# Code 3 response to hospital



## daedalus (Mar 4, 2009)

While we are on the subject of debating the use of lights and sirens, I figure I'd bring up a practice we use in my service to see what y'all think. 

Is it ever appropriate to respond code 3 to a hospital for a STAT IFT? Usually, ALS or CCT. Los Angeles hospitals themselves frequently request use of lights and sirens to respond to their hospital, to pick up transplant teams done harvesting organs, for emergency STEMI transfers for rescue angioplasty at another facility, for urgent neurosurgical patients, etc. Please try and remember that code 3 vs no code in the greater LA area can be the difference of the response taking an hour no code or twenty minutes code 3.


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## firecoins (Mar 4, 2009)

that sounds fine.


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## JPINFV (Mar 4, 2009)

Only if directly requested by the transfering hospital for an emergency response. They're going to be less likely to request or expect it then the general public and you KNOW that it will be for a true emergency. If my memory is correct, LA and OC require private ambulance companies to report these responses to the local fire department dispatch (maybe county EMS too?), which should keep hospitals from requesting an emergency response for the simple reason as they want the bed.


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## VentMedic (Mar 4, 2009)

LA may be one of the exceptions.

Often, the time for IFT can be cut down by making the whole process more efficient. 

First you have the identification process for a need to transfer.

Then, which facility, who's the doctor on call and making contact for acceptance.

Once acceptance is finalized, a bed must be found for the patient in the receiving hospital or cath time must be confirmed. 

OR if none of the above works out, start over at locating an alternative hospital and begin the process again. 

Oops, wrong insurance...Kaiser (or whatever) patient. Start over...

Find CCT ambulance with personnel that can handle all the meds and technology. One can do this but not that. This does it all but must call their MICN to accompany. (A hospital having its own CCT is so much easier.)

Now the paperwork.

We (CCT, Flight and Specialty) fax a list of everything (pumps, IVs etc) that will need to be done prior to our arrival. 

Arrival at the facility:
Wait for elevator that takes forever.
Chit chat about the family. 
Paperwork not quite ready.
Pumps/IVs need to be switched
Stabilize vitals from pump disconnect/switch.
Stabilize on a transport ventilator...more sedation.
Move to stretcher.
Untangle everything.
More chit chat.
Depart unit...wait for elevator that takes forever...unless staff with elevator key accompanies you.

Drive real fast with L&S to the other hospital.


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## abckidsmom (Mar 4, 2009)

I'd say since it so dramatically impacts the time involved, it's fine.  Where I've worked, the difference between Code 3 and no Code 3 is less than 5 minutes, except at rush hour or in other special circumstances.  Not worth it, IMO.


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## VentMedic (Mar 4, 2009)

daedalus said:


> Los Angeles hospitals themselves frequently request use of lights and sirens to respond to their hospital, to pick up *transplant teams done harvesting organs*,


 
If communication between the organ procurement team and the ambulance service was established by just asking them to add you to their check list, there would be no need for a Code 3 response to the hospital. Organ Procurement takes about 24 hours to set up and an OR time is *scheduled *so that all the physicians picking up the organs can be present. A simple phone call notifying the ambulance of the time and confirmation when the teams are in the OR would allow for the ambulance service to have a unit waiting for them.


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## daedalus (Mar 4, 2009)

VentMedic said:


> If communication between the organ procurement team and the ambulance service was established by just asking them to add you to their check list, there would be no need for a Code 3 response to the hospital. Organ Procurement takes about 24 hours to set up and an OR time is *scheduled *so that all the physicians picking up the organs can be present. A simple phone call notifying the ambulance of the time and confirmation when the teams are in the OR would allow for the ambulance service to have a unit waiting for them.



Agreed.
Also, its hilarious reading your other post above. Except add, male CCT nurse flirts with floor nurses while EMTs transfer patient over and wait for help with vents and pumps.


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## mycrofft (Mar 5, 2009)

*Crikey, we got there early once and the pt expired while we advertised.*

I think the local EMS rules should be observed, unless it is in North Gardena, SE Central/L.A. Strip/Harbor area, or around the Olympic Auditorium, in whch case you go #3 because otherwise bad guys will jack you.

Whenever you do anything besides driving like Granny, mentally rehearse how it will sound explaining to someone why you were doing what you were doing. 

Like your boss, the insurance attorney, the assistant D.A....


