyone's points.


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## rhan101277 (Oct 30, 2012)

n7lxi said:


> I read a post in another thread that said, when referring to a city's BLS ambulance response, "you must be excited, you get to run code to everything".
> 
> When are we going to stop endangering ourselves and the public, by driving recklessly, with lights and sirens, to calls that are simply not emergent.
> 
> ...



Here where I work we don't run lights and sirens to every 911 call.  It has to meet specific guidelines to be considered a life threatening emergency.  We have the lights and sirens call codes which are the life threatening emergency, then we have a non-life threatening emergency and both of those are lights and sirens.  Then we have immediate/emergent response which is non lights and sirens for things such as, been sick for several days, non traumatic back pain, toe stubs, minor lacerations, insert minor chief complaint here.  Even in calls sent out as life threatening the medic on scene decides whether to go lights or siren or code 3 back to the hospital.  Code 3 is no lights and sirens around here.


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## Aidey (Oct 30, 2012)

MexDefender said:


> We do the same.
> 
> What's to be annoyed about?
> 
> As a kid you enjoyed it and as a newbie you did as well. Burnouts or just getting too old for it seems to be a common trend. That said I don't disagree with anyone's points.



It is unsafe an unnecessary. It can cause hearing damage in responders. It poses a major safety risk to everyone on the road, and it has been shown to have no benefit except for in cardiac arrest situations. It has nothing to do with being burned out and everything to do with getting smart.


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## waaaemt (Oct 30, 2012)

i don't see what there is to whine about running code. it's only a safety hazard on the road if you don't abide to your EVOC training like by blowing through intersections. and if you do use safe driving while going priority, the chances of someone else being stupid and hitting you is probably the same as when not code. 

i can think of a few instances where a priority response is vital other than cardiac arrest. such as stroke? you only have so much time before you are permanently damaged by a stroke. 

and like with all other unknowns, the chance that you get there in time for something that ends up being serious is totally worth it. if you guys say that it's not worth it cause only 50% of calls end up being serious, then why do CPR? cause the save rate nationally is what? 10-20%?


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## Veneficus (Oct 30, 2012)

oogemsquagger said:


> i don't see what there is to whine about running code. it's only a safety hazard on the road if you don't abide to your EVOC training like by blowing through intersections. and if you do use safe driving while going priority, the chances of someone else being stupid and hitting you is probably the same as when not code.



Not true at all. Call the insurance institute of America and ask them for the latest stas. more than 10 years ago they figured out there was a 300% increase in MVCs. That stat did not include wake effect. 



oogemsquagger said:


> i can think of a few instances where a priority response is vital other than cardiac arrest. such as stroke? you only have so much time before you are permanently damaged by a stroke. .



First I encourage you to look up the definition of a stroke.

Having now done that, time in stroke is measured in hours, not minutes.



oogemsquagger said:


> and like with all other unknowns, the chance that you get there in time for something that ends up being serious is totally worth it. if you guys say that it's not worth it cause only 50% of calls end up being serious, then why do CPR? cause the save rate nationally is what? 10-20%?



50% would be great. Since only roughl 5% is a life threatening emergency, ake a subset of time critical ones, and it is probably less than 1%.

The CPR anaology is BS. If we estimate at 20% that is bringing 1/5 of people back from the dead.

Not exactly the same as saving 2-3 minutes driving for an increased accident risk.

I need to give up arguing with EMT-Bs. It is really like trying to reason with a 2 year old.


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## NomadicMedic (Oct 30, 2012)

Veneficus said:


> I need to give up arguing with EMT-Bs. It is really like trying to reason with a 2 year old.



This. A million times this.


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## mycrofft (Oct 30, 2012)

RanchoEMT said:


> On top of Code 3 responses my system also provides code 2 responses with non-emergent BLS calls or patients deemed stable by an on scene care provider with a response time frame twice that of our normal 10 minute 911 response.  Once on scene we can upgrade(from code2) or Downgrade(from code3) as we see fit.  Not all of our transports go code 3(lights and sirens) to the ER... Good System.



One of my personal black holes..."Code 2". If you do not use your lights and sirens, you cannot expect to get anywhere faster, unless your baseline response time includes personal stops. Unless you drive faster without warning deviceds? Or code 2 means drum faster with your fingers on the dashboard while enroute?


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## NomadicMedic (Oct 30, 2012)

This is going nowhere, fast.

The original post was about ambulances responding HOT, that is, with lights and sirens, to a call where there are already EMTs on scene who have determined that the patient is stable and meets criteria for BLS transport. This is a daily occurrence in a certain city in the Pacific Northwest.  

Lets all agree that lights and sirens adds a degree of danger to responses. 

Lets also all agree that most seasoned EMS professionals do NOT like to respond hot due to the added risk of a motor vehicle collision. 

Additional points can also be made that newer EMTs and medics enjoy driving hot and the idea that "the public expects us to drive hot" continues to be promulgated. 

It is a fact that lights and sirens increase the risk of a traffic collision and it is time for us to take a long look at our response criteria and think about seriously limiting the use of lights and sirens when both responding and transporting.


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## mycrofft (Oct 31, 2012)

n7lxi said:


> This is going nowhere, fast.
> 
> The original post was about ambulances responding HOT, that is, with lights and sirens, to a call where there are already EMTs on scene who have determined that the patient is stable and meets criteria for BLS transport. This is a daily occurrence in a certain city in the Pacific Northwest.
> 
> ...



Hear hear.


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## mycrofft (Oct 31, 2012)

Aidey said:


> You keep using that word. I do not think it means what you think it means.


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## lightsandsirens5 (Oct 31, 2012)

n7lxi said:


> This is going nowhere, fast.



Agreed. I am closing this thread for now. When folks have cooled off, I'll consider re-opening it. I'll be running it be the other leaders here.


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## waaaemt (Oct 31, 2012)

*dang it the last thread was closed about codes*

okay that last thread got a little out of hand..... c'mon guys we don't need this sarcasm and the immature comments. 

anyway i wanted to reply to veneficus



Veneficus said:


> Not true at all. Call the insurance institute of America and ask them for the latest stas. more than 10 years ago they figured out there was a 300% increase in MVCs. That stat did not include wake effect.



well i'd like to see the specifics of this. like i said, if the driver adheres to strict safety guidelines while running code it should greatly reduce the chances of accidents. of course they will still happen. but the 300% you're talking about i'm sure includes all the times EMS providers drive really recklessly while code and are at fault for accidents. 




Veneficus said:


> First I encourage you to look up the definition of a stroke.
> 
> Having now done that, time in stroke is measured in hours, not minutes.



i'm not talking about TIA's if that's what you're saying. of course i'm no PhD so maybe i don't know as much about strokes as you but i'm talking about what the rest of us know as CVAs from clots and aneurysms in the brain. 

yes i know it's counted in hours, but how are we supposed to know when the onset was/how long the PT waited to call 911? then the transport time and waiting time at the hospital. plus the 3 hour window doesn't mean it gives us time to wait around for 3 hours from onset. the sooner the PT receives intervention the less damage is done.




Veneficus said:


> 50% would be great. Since only roughl 5% is a life threatening emergency, ake a subset of time critical ones, and it is probably less than 1%.
> 
> The CPR anaology is BS. If we estimate at 20% that is bringing 1/5 of people back from the dead.
> 
> ...



the 50% i said was based off a medic's comment somewhere earlier whose arguement was they shouldn't go code cause only 50% or something of *sick unknown only* calls ended up being serious. so no not all calls which would make that number roughly 5% just the unknown. and 2-3 minutes counts heck of a lot when you have cardiac arrest or serious trauma.

