# Limited use of Lights and sirens



## VentMedic (Mar 2, 2009)

*Pa. Ambulance Group Decides Quiet is Way to Go*

*Exeter association says crews no longer will activate sirens, emergency lights on most calls*

*Posted:* Monday, March 2, 2009
Reading Eagle (Pennsylvania)

http://www.emsresponder.com/article/article.jsp?id=9074&siteSection=1



> Exeter Ambulance Association announced last week that its crews no longer will activate sirens and emergency lights on most calls.
> 
> Officials cited studies and updated state guidelines as the reasoning for the policy change.
> 
> "Statistics show using lights and sirens in many instances doesn't get a crew to a scene of an emergency any faster," said Rich Bowers, executive director of Exeter Ambulance, which operates five ambulances and three wheelchair vans.


 


> While no major changes in protocol have been made, the state has been trying to discourage the unnecessary use of sirens and lights, Schmider said.
> 
> In 2007, he said, an average of one crash per day in the state involved an ambulance.
> 
> "We've really been trying educate the crews to think twice before using them because it increased your risk of having some kind of event," Schmider said.


 
http://www.emsresponder.com/article/article.jsp?id=9074&siteSection=1


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## medic417 (Mar 2, 2009)

Guess I better turn in my resignation because only reason I'm in EMS is to go fast with bright lights and lots of noise.  

Sadly though I would expect many would not stay or even enter EMS if L&S basically go the way of the dino.


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## MMiz (Mar 2, 2009)

If you read the article you'll find that they will still use lights and sirens to "emergency" calls and when transporting critical patients.  Isn't that how most folks are dispatched and transport already?


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## Aidey (Mar 2, 2009)

One crash _per day_? That is just plain old crappy driving, with or without the use of L&S.


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## karaya (Mar 2, 2009)

I'm surprised they ever used lights and siren.  Their 911 service area is a tiny borough and a small town with a combined population of only 26,812!


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## medic417 (Mar 2, 2009)

MMiz said:


> If you read the article you'll find that they will still use lights and sirens to "emergency" calls and when transporting critical patients.  Isn't that how most folks are dispatched and transport already?




Actually we go to the hospital w/o L&S the majority of our patients, even emergent ones because you can't do quality care bouncing around at high rates of speed.  Plus even on a long transport your only minutes shorter exceeding the speed limit anyway.  And if your 5 minutes to a hospital w/o L&S your still 4 1/2 minutes away with them.  So is the extra danger worth the risk?


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## medic417 (Mar 2, 2009)

karaya said:


> I'm surprised they ever used lights and siren.  Their 911 service area is a tiny borough and a small town with a combined population of only 26,812!



WOW they live in a huge city.  Theres not half that many people in the 6000 square miles in my service area.


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## MMiz (Mar 2, 2009)

medic417 said:


> Actually we go to the hospital w/o L&S the majority of our patients, even emergent ones because you can't do quality care bouncing around at high rates of speed.  Plus even on a long transport your only minutes shorter exceeding the speed limit anyway.  And if your 5 minutes to a hospital w/o L&S your still 4 1/2 minutes away with them.  So is the extra danger worth the risk?


That's what I'm saying.  I find it common to have a RLS response if dispatched to a priority call, but I rarely see RLS transports.


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## karaya (Mar 2, 2009)

medic417 said:


> WOW they live in a huge city. Theres not half that many people in the 6000 square miles in my service area.


 
Yeah, but for where this service is located, 26,812 is small.  From the looks of their service area map, it appears they only cover a few square miles.


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## VentMedic (Mar 2, 2009)

MMiz said:


> If you read the article you'll find that they will still use lights and sirens to "emergency" calls and when transporting critical patients. Isn't that how most folks are dispatched and transport already?


 
No. In many areas most 911 calls get the full L&S treatment as well as several vehicles responding. This is particularly true in fire based services. 

Example:
*Redundant Response Under Fire in Florida *
*http://emsresponder.com/article/article.jsp?siteSection=1&id=7458*

This system has a least 3 response vehicles, each running L&S, responding to everything. Unfortunately there are many systems like this in many states, counties and cities. Some even try to co-exist in the same city only to collide with each other while running L&S.


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## jrm818 (Mar 2, 2009)

(at least part) of PA has been like this for a while.  The western part of the state uses a county-level priority based dispatch, with many calls not getting L&S response.  It has been like this for a while.  L&S to the hospital is extremely rare....maybe 1/20 at the most based on listening to my service and every other service in the county on the radio.

I don't know anything about Exeter...but i'd be suprised if they didn't already restrict use of L&S.

The article really doesn't make it clear what is changing.  Did this service use L&S 100% of the time before the change?


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## daedalus (Mar 2, 2009)

MMiz said:


> If you read the article you'll find that they will still use lights and sirens to "emergency" calls and when transporting critical patients.  Isn't that how most folks are dispatched and transport already?