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## daedalus (Mar 5, 2009)

mycrofft said:


> I think the local EMS rules should be observed, unless it is in North Gardena, SE Central/L.A. Strip/Harbor area, or around the Olympic Auditorium, in whch case you go #3 because otherwise bad guys will jack you.
> 
> Whenever you do anything besides driving like Granny, mentally rehearse how it will sound explaining to someone why you were doing what you were doing.
> 
> Like your boss, the insurance attorney, the assistant D.A....



Solid advice. I always actually try to explain my actions to the fake jury, DA, and EMSA every time I have to make a difficult controversial decision. Like letting someone AMA.


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## Hastings (Mar 5, 2009)

One of the issues our service is currently dealing with is abuse of this. The hospital is making every transfer stat just to get us there faster. We tried sitting outside with the siren going for awhile to deter them, but it didn't.

We can't go faster than 72 mph in the vehicle anyway, so we never use L&S on transfers. If we do, people just pass us.


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## BLSBoy (Mar 5, 2009)

I do CCT/SCT, in addition to MICU work up here. 
While my "main" function is to drive, I set up the vent, get the patient hooked up to monitor, start a second line, backboard the pt if need be, or if done incorrectly, and get the patient prepared to move to the cot, while my MICN partner gets everything else squared away. 
We do go emergency traffic to facilities for STEMIs, trauma transfers, and as requested by an MD. It is up to us to keep the emergency traffic, or downgrade to normal traffic. 
For routine SCT/CCT transfers, yea, we lollygag (down to first, we lollygag coming off the field) around, but for emergent runs, we are strictly business.


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## Airwaygoddess (Mar 5, 2009)

*"Real Time"*



VentMedic said:


> LA may be one of the exceptions.
> 
> Often, the time for IFT can be cut down by making the whole process more efficient.
> 
> ...



^_^^_^^_^   I need Vent to be my partner!


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## Ridryder911 (Mar 5, 2009)

With the increase knowledge of not using HEMS, there are specific things for IFT code three or emergency status ( In OKC, code 3 is no l/s). Such patients that are about ready to code such as cardiogenic shock, severe trauma patients, or O.B. patients that are not stabilized, etc, 

Most where the surgical team is awaiting for them. Does it make up the time? Yes, in some circumstances reducing anywhere from 15-25 minutes. 

It is very seldom such of those occur, but do. As well, we are decreasing our usage of helicopter flights. Usually we will transport our severely trauma patients to the Trauma Center in emergency status. Even though our nearest hospital is over 200 bed, they do not nor do they want to receive trauma patients as they only have general surgeons. We are now exploring by-passing as well, with true cardiac patients that need to be cathed. Yes, local have a cath lab (non-interventional & only 9-5) but is for scheduled ones only.


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## VentMedic (Mar 5, 2009)

While the distant outlying areas have helicopter access, the immediate county areas have relied on taking the patient to the most appropriate facility be it trauma or cardiac for the past 25 years. When hospitals are easily within within an obtainable distance from each other, there should be little reason to take to a hospital that does not have adequate services and then expect another transfer immediately for the patient. Unfortunately, many EMS agencies still have the "take to the nearest facility and dump" policy.

A patient will also not be transferred if unstable except for extreme exceptions. There is no need to put a dead patient into either a helicopter or ambulance.


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## VentMedic (Mar 5, 2009)

Hastings said:


> One of the issues our service is currently dealing with is abuse of this. The hospital is making every transfer stat just to get us there faster. We tried sitting outside with the siren going for awhile to deter them, but it didn't.
> 
> We can't go faster than 72 mph in the vehicle anyway, so we never use L&S on transfers. If we do, people just pass us.


 
Some hospitals and ambulance services also have a difficult time getting thier "terminology" together. For some, if a hospital doesn't say STAT, the ambulance company will take it to mean they have 2 hours to get there which is standard per some policies for a routine call. What the hospital may actually mean is, "emergent- but don't kill yourself getting here". There just doesn't seem to be a good middle ground in the policies to get all on the same page for "Yes we need you now but not NOW".


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## medicdan (Mar 5, 2009)

My company routinely responds to a hospital L&S. Most recently, we got a call about an organ procurement that several other companies had rejected. By that time, the organ was already harvested, and they were anxious to get it on the road. The hospital was aprox 15 miles from our base, and was being transported by ground another 180 miles. In fact, I think our contract with New England Organ Bank specifies response times depending on when we get the call.

We also routinely respond L&S to a hospital where we have the IFT contract to bring impending STEMI patients from one building to another. In fact, our response time is closely tracked by the hospital. 

I see no other reason to respond. No reason for the added liability.