------------

to N7lxi

i get your point and know exactlyyyy what you're talking about since my comment was the one you talked about in your OP. yeah i know it increases risks and i don't think code should be a thing for headaches and stubbed toe type calls.  i don't remember a recent MVC involving an AMR unit responding code in recent years either. i think it's good learning experience having priority calls though.


another point i'd like to make is to people on here who are saying absolutely no L/S no any BLS. like i said i agree that not all BLS need a code response but it really depends on the call. what if you have someone with a compound ankle fracture? that's not ALS unless they have a severed artery or another life threatening complication. but how long do you want to wait for an ambulance to show up if you're sitting there with your tib/fib poking out of your skin? 

for BS or abuse of system calls, sure let them wait but not the people who have a legitimate injury even if it's not life threatening. i think if all code response is eliminated for BLS, people would rather forget 911 and have family take them to the hospital cause it'd be faster. then you'll have private ambulances AND fire departments loose the transport revenue which..is really the only source of revenue.


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## waaaemt (Oct 31, 2012)

also i think it's really funny how in some threads we all love each other and in other ones everybody wants to give each other stomas


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## JPINFV (Oct 31, 2012)

oogemsquagger said:


> i'm not talking about TIA's if that's what you're saying. of course i'm no PhD so maybe i don't know as much about strokes as you but i'm talking about what the rest of us know as CVAs from clots and aneurysms in the brain.



A stroke and a TIA are both types of CVAs. A TIA is a CVA that resolves in less than 24 hours, an aborted stroke is a CVA that resolves in less than 24 hours *with treatment,* and a stroke is a CVA that lasts longer than 24 hours. Regardless, the treatment time frame for a CVA is measured in hours, normally at 3 hours, but many hospitals/physicians are pushing that to 4 hours or more. 



> yes i know it's counted in hours, but *how are we supposed to know when the onset was/how long the PT waited to call 911?* then the transport time and waiting time at the hospital. plus the 3 hour window doesn't mean it gives us time to wait around for 3 hours from onset. the sooner the PT receives intervention the less damage is done.



[emphasis added]

You can start with asking the patient or the family. Besides, if EMS is unable to get that little tidbit of history, how is the hospital going to get that tidbit of history. Do you think the time stops just because you reached the hospital? Do you think the hospital is going to go "Well, 3 hours and 1 minute. Damn, missed it by thiiisssss much!"? 




> the 50% i said was based off a medic's comment somewhere earlier whose arguement was they shouldn't go code cause only 50% or something of *sick unknown only* calls ended up being serious. so no not all calls which would make that number roughly 5% just the unknown. and 2-3 minutes counts heck of a lot when you have cardiac arrest or serious trauma.



Except most places aren't saving 2-3 minutes. Furthermore, if 2-3 minutes count, then EMS should be required to wait in the ambulance, engine on, map book out, ready to respond instantly. After all, you would be able to save that minute of chute time, and "minutes count."




> another point i'd like to make is to people on here who are saying absolutely no L/S no any BLS. like i said i agree that not all BLS need a code response but it really depends on the call. what if you have someone with a compound ankle fracture? that's not ALS unless they have a severed artery or another life threatening complication. but how long do you want to wait for an ambulance to show up if you're sitting there with your tib/fib poking out of your skin?



So, what pain control is available to EMTs? Somehow an open tib/fib isn't going to respond to just splinting and ice. Some opioids would probably be really appreciated.... therefore making it a paramedic level call in an ideal world. 



> for BS or abuse of system calls, sure let them wait but not the people who have a legitimate injury even if it's not life threatening. i think if all code response is eliminated for BLS, people would rather forget 911 and have family take them to the hospital cause it'd be faster. then you'll have private ambulances AND fire departments loose the transport revenue which..is really the only source of revenue.


Even with code response and code transport, the vast majority of time it would be faster anyways for private transport. It's amazing how much time is saved without having to deal with the 911 operator, ambulance chute time, and ambulance response time, regardless of transport mode. 

Besides, now we're justifying using lights and sirens because it keeps the call volume up? I think you're grasping at straws now.


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## ffemt8978 (Oct 31, 2012)

That thread was closed for a reason, and it wasn't so you could start another one to post your response.

EDIT: Okay, I've reopened this thread after it's cool down period.  If it gets closed again, somebody is getting a forum vacation.


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## Jon (Nov 2, 2012)

Interesting thread. VERY important point, and something that has been getting a lot of discussion out my way in the last year or so.


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## NomadicMedic (Nov 4, 2012)

There's more than a few points made in this thread. None of which are good...

1) New providers like to run code. Lights and sirens are fun and are a break from the monotony of the Renal Rodeo. 

2) private EMS companies run code to meet response time criteria and keep units in service. 

3) 911 services use L&S to meet the public perception of "emergent response". 

It's a fact that L&S increases the risk of a motor vehicle crash and does not save a significant amount of time. 

So, rather than post with "my service runs code 2 or 3..." Or whatever, I'd love to see some constructive ideas as to how we can educate our fellow providers and employers that hot responses and transports are mostly unneeded and dangerous.


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## Veneficus (Nov 4, 2012)

n7lxi said:


> So, rather than post with "my service runs code 2 or 3..." Or whatever, I'd love to see some constructive ideas as to how we can educate our fellow providers and employers that hot responses and transports are mostly unneeded and dangerous.



Personally I would like to see the pay and benefits of providers at any given service reduced to cover the cost of all damages instead of insurance payouts.

But on the constructive side:

It is all about culture. Safety is a way of thinking. 

The first thing that would help is making it illegal for all ambulances that are not part of a 911 system to use a lights and sren response or disobey any traffic law.

I am sure the IAFF and some other powerful backers would get behind sponsoring that legislation.

Another thing is to not let new people drive. This was also pioneered by the fire service where driving was a promotion to be earned over time and training.  I have even worked one place where people with less than 6 months were not permitted to drive any vehicle in emergent conditions.

As for getting the word out, we need to consistently an relentlessly smack down any provider who has an answer other than this is a dangerous practice that needs to stop through peer pressure.

There needs to be grassroots campaigns by providers that challenge EMS leaders anytime they say response times matter or attempt to use them to justify a budget.

We need to create mandatory training not just the safe use of lights and sirens but points out the dangers and consequences of doing it also.

We need to stop teaching moments matter.

We need educated providers who understand why.

Most important, we need real preventative EMS that reduces the need for emergency response though community paramedicine and proactive involvement.

Edit: The use of lights and sirens by an interfacility transport should result in a 6 point penalty automatically to the driver. That will not only make it highly undesirable to get caught, but it will make it near impossible for agencies that push it to mantain employees or pay insurance costs.


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## RocketMedic (Nov 4, 2012)

Emergent responses and L/S have a place (known critical call, heavy traffic, scene marking/warning), but that place is rare and dramatically overused. I have no problems throwing on the lights if I need my ambulance marked, stationary, on the side of a road. Going to that MVA with lights and sirens on, however, is reckless and unsafe. That patent's been sick/injured for some time, and barring extremely heavy traffic, my L/S aren't going to get me there safely any faster. 

They will, however, place everyone at more risk.


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## usalsfyre (Nov 4, 2012)

Veneficus said:


> The first thing that would help is making it illegal for all ambulances that are not part of a 911 system to use a lights and sren response or disobey any traffic law.