Yes.
I laugh when I read some of these because in my home community, most calls are already a "Medical NO CODE" (Medical call, no code response). In my community, only potentially life threatening calls are dispatched emergency, such as chocking and arrest, chest pain, difficulty breathing, etc. 

Than, I remember where I work. In LA county, the stupi.....silly fire paramedics transport everything code three, even wrist pain or musculoskeletal injuries in healthy people.


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## VentMedic (Mar 2, 2009)

daedalus said:


> Yes.
> 
> Than, I remember where I work. In LA county, the stupi.....silly fire paramedics transport everything code three, even wrist pain or musculoskeletal injuries in healthy people.


 
Not only do the fire paramedics do this but some private ambulance companies do as well to "keep a schedule".   But it is not just LA.  Many private ambulance companies across the country allow and often encourage running the routines L&S to get more calls done in a timely manner.


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## Sasha (Mar 2, 2009)

VentMedic said:


> No. In many areas most 911 calls get the full L&S treatment as well as several vehicles responding. This is particularly true in fire based services.
> 
> Example:
> *Redundant Response Under Fire in Florida *
> ...




Where I do clinicals at, you get the rescue(ambulance) and the engine, sometimes the tower!

Most of the time it's unneeded and there's a lot of folks standing around doing nothing waiting for the LT to tell them they can go back to the station and finish their lunch/nap/whatever. Useful on a code, though!


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## MMiz (Mar 2, 2009)

VentMedic said:


> Not only do the fire paramedics do this but some private ambulance companies do as well to "keep a schedule".   But it is not just LA.  Many private ambulance companies across the country allow and often encourage running the routines L&S to get more calls done in a timely manner.


I did my clinicals with AMR in Michigan.  We ran RLS to every call, urgent or not, due to always being late.

Working for another private service in the same county years later, we *never* ran RLS due to tight scheduling or running behind.


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## Jon (Mar 2, 2009)

I find the article confusing. The company does lots of non-emergency interfacility work to begin with. They also don't say if they aren't going to be RESPONDING priority, or if they aren't going to be TRANSPORTING priority.


I'll ask around and have some more info later.





Aidey said:


> One crash _per day_? That is just plain old crappy driving, with or without the use of L&S.


That is the grand average of EMS-involved MVA's in the state... everything from my wrecking an ambulance to avoid striking a motorcylcist who lost control in front of me (I had no place to go but off road, into a tree. Motorcyclist lived... and would not have had I hit him with a big ol' Type III Horton).

That also includes the fender-bender another in-county squad had the last snowstorm... they lost it on black ice and tapped a tree - minor damage, but reported.

That ALSO includes the truck from my county that had a suicidal deer jump out in front of them on the highway last week.

PA's a huge state... LOTS and LOTS of ambulances. I can list these three from the last 6 months, off the top of my head.



karaya said:


> I'm surprised they ever used lights and siren.  Their 911 service area is a tiny borough and a small town with a combined population of only 26,812!



Yep. What the article doesn't say is that they do a lot of routines. And, at least sometimes, they have their 911 truck tied up with routines. The local fire Co. also responds as a BLS first responder if they aren't immediatly availible. They respond as volunteers, in a QRS/utility vehicle - NO, they don't bring the engine on every EMS run.





MMiz said:


> That's what I'm saying.  I find it common to have a RLS response if dispatched to a priority call, but I rarely see RLS transports.


That's how we run in my area. Almost every dispatch gets an emergent  response, but very, very few get emergent transports.


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## DR_KSIDE (Mar 2, 2009)

Anyone notice that most of these L&S articles deal with EMS more than Fire or Law Enforcement? I would bet that if the people who wrote these would start attacking the other two emergency fields there would be a great uproar.

Just my opinion.


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## VentMedic (Mar 2, 2009)

DR_KSIDE said:


> Anyone notice that most of these L&S articles deal with EMS more than Fire or Law Enforcement? I would bet that if the people who wrote these would start attacking the other two emergency fields there would be a great uproar.
> 
> Just my opinion.


 
PDs do have very strict rules for running L&S fortunately or it would be one noisy mess if they ran L&S to ALL of their calls. 

The other article I posted involved the FD.  
*Redundant Response Under Fire in Florida *

It wanted answers why 3 vehicles, 2 of which are FD, respond L&S to every call regardless how minor.


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## AJ Hidell (Mar 2, 2009)

daedalus said:


> Than, I remember where I work. In LA county, the stupi.....silly fire paramedics transport everything code three, even wrist pain or musculoskeletal injuries in healthy people.


Yep.  And it is more common than we like to admit.  Even those who do it refuse to admit it.  There are a whole lot of "precautionary code 3" transports going on out there.  Most of them are probably just the medic or EMT's incompetence and discomfort with a patient that they don't know how to diagnose or treat.  They're in a hurry to get rid of it.  A great many are just looking for an excuse to run hot, and will jump on any chance to do so.  If you stopped those code 3 transports, as well as stopping the rolling codes, the number remaining would be microscopic.