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## rescuepoppy (Mar 5, 2009)

The lights and siren on our trucks are a tool. Like any other tool on the truck we have to use them correctly when used in the proper manner they serve a purpose but when used incorrectly they can be dangerous. The key here is when needed use them but also turn up the common sense factor.


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## medicdan (Mar 5, 2009)

rescuepoppy said:


> The lights and siren on our trucks are a tool. Like any other tool on the truck we have to use them correctly when used in the proper manner they serve a purpose but when used incorrectly they can be dangerous. The key here is when needed use them but also turn up the common sense factor.



x2! Cant agree more!


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## VentMedic (Mar 5, 2009)

emt.dan said:


> My company routinely responds *to a hospital L&S.* Most recently, we *got a call about an organ procurement that several other companies had rejected. By that time, the organ was already harvested,* and they were anxious to get it on the road. The hospital was aprox 15 miles from our base, and was being transported by ground another 180 miles. In fact, I think our contract with New England Organ Bank specifies response times depending on when we get the call.


 
This is a very grave error on either the hospital or the organ procurement team.  They know this is going to happen for at least 24 hours. The OR is SCHEDULED.  So there should be no reason why transportation should ever be an issue for organ procurement.


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## medicdan (Mar 5, 2009)

I agree. It was poor planning. Evidently, several other private ambulance companies had refused the transport because of the long distance. My company is known for never rejecting a call. I was in dispatch when the call came in-- it certainly was not scheduled on our end. AFAIK, other organ transports are scheduled, although we often get a narrow window for the arrival of the organ and team by air.


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## Veneficus (Mar 5, 2009)

does responding with light and sirens decrease time?

these

http://www.emergencydispatch.org/articles/ambulancetransporttime1.htm

and others say "no."  So apparently it is just an illusion. In addition I might think that if it is saving "considerable" time at your agency, it may not be because of lights and sirens, but unsafe driving practices.

In my squad days I worked for a company that did IFT for a bit. There were frequently nurse practicioners that wanted us to lights and siren their peds patients to a hospital with a CT scan for their routine CT use. They originally didn't really like it when I told them "no." When I explained and showed them the studies at the time (similar to the above link as well as crashes and fatalities involving ambulances)  they stopped asking.

One NP early on went nuts and pulled some "I am the senior healthcare professional and it is my decision" BS. (quickly countered with: "if you want to accept the responsibility of driving this box, here are the keys.") 

If somebody has a scheduled IFT, it is not emergent, why risk your life and the life of bystanders for a BS concept of speed.


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## JPINFV (Mar 5, 2009)

It's pretty established that L/S saves time. The real question is "How much time?" and "Is it enough to affect patient outcomes?" (statistical significance vs clinical significance).


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## medic417 (Mar 5, 2009)

JPINFV said:


> It's pretty established that L/S saves time. The real question is "How much time?" and "Is it enough to affect patient outcomes?" (statistical significance vs clinical significance).




How much time and does that time actually = more lives saved especially when we factor in lives lost or ruined in amulance crashes.  

Based on studys that have been posted on this site and others recently a few more minutes is not actually going to change outcome the majority of the time.


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## emtfarva (Mar 5, 2009)

In my area, for my service, we only respond into the hosp for a couple of things:
1) Cath lab standbys. This has to be done per state protocols for a Hosp that doesn't do open heart.
2) Organ runs.
3) Priority one calls (Pt that will be dead if they don't get to a much better hosp)
Also our CCT team will run code to a hosp. Some times from Boston to Maine and back to Boston.


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## Veneficus (Mar 6, 2009)

2-3 minutes is not going to save anyone's life.

several years ago there was an initiative where I live to stop using lights and sirens entirely. Want to guess who the lobby against it was? 

FDs and volunteers...


tradition unimpeded by progress


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## daedalus (Mar 6, 2009)

Stop using L&S entirely? 

I am sorry, but there is a hint of elitism there. It is not "cool" to be above something because there is some new evidence to suggest it is ineffective in many cases. It still has, and anyways will have its uses. A much smaller role in the future, no doubt, but a role.


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## AJ Hidell (Mar 6, 2009)

daedalus said:


> It still has, and anyways will have its uses.


I totally agree.

I never park in the middle of the highway at an accident scene without my lights on.  Can't find too much use for them, or the siren, otherwise though.  At least not any that can be scientifically validated with evidence.  And I'm not into doing things simply because we've always done it that way, or because my partner may think it's "cool".