I disagree, only because their are certain cases where emergent trips do make sense. Granted they are very rare. The last one I can recall was a 28wk pregnant patient in active labor who had presenting fetal parts, but who's membranes were not ruptured. She was being transferred from an ED in a hospital without a NICU to an academic center. She delivered 5 minutes after arrival. Another case is post-ROSC patients who are transported to non-interventional cath facilities because the protocols say "closest facility". 



Veneficus said:


> I am sure the IAFF and some other powerful backers would get behind sponsoring that legislation.


I would rather keep the IAFF as far away from any legislation involving EMS as possible. We've made enough deals with the devil. 

Perhaps a mandatory utilization review on emergent IFT trips?


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## RocketMedic (Nov 4, 2012)

I think that any change in emergent vs non-emergent responses would predicate a provider who did not believe that occlusive dressings control external hemorrhage, for starters.

I also think that dialysis and discharge trips could be easily handled by ambulettes at far less risk to us, our patients, and the public.


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## Veneficus (Nov 4, 2012)

usalsfyre said:


> Perhaps a mandatory utilization review on emergent IFT trips?



Who is going to do the review? 

The company management who overbooks their dialysis transfers?

The company that wants to keep a contract for IFT with a specific hospital?

What is the penalty?

Against who?

If you need to do an emergent delivery or c-section staff your CCT with a doc that can do it.

Otherwise, no need to whine.

In disasters, countries ask for medical teams. Not individual surgeons or nurses.

If your team cannot handle a case, it is no more critical care than a 911 ambulance.

As for the IAFF, if EMS cannot police itself and outside agency needs to.


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## DrParasite (Nov 4, 2012)

Veneficus said:


> The first thing that would help is making it illegal for all ambulances that are not part of a 911 system to use a lights and sren response or disobey any traffic law.


oh i disagree with you 100%.  even IFTs ambulances, renal runs, and dialysis derby trucks can be dispatched to a routine run, and find their patient is really sick.  If you want to say they shouldn't respond with L&S, that I can agree with.  

but if you have a critical patient (even one that didn't come in as critical), and upon your assessment, you determine the patient needs a higher level of care than you can provide, than absolutely I can see the justification for using your L&S to get the patient to an ER.


----------



## Tigger (Nov 4, 2012)

Veneficus said:


> Who is going to do the review?
> 
> The company management who overbooks their dialysis transfers?
> 
> ...



Who does the review for RSIs and other "advanced" procedures? Usually the company's QA. How is the use of L&S any different?


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## RocketMedic (Nov 4, 2012)

DrParasite said:


> oh i disagree with you 100%.  even IFTs ambulances, renal runs, and dialysis derby trucks can be dispatched to a routine run, and find their patient is really sick.  If you want to say they shouldn't respond with L&S, that I can agree with.
> 
> but if you have a critical patient (even one that didn't come in as critical), and upon your assessment, you determine the patient needs a higher level of care than you can provide, than absolutely I can see the justification for using your L&S to get the patient to an ER.



Many of these rigs are BLS only. This is why ALS 911 exists.


----------



## DrParasite (Nov 4, 2012)

Rocketmedic40 said:


> Many of these rigs are BLS only. This is why ALS 911 exists.


all the more reason to use L&S.  BLS can give oxygen and rapid transport to either ALS or the hospital.  if your ALS is 20 minutes out, and your BLS truck is 10 minutes from the ER, why not just load and go to the ER?

Of course, that would require your BLS crews to be able to identify a sick person, as well as what ALS can do for this sick person, and judging from what I have read on here, many cannot tell the difference between sick and not sick.


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## JPINFV (Nov 4, 2012)

Tigger said:


> Who does the review for RSIs and other "advanced" procedures? Usually the company's QA. How is the use of L&S any different?




Something about chickens and the fox hole... or something like that.


----------



## RocketMedic (Nov 4, 2012)

DrParasite said:


> all the more reason to use L&S.  BLS can give oxygen and rapid transport to either ALS or the hospital.  if your ALS is 20 minutes out, and your BLS truck is 10 minutes from the ER, why not just load and go to the ER?
> 
> Of course, that would require your BLS crews to be able to identify a sick person, as well as what ALS can do for this sick person, and judging from what I have read on here, many cannot tell the difference between sick and not sick.



*cough Jersey medicine* uncough*


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## ffemt8978 (Nov 4, 2012)

So are we assuming that this discussion is only about running L&S within a town or city instead of long, deserted stretches of highways?


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## RocketMedic (Nov 4, 2012)

ffemt8978 said:


> So are we assuming that this discussion is only about running L&S within a town or city instead of long, deserted stretches of highways?



L&S in rural settings is just as dangerous. Plenty of drivers speed up and overdrive the truck and their abilities because it's rural and deserted, and get complacent.


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## ffemt8978 (Nov 4, 2012)

Rocketmedic40 said:


> L&S in rural settings is just as dangerous. Plenty of drivers speed up and overdrive the truck and their abilities because it's rural and deserted, and get complacent.



Agreed, but complacency is not something that is exclusive to driving L&S or even in a rural area.  For my agency, the difference in transport time to an ALS unit is 10 minutes, and to the hospital it is 20 minutes when we drive L&S on the highway and shut down the code when we approach city limits.


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## Jambi (Nov 4, 2012)

ffemt8978 said:


> ...instead of long, deserted stretches of highways?



which seems pointless, though that me be your point no?


----------



## usalsfyre (Nov 4, 2012)

Veneficus said:


> Who is going to do the review?


My thought in my area is the local Regional Advisory Councils. We currently do an internal review of all emergent runs.



Veneficus said:


> What is the penalty?


We start with education and move through the disciplinary process as needed. I assume a RAC would do something similar.



Veneficus said:


> Against who?


At the regional level? Fine the company. This gives them incentive to educate their people



Veneficus said:


> If you need to do an emergent delivery or c-section staff your CCT with a doc that can do it.


You're still delivering a 28 wk'r in the out-of-hospital environment which is less than ideal. 



Veneficus said:


> Otherwise, no need to whine.


Not whining, just disagreeing. I'm not a fun of running emergent by any means. But there are a very few circumstances where it's called for.



Veneficus said:


> In disasters, countries ask for medical teams. Not individual surgeons or nurses.
> 
> If your team cannot handle a case, it is no more critical care than a 911 ambulance.


I would wager the vast (95%+) majority of CCT teams in the US are ill prepared for the above circumstance no matter what the team make up. 



Veneficus said:


> As for the IAFF, if EMS cannot police itself and outside agency needs to.


Then lets have it be a governmental function and not involve an organization that has shown no inkling towards actually improving EMS.


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## ffemt8978 (Nov 4, 2012)

Jambi said:


> which seems pointless, though that me be your point no?



See my post about transport times.


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## DrParasite (Nov 4, 2012)

Rocketmedic40 said:


> *cough Jersey medicine* uncough*


*cough if you want to wait for your 911 ALS units, you must have a plethora of unused ALS units just waiting around or too many ALS units who never see sick people, so you wouldn't know one if it spit in your face *uncough*

are you really arrogant enough to think that OK mortality rates are that much better than that of NJ?  and if you are, do you have the date to back it up, as well as the hard evidence to conclusively show that it is a direct result of your all ALS systems?  

if not, than feel free to STFU


----------



## ffemt8978 (Nov 4, 2012)

Play nice or become the focus of my complete and undivided attention.


----------



## Tigger (Nov 4, 2012)

DrParasite said:


> *cough if you want to wait for your 911 ALS units, you must have a plethora of unused ALS units just waiting around or too many ALS units who never see sick people, so you wouldn't know one if it spit in your face *uncough*
> 
> are you really arrogant enough to think that OK mortality rates are that much better than that of NJ?  and if you are, do you have the date to back it up, as well as the hard evidence to conclusively show that it is a direct result of your all ALS systems?



If we limit mortality rates to be the only determinant of a successful system then we are doing our patients a disservice. If you break your leg do you want paramedics to show up immediately and provide pain control, or would you rather a BLS crew splint you, move you as scream to the truck, and then maybe get an ALS rendezvous on the way to the hospital? I know which one I want, and I know it from experience. 



> if not, than feel free to STFU



Also, feel free to be respectful.


----------



## ffemt8978 (Nov 4, 2012)

Last warning...


----------



## Tigger (Nov 4, 2012)

JPINFV said:


> Something about chickens and the fox hole... or something like that.



Yet so many are quick to praise services that have extensive in house review programs along with the ability to reeducate those that have made mistakes as progressive and those that we should look up to.


----------



## JPINFV (Nov 4, 2012)

Tigger said:


> Yet so many are quick to praise services that have extensive in house review programs along with the ability to reeducate those that have made mistakes as progressive and those that we should look up to.




I might be assuming a little too much, but I get the feeling that the companies that play fast and loose with lights and sirens aren't the ones with the legitimate in-house review programs. 

Of course no sooner I say then than I think, "Boston EMS."


----------



## usalsfyre (Nov 4, 2012)

Tigger said:


> Yet so many are quick to praise services that have extensive in house review programs along with the ability to reeducate those that have made mistakes as progressive and those that we should look up to.



This is the point I'm making. I obviously work for a non-911 private. We're also HIGHLY aware of the liability involved in emergent response. If anyone gets caught running code to a dialysis run it would be bad to say the least.


----------



## RocketMedic (Nov 4, 2012)

I feel that a huge portion of our accidents as an industry "running code" involve volunteers and ill-trained responders "racing to the scene because moments matter". Why do I pick on them? Because they are, statistically, the most common EMS providers, and they are the most likely to lack exposure to large vehicle operation and proper medical training. There is a definite time for speed and our alarm systems (respiratory distress, witnessed arrests, etc). These situations are few and far between. My service runs L/S to every call, regardless of priority, and it has killed and injured people. We have not learned from our mistakes, and expect EVOC classes to somehow keep accidents from happening.

Until we, as a profession, can keep our members from putting lightbars on POVs and educate our management staff as to the import of response times, we are going to keep seeing crashes, injuries and deaths.


----------



## ffemt8978 (Nov 4, 2012)

Rocketmedic40 said:


> I feel that a huge portion of our accidents as an industry "running code" involve volunteers and ill-trained responders "racing to the scene because moments matter". Why do I pick on them? Because they are, statistically, the most common EMS providers, and they are the most likely to lack exposure to large vehicle operation and proper medical training. There is a definite time for speed and our alarm systems (respiratory distress, witnessed arrests, etc). These situations are few and far between. My service runs L/S to every call, regardless of priority, and it has killed and injured people. We have not learned from our mistakes, and expect EVOC classes to somehow keep accidents from happening.
> 
> Until we, as a profession, can keep our members from putting lightbars on POVs and educate our management staff as to the import of response times, we are going to keep seeing crashes, injuries and deaths.



And yet my volunteer agency has only had one accident while running code (other driver ran a red light and clipped the front of the ambulance - in full view of a police officer waiting at the light).  

Tossing this out for discussion, but maybe are lack of exposure to daily code 3 driving actually makes us more cautious when we do it, rather than adopting an attitude of complacency from doing it every day.


----------



## RocketMedic (Nov 4, 2012)

ffemt8978 said:


> And yet my volunteer agency has only had one accident while running code (other driver ran a red light and clipped the front of the ambulance - in full view of a police officer waiting at the light).
> 
> Tossing this out for discussion, but maybe are lack of exposure to daily code 3 driving actually makes us more cautious when we do it, rather than adopting an attitude of complacency from doing it every day.



It's highly agency-dependent. Some of the volunteers I've seen are very careful, safe drivers. I've also seen ones who drive like they're on fire. I think it's leadership-dependent.


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## ffemt8978 (Nov 4, 2012)

Rocketmedic40 said:


> It's highly agency-dependent. Some of the volunteers I've seen are very careful, safe drivers. I've also seen ones who drive like they're on fire. I think it's leadership-dependent.



I'll agree with that.  All of our people authorized to drive the ambulances are farm boys with years of experience driving bigger vehicles.


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## Aidey (Nov 4, 2012)

ffemt8978 said:


> And yet my volunteer agency has only had one accident while running code (other driver ran a red light and clipped the front of the ambulance - in full view of a police officer waiting at the light).
> 
> Tossing this out for discussion, but maybe are lack of exposure to daily code 3 driving actually makes us more cautious when we do it, rather than adopting an attitude of complacency from doing it every day.



N=1 

It is probably tied into miles driven and traffic density, along with experience.


----------



## Rialaigh (Nov 4, 2012)

Part of the issue is the agency protocols or the contract with dispatch. I know in our fire department if we get toned out for a call, unless dispatch says non-emergent we are required to run the call emergent. If we get toned out for a 70 year old who fell 5 minutes ago. We are required to run emergent until another unit on scene (LEO, EMS, or another fire unit) downgrades us to non emergent. If we were to get in a wreck going to the call with out lights and sirens off we would be liable for NOT running emergent. 

The county fire service made the decision to remove the responsibility of determining the urgency of a call from the fire department members "scope of practice" for lack of better term. We don't have the ability to make that decision anymore until there is someone with a radio on scene or unless the persons on scene request us non emergent or it is classified as a "non emergent call" (such as, traffic control). All "emergent calls" that we are toned out for are supposed to be responded to with the same urgency (emergent) as they are all "emergencies"


----------



## DrParasite (Nov 4, 2012)

Tigger said:


> If we limit mortality rates to be the only determinant of a successful system then we are doing our patients a disservice. If you break your leg do you want paramedics to show up immediately and provide pain control, or would you rather a BLS crew splint you, move you as scream to the truck, and then maybe get an ALS rendezvous on the way to the hospital? I know which one I want, and I know it from experience.


honest answer?  and this one I will blame on "jersey prehospital medicine", have the BLS crew splint the leg, and take a nice slow ride to the ER.  If I called for ALS for pain control for a simple broken leg (or arm, or finger, or toe, etc), I would get laughed at by the paramedics.  Might not be right, but it is how our state's medical director (he's that doctor guy who designs protocols for the dept of health) has the pain management protocols written.  not necessarily right or wrong, but it is what it is.





Tigger said:


> Also, feel free to be respectful.


your right, I answer an extremely inappropriate comment with an equally inappropriate comment.  Apologies to those who I offended.


----------



## DrParasite (Nov 4, 2012)

Aidey said:


> N=1
> 
> It is probably tied into miles driven and traffic density, along with experience.


in that case, I would argue that an IFT/private company would drive more miles than a 911 ambulance in an urban setting.  in fact, the only way for them to gain more L&S experience is to, well, drive more often with L&S.


----------



## Aidey (Nov 4, 2012)

My supposition is that the accident rate for L&S is tied to those things in addition to experience with L&S. It is a little hard to cause a crash with another vehicle if you work in an area with no traffic.


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## RocketMedic (Nov 4, 2012)

DrParasite said:


> honest answer?  and this one I will blame on "jersey prehospital medicine", have the BLS crew splint the leg, and take a nice slow ride to the ER.  If I called for ALS for pain control for a simple broken leg (or arm, or finger, or toe, etc), I would get laughed at by the paramedics.  Might not be right, but it is how our state's medical director (he's that doctor guy who designs protocols for the dept of health) has the pain management protocols written.  not necessarily right or wrong, but it is what it is.your right, I answer an extremely inappropriate comment with an equally inappropriate comment.  Apologies to those who I offended.