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## Veneficus (Mar 6, 2009)

daedalus said:


> Stop using L&S entirely?
> 
> I am sorry, but there is a hint of elitism there. It is not "cool" to be above something because there is some new evidence to suggest it is ineffective in many cases. It still has, and anyways will have its uses. A much smaller role in the future, no doubt, but a role.



New evidence?

There has been evidence on this sbject for years.

http://firechief.com/news/second-phase-light042505/

l see articles dating back to 1980 on a quick google search. It was a hot topic at the FD I was at in 1993

A brief web search will show several places that have made a policy of not using lights and sirens.

Also suggest this site.

www.canton.edu/ncems/forms/red_light_siren_readonly.pps

Warning lights? I will agree they have their uses. But consider:

What are the most visible colors for warning lights day or night? Unless my memory fails, it is blue. How many non LE agencies use blue lights in the US?

So you are using less than optimal warning lights with red or white to be safe?

Some years ago  The fire service embraced putting yellow lights on the back of the trucks because they found that the red and white ones actually increase the likeylhood of a collision when on the roadside.

Have you seen the patterns on the back of European ambulances for road visibility? Compare that to ones in the US. Furthermore, there is now a federal standard on the type of safety equipment that must be in place on roadway incidents.

Sirens: back in the day when there were fewer cars on the road and people actually cared to pull over for an emergency vehicle, these might have had a purpose. Agencies are putting dual sirens on ambulances now. If the motorist didn't pay attention to 1, what is the chances that 2 will make a difference? I have sat in cars with such soundproofing that with the radio at a moderate volume I couldn't hear the engine running, I wouldn't have heard 10 sirens.

Have you ever turned on a siren in heavy traffic and watched everyone stop in front of you because there was no place to go? Certainly that doesn't decrease response time. In addition if you sit behind somebody with your lights and sirens sounding a horn to "push" them forward, you are likely responsible if they get into an accident as well.

How many EMTs are required to take an EVOC course? How many agencies (especially IFT) spend time on teaching new members how to safely drive? 

Even though the fire service in one area did lobby against limiting lights and sirens a large part is catching on and they are 20 years ahead of most US EMS agencies. 

Look at the incidents involving ambulances and fire apparatus collisions. What do you think the safety of Ricky Rescue with a light bar (or dash lights and grill strobes) and a siren on the POV is?

In 2 states where I have worked on a truck, in an MVA involving an emergency vehicle responding lights and sirens the operator of the emergency vehicle is always at fault for "failure to operate with due regard for public safety." That makes you responsible not only for your operation, but every other person on the road. (or pedestrain)

though I am an elitist, I don't think this qualifies as much as it is looking past "what is cool" or "what we have always done," for the purpose of saving lives and limbs. (maybe even a job or 2)


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## karaya (Mar 6, 2009)

daedalus said:


> Stop using L&S entirely?
> It still has, and anyways will have its uses. A much smaller role in the future, no doubt, but a role.


 
I also agree with this.  I travel with EMS all over the country and clearly the use of sirens has markedly reduced, especially when transporting a patient.  There does seem to be an increased awareness of its appropriate use.  But, in areas of long lights, heavy traffic, etc., the use of lights and siren may be clearly warranted.  In a few areas where I ride with paramedic supervisors, the delay through a myriad of traffic lights is as much as five to six minutes.  With L&S, this is reduced to seconds.  Now when your responding from one end of town to the other, this delay without a siren can quickly add up.

I couldn't imagine the LA area, where Daedalus works, getting around without a siren.  I've seen that mess out there many times!


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## HereToLearn (Mar 6, 2009)

karaya said:


> I couldn't imagine the LA area, where Daedalus works, getting around without a siren.  I've seen that mess out there many times!



I was just about to say the same thing. Being an EMT here in LA myself, the need to get places quickly going Code 3 is essential. But realize, this is a place where it can take 30 mins or more to go a couple of miles.


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## BossyCow (Mar 6, 2009)

Sometimes, here in the toolies, having those lights going makes the farmer a quarter mile up the road decide to not pull his tractor, cultivator and 8 bales of hay out into the road until after we pass. 

I'm not a big fan of running code. I don't think it makes things that much faster, and it can make things much, much worse. Generally it amps up the stress in everyone who hears it, including the pt, pt's family and the responders. My drivers are pretty used to me telling them I want a 'gentle code'. That means, use the lights and burp the sirens at the intersections to let people know we are coming, but don't push the speed limit. 

Instead of a "GET OUT OF THE WAY!!!" it's more of an "Excuse me please?"