That's a horrible MD then, with equally lazy paramedics. Palliation of pain is literally one of the only things that separates ALS from BLS, and any paramedic that laughs at a BLS crew for requesting their services to comfort a patient should be remediated at the least.


----------



## Tigger (Nov 5, 2012)

usalsfyre said:


> This is the point I'm making. I obviously work for a non-911 private. We're also HIGHLY aware of the liability involved in emergent response. If anyone gets caught running code to a dialysis run it would be bad to say the least.



Exactly, it seems unlikely that private companies would be likely to sweep this sort of issue under the rug given the liability. Coworkers have been fired on the spot for this sort of transgression because as it is the company hates how much liability emergent responses open the company up to. 

I imagine most companies care greatly about this as this litigation resulting from a crash in this scenario could probably bankrupt many companies. 

Every BLS emergency and all ALS calls get reviewed where I work (no idea how they have time for that). 911 calls get an internal review and by a third party QA company as mandated by the 911 contract. Unfortunately everyone around here transports  to the hospital emergent so that isn't frowned upon by anyone. That is a separate, cultural issue that needs to be addressed.



DrParasite said:


> honest answer?  and this one I will blame on "jersey prehospital medicine", have the BLS crew splint the leg, and take a nice slow ride to the ER.  If I called for ALS for pain control for a simple broken leg (or arm, or finger, or toe, etc), I would get laughed at by the paramedics.  Might not be right, but it is how our state's medical director (he's that doctor guy who designs protocols for the dept of health) has the pain management protocols written. * not necessarily right or wrong, but it is what it is.*


*
*
It's not right or wrong, it's plain and simply wrong. We have the ability to control pain in the field, to not do so is simply bad medicine. If I break my leg where I am sitting here in Colorado, I will receive pain control. Why should these regional variances exist? 

I point you towards this blog post from Peter Canning, note the following as originally published in the _Journal of the Royal Army Medical Care_ "The effective management of pain in the pre-hospital environment may be the most important contribution to the survival and long term well being of a casualty that we can make. The pre-hospital practitioner has the first and perhaps only opportunity to break the pain cascade.”

EMS can make a difference here, there are unfortunately still places that choose not to.


----------



## Veneficus (Nov 5, 2012)

usalsfyre said:


> My thought in my area is the local Regional Advisory Councils. We currently do an internal review of all emergent runs.



You work for an upstanding service and are an upstanding provider. I respectfully, but emphatically doubt even 10% of IFT services are of such caliber.




usalsfyre said:


> We start with education and move through the disciplinary process as needed. I assume a RAC would do something similar..



Even the best services I have worked for that did IFT would use lights and sirens as policy to protect contracts or meet unreasonable demands. I have also never worked in an area where the regional advisory council existed or had anymore input than medical protocol advice.

I agree though that this would probably work if there was a financial fine and real teeth leveled against companies inappropriately using L/S.




usalsfyre said:


> At the regional level? Fine the company. This gives them incentive to educate their people..



In my experience it is not the individuals that push for L/S in IFT, it is the company management themselves. I would be concerned about companies creating "magic word" run reports to justify their practices and avoid sanction.




usalsfyre said:


> You're still delivering a 28 wk'r in the out-of-hospital environment which is less than ideal.



Fully agree. Life is imperfect though. 




usalsfyre said:


> Not whining, just disagreeing. I'm not a fun of running emergent by any means. But there are a very few circumstances where it's called for.



Do you think there is a way of preventing the need?

Sorry, the original quote came off harsher than I intended, I wrongfully was presuming a response from somebody (other than you actually) about how doctors are not on ambulances.




usalsfyre said:


> I would wager the vast (95%+) majority of CCT teams in the US are ill prepared for the above circumstance no matter what the team make up.



I would agree, but I also think that it is not because they need to be ill prepared. The use of physicians out of the hospital is re-catching on in the US. I think coupled with the emerging discipline of perinatology, I do not think having a CCT team and equipment that could handle this is outrageous or out of reach. I think it is simply a matter of profit margin.



usalsfyre said:


> Then lets have it be a governmental function and not involve an organization that has shown no inkling towards actually improving EMS.



Again I agree, but there is a push for less government, not more. What I would really like to see in joint commision or similar body get involved in EMS regulation. 

American Ambulance Association is definately too biased to do it.


----------



## DrParasite (Nov 5, 2012)

Tigger said:


> Why should these regional variances exist?


Can't answer that one.... but I know regional variances exist nationwide, even between different regions within a state, and sometimes the variances are agency specific.  More often than not its a decision made by a medical doctor *you know, those all knowing people who have 8+ years of schooling that can do no wrong, not us less than 2 year degree people*, and we (the EMTs, paramedics, field personnel) can just do what they are told.

and you think it's wrong (with your 3 month patch or 1 year patch), that's your prerogative, go tell the doctor that he's wrong.  Tell him all your education means you know more than him.  Let me know what he says.  If he says give pain meds, than I will give pain meds.  if he says not to, than I got to follow the doctor's orders.  Remember, we all operate under a doctor's license.


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## usalsfyre (Nov 5, 2012)

DrParasite said:


> Can't answer that one.... but I know regional variances exist nationwide, even between different regions within a state, and sometimes the variances are agency specific.  More often than not its a decision made by a medical doctor *you know, those all knowing people who have 8+ years of schooling that can do no wrong, not us less than 2 year degree people*, and we (the EMTs, paramedics, field personnel) can just do what they are told.
> 
> and you think it's wrong (with your 3 month patch or 1 year patch), that's your prerogative, go tell the doctor that he's wrong.  Tell him all your education means you know more than him.  Let me know what he says.  If he says give pain meds, than I will give pain meds.  if he says not to, than I got to follow the doctor's orders.  Remember, we all operate under a doctor's license.



I do not know more about medicine than any physician. That said, I am probably more up to date on current standards and practices in a number of areas than many. A blanket "the doc knows best" is a poor excuse. I've seen physicians blatantly violating standards of care because they weren't up to date or weren't familiar with what they were doing. Should I give them a pass too?


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## Hunter (Nov 5, 2012)

DrParasite said:


> and you think it's wrong (with your 3 month patch or 1 year patch), that's your prerogative, go tell the doctor that he's wrong.  Tell him all your education means you know more than him.  Let me know what he says.  If he says give pain meds, than I will give pain meds.  if he says not to, than I got to follow the doctor's orders.  Remember, we all operate under a doctor's license.



We had a pair of medical students starting their rotations after all their class room time, me and my partner helped them start an iv on a patient. I will tell a doctor that he's wrong, because with all their knowledge they're still human, which means they can make mistakes. I will ofcourse do it in a professional/respectful manner. Specially on something line running code where I have more first hand experience.


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## TransportJockey (Nov 5, 2012)

DrParasite said:


> Can't answer that one.... but I know regional variances exist nationwide, even between different regions within a state, and sometimes the variances are agency specific.  More often than not its a decision made by a medical doctor *you know, those all knowing people who have 8+ years of schooling that can do no wrong, not us less than 2 year degree people*, and we (the EMTs, paramedics, field personnel) can just do what they are told.
> 
> and you think it's wrong (with your 3 month patch or 1 year patch), that's your prerogative, go tell the doctor that he's wrong.  Tell him all your education means you know more than him.  Let me know what he says.  If he says give pain meds, than I will give pain meds.  if he says not to, than I got to follow the doctor's orders.  Remember, we all operate under a doctor's license.


No. If i am getting orders from a doc for (the few times i am required to by my protocol, since most, including narcotics are standing orders) meds, and they give me a dangerous dose or an incorrect dose, it is my job to ask the doctor if he is giving the right dose of the right med. I will gladly ask the doctor if he is thinking correctly


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## mycrofft (Nov 6, 2012)

5=4


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## Tigger (Nov 6, 2012)

DrParasite said:


> Can't answer that one.... but I know regional variances exist nationwide, even between different regions within a state, and sometimes the variances are agency specific.  More often than not its a decision made by a medical doctor *you know, those all knowing people who have 8+ years of schooling that can do no wrong, not us less than 2 year degree people*, and we (the EMTs, paramedics, field personnel) can just do what they are told.
> 
> and you think it's wrong (with your 3 month patch or 1 year patch), that's your prerogative, go tell the doctor that he's wrong.  Tell him all your education means you know more than him.  Let me know what he says.  If he says give pain meds, than I will give pain meds.  if he says not to, than I got to follow the doctor's orders.  Remember, we all operate under a doctor's license.



I have a hard time believing any doctor actually believes that it would be poor patient care to provide pain management in the field. I am sure there are many medical directors that are afraid of the risk (real or imagined) associated with giving paramedics this ability, however that does not mean that they are practicing good medicine.


----------



## bigslaank (Nov 6, 2012)

*Illinois*

Illinois already has it in the works they are going to limit ambulance speeds to 75 or 72 miles an hour sounds like a good idea.  Might help keep people in check a little bit.  After watching a fire truck roll in front of me a few years ago when a car turned in front of them. I'm not a fan of lights and sirens. And the people that get way to worked up when they are on.


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## medic17 (Nov 7, 2012)

n7lxi said:


> I read a post in another thread that said, when referring to a city's BLS ambulance response, "you must be excited, you get to run code to everything".
> 
> When are we going to stop endangering ourselves and the public, by driving recklessly, with lights and sirens, to calls that are simply not emergent.
> 
> ...



That is why my EMS only responds hot to calls that may be life threatening or might involve series damage to the pt. The dispatcher is a medic with training in threat assessment as well. what you said about headache or general feeling of illness not needing lights and sirens may not always be true, they can be a not so obvious CVA, TIA or MI. In your situation our BLS team is usually already there.


----------



## NomadicMedic (Nov 7, 2012)

medic17 said:


> That is why my EMS only responds hot to calls that may be life threatening or might involve series damage to the pt. The dispatcher is a medic with training in threat assessment as well. what you said about headache or general feeling of illness not needing lights and sirens may not always be true, they can be a not so obvious CVA, TIA or MI. In your situation our BLS team is usually already there.



Did you read any of the other posts? The point is, private ambulance companies respond emergent to calls where there is already an EMT on site, who is managing patient care and HAS NOT called for ALS. They do this ONLY to meet time requirements in the contract. That is simply dangerous and reckless. 

I have no issue with first responders making a hot initial response if the dispatch criteria warrants. i.e., a reported cardiac arrest or severe respiratory difficulty. I also have no problem with medics making a response to an emergent ALS call, if the dispatch criteria is met.


----------



## medic17 (Nov 7, 2012)

n7lxi said:


> Did you read any of the other posts? The point is, private ambulance companies respond emergent to calls where there is already an EMT on site, who is managing patient care and HAS NOT called for ALS. They do this ONLY to meet time requirements in the contract. That is simply dangerous and reckless.
> 
> I have no issue with first responders making a hot initial response if the dispatch criteria warrants. i.e., a reported cardiac arrest or severe respiratory difficulty. I also have no problem with medics making a response to an emergent ALS call, if the dispatch criteria is met.



Yes but it should be illegal to go hot for any reason that i did not mention.


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## Handsome Robb (Nov 7, 2012)

medic17 said:


> Yes but it should be illegal to go hot for any reason that i did not mention.



You should look up Emergency Medical Dispatching.

We go cold to headaches and "sick people" all day long. Hell, I want cold to a chest pain call the other day. Albeit he was 18 and had no other symptoms.

Who made your word law?


----------



## Tigger (Nov 7, 2012)

NVRob said:


> You should look up Emergency Medical Dispatching.
> 
> We go cold to headaches and "sick people" all day long. Hell, I want cold to a chest pain call the other day. Albeit he was 18 and had no other symptoms.
> 
> Who made your word law?



As it should be. It is not possible for only certain "conditions" to determine the priority of a response. Certain signs and symptoms (as you note) trigger the dispatcher to assign a priority. 

It would be foolish for a field provider to make their own priority determination based on what information dispatch has given them as more often than not the responding unit is not necessarily getting the whole picture.


----------



## mpena (Nov 10, 2012)

Medic Tim said:


> And then spend 5+ minutes before unloading the pt once at the hospital.
> 
> We have priority dispatch. We run hot to about 60% of our calls. Most of them do not require a hot responce. I can count on one hand the number of times I have gone to the hospital hot this year. We have some crews that go hot for just about everything. *It has been my experience that ppl who run code for everything are not comfortable in their assessment/skills or are new.[/*



Please, enlighten us..


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## Medic Tim (Nov 10, 2012)

mpena said:


> Please, enlighten us..



What do you want to hear? do you disagree?

I have worked for different companies in different countries and my experiences were similar. Providers who for whatever reason are not confidentcomfortable assessing pt usually go code for the slightest thing. With experience , time, and education some become more comfortable with their role and abilities. There are also those that have the notion that driving code is safer and saves time. Instead of addressing the needs of the pt they rush to the hospital with minimal assessment and treatment.

I am sure other peoples experiences are different than mine but I know others have had the same/similar experience.


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## medic17 (Nov 10, 2012)

Medic Tim said:


> What do you want to hear? do you disagree?
> 
> I have worked for different companies in different countries and my experiences were similar. Providers who for whatever reason are not confidentcomfortable assessing pt usually go code for the slightest thing. With experience , time, and education some become more comfortable with their role and abilities. There are also those that have the notion that driving code is safer and saves time. Instead of addressing the needs of the pt they rush to the hospital with minimal assessment and treatment.
> 
> I am sure other peoples experiences are different than mine but I know others have had the same/similar experience.



In my EMS we have protocol to keep time in the field to a minimum. Unless we can diagnose the sickness (or no sickness sometimes) we transport and do the second survey in the rig (although this is not always the case and much is left to the highest ranking medic to decide) . I remember a call i witnessed before i got licensed for 38 y/o F chest pain and difficulty breathing no history of lung or heart problem. The EMT at the seen measured VS all normal and transported. (It turned out to be a vary Mysterious case. The doc said panic attack but 4 months later she was diagnosed with a severe psychiatric condition and sent to a mental hospital. Left with 100% disability.)


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## medic17 (Nov 10, 2012)

NVRob said:


> You should look up Emergency Medical Dispatching.
> 
> We go cold to headaches and "sick people" all day long. Hell, I want cold to a chest pain call the other day. Albeit he was 18 and had no other symptoms.
> 
> Who made your word law?



It is up to the dispatcher to try to get all the picture but if there is no clear picture we respond hot. The example you mentioned is not a hot case.


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## Handsome Robb (Nov 10, 2012)

medic17 said:


> It is up to the dispatcher to try to get all the picture but if there is no clear picture we respond hot. The example you mentioned is not a hot case.



Our dispatchers don't gather information, call takers do though.