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## BLSBoy (Mar 7, 2009)

Veneficus said:


> =What are the most visible colors for warning lights day or night? Unless my memory fails, it is blue. How many non LE agencies use blue lights in the US?
> 
> So you are using less than optimal warning lights with red or white to be safe?
> 
> ...



Actually, red is best seen during the day, and blue is best seen at night. 
White/clear is not a color, per se, since it has no "filter" to go through. It is broadcast easier. 

I believe that it is the new KKK reg to have the chevrons on the back now. 

With the exception of the Northeast, Blue is a LEO color, and it should be that way, for ID purposes. 

Posession of a Blue vehicle light would be a Felony, impersonating a LEO.


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## Veneficus (Mar 7, 2009)

to remedy my ignorance on the subject, I spent a few minutes doing some research on the research,

http://onlinepubs.trb.org/onlinepubs/nchrp/nchrp_rpt_624.pdf

http://onlinepubs.trb.org/Onlinepubs/circulars/ec013/1CUllman.pdf

http://www.naemd.org/articles/warningsystems1.htm

was the research I decided to read through.

The first article spent $300,000 to decide that yellow and white were the best color combinations for maintenance workers.  However, in digging through the data, it also demonstrates those 2 colors have the highest visibility rating both day and night, by a long shot. They also reduce glare making it more likely drivers would see pedestrians in the area. 

It further determined blue light was most visible in fog or in climate weather.

 In both the first and second studies, they were set up specifically for maintenance workers and I noticed a flaw that would prevent them from being applicable to safety forces. Both studies state that the color of the light is associated with the type of vehicle. (fire, police, etc)

However it is worth pointing out that the Texas study shows that when drivers see blue lights they have a more controlled reaction. Like taking their foot off the accelerator or slowly braking. The study also demonstrates drivers are more likely to look for pedestrians when seeing amber/white lights than with the other colors.

The third study supports the information found in the other two that red lights seem to be the least effective as a visual cue, have a high level of glare making it tougher to spot pedestrians, as well as being associated with hazardous driving behaviors. As well, it also identifies that a siren does not seem to be an adequate warning device. 


So my information did fail (happens from time to time), blue is only most visible in adverse weather conditions. But they do inspire the safest driving behaviors once noticed. However, all of these studies demonstrate that red lights are the least optimal for anything we would want to use them for in emergency service. I would conclude the amber/white combination is best for the safety of anyone working an accident scene. 


My original point was to promote the best practice, not argue the legal ramifications of various colors. Laws can be changed to accommodate that. It is interesting to note, there is no information on the use of green flashing lights, so perhaps a study including them would be in order as well. If for no other reason than to rule out the effectiveness.


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## Duncan Hitchcock (Mar 7, 2009)

*Dealing with it head-on*

We were experiencing this problem.  We began a post incident review of every "STAT" or "Emergent" transport that we received from an ED or hospital unit with our Medical Director and QA Committee.  We notified the hospitals that we were doing this.  We advised them that we viewed a request for a "STAT" transport to be the same as a 911 call.  When we find abuses of placing 911 calls we refer it to the local law enforcement agency and the State Attorney.  The hospitals were notified that if we find on abuses of the use of the term "STAT" we would follow our normal procedures and also report it to as many oversight agencies as we could find.

After about three months the abuse decreased remarkably and remains so.


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## ffemt8978 (Mar 7, 2009)

BLSBoy said:


> With the exception of the Northeast, Blue is a LEO color, and it should be that way, for ID purposes.
> 
> Posession of a Blue vehicle light would be a Felony, impersonating a LEO.



Not true...this varies state to state.


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## Kookaburra (Mar 7, 2009)

ffemt8978 said:


> Not true...this varies state to state.



Correct...Eugene's medic unit ambulances have blue and red lights. I can't remember what Springfield's have.


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## Kookaburra (Mar 7, 2009)

Hastings said:


> We can't go faster than 72 mph in the vehicle anyway, so we never use L&S on transfers. If we do, people just pass us.



Ha ha, maybe you should do like Italy does for organ transport, and get your department one of these babies:






More info here.


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## daedalus (Mar 7, 2009)

Kookaburra said:


> Ha ha, maybe you should do like Italy does for organ transport, and get your department one of these babies:
> 
> 
> 
> ...



YES! YES!!!!

YES!

120 mph response!
I can feel the adrenaline now!!


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## Kookaburra (Mar 7, 2009)

120 mph?! Try over 200.

VRRRRROOOOOOOOOMMMMMM!!!!


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