This whole grab and run mantra in EMS is ridiculous except in a very few cases.

Let me ask you this, I spent an extra two minutes on scene of a nasty 100 mph motorcycle accident so my partner and I could drop bilateral large bore lines because I wouldn't have had time to do both en route. Total scene time was 14 minutes. Did I do it wrong?


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## RocketMedic (Nov 10, 2012)

medic17 said:


> In my EMS we have protocol to keep time in the field to a minimum. Unless we can diagnose the sickness (or no sickness sometimes) we transport and do the second survey in the rig (although this is not always the case and much is left to the highest ranking medic to decide) . I remember a call i witnessed before i got licensed for 38 y/o F chest pain and difficulty breathing no history of lung or heart problem. The EMT at the seen measured VS all normal and transported. (It turned out to be a vary Mysterious case. The doc said panic attack but 4 months later she was diagnosed with a severe psychiatric condition and sent to a mental hospital. Left with 100% disability.)



$15/hour. (seen = scene, very, mysterious need not be capitalized.) Writing is one of my pet peeves, and it helps you to communicate ideas when you use correct punctuation. 


This is a perfect example of poor education, folks (not to pick on you, medic17.) Even with an active, severe medical or psychiatric emergency, the vast majority of our patients are _not_ actively dying, nor are they going to benefit from emergent transport. Unless those assessment findings detect an emergent life threat that can literally kill/disable them in minutes _and_ your transport time will be impacted by L/S, the only thing you did for that patient was to place her and yourselves at risk where there need be none.
We've all done it, either due to inexperience, ignorance or procedure. It's done every day. That doesn't make it right.


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## Jon (Nov 11, 2012)

Medic Tim said:


> What do you want to hear? do you disagree?
> 
> I have worked for different companies in different countries and my experiences were similar. Providers who for whatever reason are not confidentcomfortable assessing pt usually go code for the slightest thing. With experience , time, and education some become more comfortable with their role and abilities. There are also those that have the notion that driving code is safer and saves time. Instead of addressing the needs of the pt they rush to the hospital with minimal assessment and treatment.
> 
> I am sure other peoples experiences are different than mine but I know others have had the same/similar experience.



I tend to use lights far more during transport at my rural/suburban job than my suburban or suburban/urban jobs. When every hospital is 15-20 minutes away, I'm a fan of "getting there" sometimes, especially if there really isn't anything I can do for the patient.

As to the comment of "5 minutes in the back before you unload" - It's always bugged me when I see medics that will sit at a scene and camp out in the truck for 5-10 minutes (when the hospital is 5 minutes away) or futz around in the back at the hospital. If you can't get it done, don't do it, and don't let a nurse browbeat you because she has to *do her job* and start an IV and draw bloods. I try to spend as little time camped on a scene as possible - if the patient truly needs IV meds, I might get a line, but we're moving as soon as it's secured.

Jon


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## Veneficus (Nov 11, 2012)

NVRob said:


> Let me ask you this, I spent an extra two minutes on scene of a nasty 100 mph motorcycle accident so my partner and I could drop bilateral large bore lines because I wouldn't have had time to do both en route. Total scene time was 14 minutes. Did I do it wrong?



I wouldn't say wrong, but not a good idea. 

So you have 2 IV lines? So what?

Serious trauma does benefit by grab and run.


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## medicsb (Nov 11, 2012)

NVRob said:


> Our dispatchers don't gather information, call takers do though.
> 
> This whole grab and run mantra in EMS is ridiculous except in a very few cases.
> 
> Let me ask you this, I spent an extra two minutes on scene of a nasty 100 mph motorcycle accident so my partner and I could drop bilateral large bore lines because I wouldn't have had time to do both en route. Total scene time was 14 minutes. Did I do it wrong?



I tend to agree that "load and go" is wayyy over-rated.  In most cases, taking an extra 5 minutes to get everything in order is not a bad idea.  I generally think it's fine if scene time is ≤ 20 minutes.  But, for severe trauma, it is best to keep it short as possible.  The 2 large bore IVs should be thought of as a courtesy to the hospital and not a requirement.  My general approach was get any IV (even if just a 20g) as soon as the patient was loaded as it would usually take a minute or 2 for equipment to be loaded and for the EMT to get in the driver's seat.  I'd use that interval to get an IV and then go for a 16 or 14 enroute.  

If all you get is a 20g, it can still be used for meds.  If the patient really needs blood/fluid, the trauma team should be able to throw in a 8.5 fr CVC pretty easily.


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## RocketMedic (Nov 11, 2012)

I'll delay onscene to secure an airway, but generally, IVs aren't on my short list for serious trauma.


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## TransportJockey (Nov 11, 2012)

Rocketmedic40 said:


> I'll delay onscene to secure an airway, but generally, IVs aren't on my short list for serious trauma.



Same here, especially with my long transport times. Although half the time I will just throw in an MLA and call it good.


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## medic417 (Nov 11, 2012)

Veneficus said:


> I wouldn't say wrong, but not a good idea.
> 
> So you have 2 IV lines? So what?
> 
> Serious trauma does benefit by grab and run.





medicsb said:


> I tend to agree that "load and go" is wayyy over-rated.  In most cases, taking an extra 5 minutes to get everything in order is not a bad idea.  I generally think it's fine if scene time is ≤ 20 minutes.  But, for severe trauma, it is best to keep it short as possible.  The 2 large bore IVs should be thought of as a courtesy to the hospital and not a requirement.  My general approach was get any IV (even if just a 20g) as soon as the patient was loaded as it would usually take a minute or 2 for equipment to be loaded and for the EMT to get in the driver's seat.  I'd use that interval to get an IV and then go for a 16 or 14 enroute.
> 
> If all you get is a 20g, it can still be used for meds.  If the patient really needs blood/fluid, the trauma team should be able to throw in a 8.5 fr CVC pretty easily.





Rocketmedic40 said:


> I'll delay onscene to secure an airway, but generally, IVs aren't on my short list for serious trauma.





TransportJockey said:


> Same here, especially with my long transport times. Although half the time I will just throw in an MLA and call it good.




Exactly because we don't want them to die because we missed the golden hour.:rofl:


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## TransportJockey (Nov 11, 2012)

medic417 said:


> Exactly because we don't want them to die because we missed the golden hour.:rofl:



Lol even if I do nothing on scene I miss that fictional golden hour. I just have plenty of time to do everything en route... And then some.


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## medic417 (Nov 11, 2012)

TransportJockey said:


> Lol even if I do nothing on scene I miss that fictional golden hour. I just have plenty of time to do everything en route... And then some.



When they used to preach the golden hour I used to ask why do I even bother trying to help the patient cause they won't be in surgery in an hour or even two.


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## VFlutter (Nov 11, 2012)

On a side note: I was downtown yesterday walking around for school when a multi-alarm fire was paged out. I ended up seeing 3 STLFD Fire trucks and 2 ambulances from various stations going to the scene and all of them did a horrible job of clearing intersections. The one firetruck was going ~35 mph through a red light with no attempt to slow down or check for oncoming traffic with almost resulted in an accident. It was insane. 


Reminds me of this crash that happened a while ago. 

http://www.youtube.com/watch?v=3jAmoXl8fws&feature=plcp


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## AnthonyM83 (Nov 11, 2012)

medic417 said:


> When they used to preach the golden hour I used to ask why do I even bother trying to help the patient cause they won't be in surgery in an hour or even two.


 I've definitely seen them in surgery within that time.





Medic Tim said:


> What do you want to hear? do you disagree?
> 
> I have worked for different companies in different countries and my experiences were similar. Providers who for whatever reason are not confidentcomfortable assessing pt usually go code for the slightest thing. With experience , time, and education some become more comfortable with their role and abilities.


I've only worked in systems were responding code 2 or code 3 is pre-decided by EMD and protocols, not at discretion of ambulance....still, I haven't noticed a correlation between poor assessment skills and wanting to go faster. The determinant to wanting to get to the call faster usually has to do with age and newness level and excitability.

Now, wanting to transport code 3 TO the hospital, does seem to have some correlation with confidence in TREATMENT skills (which is also based on assessment).


Also, might be different in some areas, but around the busy areas here, going code 3 isn't about rushing to get to the call. It's just a routine driving to cut response times by 10 to 30 minutes...it's not unusual to see the attendant sleeping or reading the paper on the way there (not that that's appropriate). Lights/Sirens does NOT equal HaulAss.


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## medic417 (Nov 11, 2012)

AnthonyM83 said:


> I've definitely seen them in surgery within that time.



In other words my patients won't as they won't even be at hospital yet in many cases.


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## ffemt8978 (Nov 11, 2012)

medic417 said:


> In other words my patients won't as they won't even be at hospital yet in many cases.



Ditto.  We may not even be on scene in the "Golden Hour", depending upon where they are.


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## AnthonyM83 (Nov 11, 2012)

NVRob said:


> Our dispatchers don't gather information, call takers do though.
> 
> This whole grab and run mantra in EMS is ridiculous except in a very few cases.
> 
> Let me ask you this, I spent an extra two minutes on scene of a nasty 100 mph motorcycle accident so my partner and I could drop bilateral large bore lines because I wouldn't have had time to do both en route. Total scene time was 14 minutes. Did I do it wrong?



I'm a big fan of load an go. There is a correlation with time to trauma center and survival rates. I tend to emphasize it mainly because our service area has a problem with long scene times with critical traumas.

There definitely might be sometimes you'll decide to get an IV on-scene, because you feel you have a chance then, and he might lose pressure by the time you're en-route, etc etc, but that should me more of an exception.

Also, on-scene, I'd prefer all hands to be working on exposing and getting patient loaded as fast as possible, rather than setting up needles and IV bags. It would take a pretty big exception for me to stay on-scene two minutes for an IV. It's hard to justify how that benefits the patient. Get going, get one en-route, the second at the ER.

And to MedicSB said starting large bore IVs is just a courtesy to the ER, with a critical trauma, it's part of the standard of care to get your vascular access in case the patient needs intervention (whether from you or ER staff). It's not doing it for the ER, it's doing it because the patient requires it.


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## medic417 (Nov 11, 2012)

ffemt8978 said:


> Ditto.  We may not even be on scene in the "Golden Hour", depending upon where they are.



Really sucs when the family has to watch someone die waiting for us for hours.


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## medicsb (Nov 11, 2012)

AnthonyM83 said:


> And to MedicSB said starting large bore IVs is just a courtesy to the ER, with a critical trauma, it's part of the standard of care to get your vascular access in case the patient needs intervention (whether from you or ER staff). It's not doing it for the ER, it's doing it because the patient requires it.



I know I didn't explicitly say it but my point is that one shouldn't sacrifice transport time for time to get 2 large bore IVs on scene.  If you can get one quickly on scene then great, if you can't then go for it enroute.  If you don't get 2 large bores, no big deal, the trauma team is fully capable of doing it themselves.  Right now, there's no evidence that the prehospital IV (or 2) makes a difference (remember how the back of a police car has been shown to be just as good as an ambulance, if not better).  If it makes a difference, it will be for TBI (via RSI) or pain management for the not-so-critical, less time-sensitive patient.  In those cases, a 22g would be adequate most of the time (not that I'd place a 22).


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## TransportJockey (Nov 11, 2012)

ffemt8978 said:


> Ditto.  We may not even be on scene in the "Golden Hour", depending upon where they are.



Assume for us. I love rural EMS for that reason lol


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## Veneficus (Nov 11, 2012)

medic417 said:


> When they used to preach the golden hour I used to ask why do I even bother trying to help the patient cause they won't be in surgery in an hour or even two.



You must work in the middle of nowhere.

For us dwntown, surgery within 20 minutes of EMS drop off is a normal event. Only because it takes time to set up an OR.

When needed surgical intervention takes place right in the ED.

But aside from the relatively small amount of people who need immediate surgical intervention, there are still toys like blood that help considerably more than normal saline for those who are actually seriously injured.

As well for those with wounds that can be managed nonoperably, like low grade liver lacerations and some stabs and GSWs, knowing and initiating treatment sooner rather than later is just more useful that somebody laying in the street getting a couple of IVs.

For people who live and play where the benefits of society are not available, they can expect to die out there. Tragic perhaps, but predictable.


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## RocketMedic (Nov 12, 2012)

medic417 said:


> Really sucs when the family has to watch someone die waiting for us for hours.



Meh, living in the sticks has its pros and cons. I personally live within 15 miles of a Level-1 trauma center and within eyesight of a regional hospital.


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## RocketMedic (Nov 24, 2012)

Update: Responding emergent to everything really, really sucks.


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## Veneficus (Nov 24, 2012)

Rocketmedic40 said:


> Update: Responding emergent to everything really, really sucks.



I could use some lunch actually, if you're bringing it, lights and sirens are ok.


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## RocketMedic (Nov 24, 2012)

Veneficus said:


> I could use some lunch actually, if you're bringing it, lights and sirens are ok.



"Priority three, hand pain!"

"It's literally down the road. She's waving to us."

"EMERGENCY! ALL CALLS DESERVE AN EMERGENT RESPONSE!"


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## ffemt8978 (Nov 24, 2012)

Rocketmedic40 said:


> "Priority three, hand pain!"
> 
> "It's literally down the road. She's waving to us."
> 
> "EMERGENCY! ALL CALLS DESERVE AN EMERGENT RESPONSE!"



Did she injure it while dialing 911?  :rofl:


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## RocketMedic (Nov 24, 2012)

ffemt8978 said:


> Did she injure it while dialing 911?  :rofl:



Starcare!


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## Veneficus (Nov 24, 2012)

Rocketmedic40 said:


> "Priority three, hand pain!"
> 
> "It's literally down the road. She's waving to us."
> 
> "EMERGENCY! ALL CALLS DESERVE AN EMERGENT RESPONSE!"



Hey, you never know what she uses that hand for. It could be really an emergency.


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## Amberlamps916 (Nov 25, 2012)

I'll throw in my 2 cents. My company didn't have any primary 911 contracts but we would be called in for backup service from time to time. Even though we were entrusted to provide emergency transport, we were never trained to use discretion when it came to driving either code 2 or 3. Now I know common sense plays into discretion at times but seriously, there are some people who don't have it.

  For example, I recall one instance where a partner told me that they responded to a 5150 danger to self patient. He told me that they drove code 3 to the hospital because the patient was "suicidal" and it was a true emergency. I guess he didn't factor in the patient being in 4 point restraints into his decision to drive code 3. 

  I feel that companies should train and aid responders into making the right decision when it comes to driving lights and sirens.


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## DrParasite (Nov 26, 2012)

Addrobo87 said:


> Even though we were entrusted to provide emergency transport, we were never trained to use discretion when it came to driving either code 2 or 3. Now I know common sense plays into discretion at times but seriously, there are some people who don't have it.


you know, this is a great statement: who among us was actually (formally) trained and educated in the use of discretion for emergency response?  

And while common sense might dictate at lot, we all know common sense isn't all that common.


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