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## jrm818 (Mar 2, 2009)

I think microscopic may be pushing it a bit much.  There are a number of conditions which legitimately deserve to go L&S to the hospital...CVA, MI, AAA, major traumas, bad bleeds (I'm thinking of the GI variety..but anywhere internal really) etc.


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## medic417 (Mar 2, 2009)

jrm818 said:


> I think microscopic may be pushing it a bit much.  There are a number of conditions which legitimately deserve to go L&S to the hospital...CVA, MI, AAA, major traumas, bad bleeds (I'm thinking of the GI variety..but anywhere internal really) etc.



Nope L&S could actually worsen several of those.


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## AJ Hidell (Mar 2, 2009)

jrm818 said:


> There are a number of conditions which legitimately deserve to go L&S to the hospital...CVA, MI, AAA.


Interesting.  Every textbook I have ever read specifically mentioned those three conditions as requiring a smooth and quiet ride.  Are you reading this in a text somewhere?  Where you taught this by an instructor?  Agency policy?  Medical protocol?  Is it just your opinion?  If so, based upon what?


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## jrm818 (Mar 2, 2009)

Medic:

Because it interferes with the prehospital care of eg. a CVA.....?

Which ones, and how would L&S hurt? Unless you can do thrombolysis or something for a MI or whole blood for the hypovolemic type emergencies, none of those can be treated in any way that is even close to definitive in the field.  They are all time-sensitive, and outcomes worsen with more time until intervention (research supported for CVA and MI, probably for trauma, when bleeding out time = more blood out =  bad)


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## jrm818 (Mar 2, 2009)

AJ Hidell said:


> Interesting.  Every textbook I have ever read specifically mentioned those three conditions as requiring a smooth and quiet ride.  Are you reading this in a text somewhere?  Where you taught this by an instructor?  Agency policy?  Medical protocol?  Is it just your opinion?  If so, based upon what?



My opinion primarily (although it is also a medical and agency protocol).  there is good research which indicates that CVA and MI outcomes are worse the longer the time between onset and treatment (at the hospital..unless you've got tpa).  No, there are no studies looking specifically at L&S response...but logic says that if a. time = cells and b. L&S = less time, than logically L&S can improve outcomes.

Who said L&S driving is not smooth?  lights just get you through traffic and traffic lights...i'm not talking about driving like a banshee.  

quiet?  how exactly does that impact outcomes?  are the brain cells going to be disturbed by all the noise and die?

Edit: and even if you have a banshee driver..whats the evidence that lack of smoothness has a negative impact on CVA or MI outcome?  I don't mean "the book said so"...I'm legitimately curious if there is any evidence that suggests this.  First i've heard of it.


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## medic417 (Mar 2, 2009)

jrm818 said:


> Medic:
> 
> Because it interferes with the prehospital care of eg. a CVA.....?
> 
> Which ones, and how would L&S hurt? Unless you can do thrombolysis or something for a MI or whole blood for the hypovolemic type emergencies, none of those can be treated in any way that is even close to definitive in the field.  They are all time-sensitive, and outcomes worsen with more time until intervention (research supported for CVA and MI, probably for trauma, when bleeding out time = more blood out =  bad)



Please do some research grasshopper.  Yes there are studys out there that show even in trauma rapid transport does not impact survivorability.  As to CVA, AAA, MI sorry you are harming patients.  The 1 or two minutes you might save if you arrive safely has no positive affect.  Again time to get current research.


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## JPINFV (Mar 2, 2009)

jrm818 said:


> Who said L&S driving is not smooth?  lights just get you through traffic and traffic lights...i'm not talking about driving like a banshee.
> 
> quiet?  how exactly does that impact outcomes?  are the brain cells going to be disturbed by all the noise and die?



How many drivers actually drive code 3 smoothly instead of doing the bat out of hell routine? I was talking to my normal partner on the phone (I've taken about a week and a half off from work for interviews) and he mentioned that he had a critical call and were transporting emergently and his partner that day, an EMT instructor and who has been in the field for years, ended up having to make a hard maneuver that resulted in my partner being slammed into the cabinets. 


As far as the sound, it's all about classical conditioning. You hear a siren (a neutral sound. It is just a sound in the end.) and see it associated with emergency vehicles. After years of this conditioning you no longer need to see the emergency vehicle to know that siren=emergency. The siren can be heard in the back, so the patient hears it, thinks emergency, and you get a stress response.


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## ffemt8978 (Mar 2, 2009)

medic417 said:


> Please do some research grasshopper.  Yes there are studys out there that show even in trauma rapid transport does not impact survivorability.  As to CVA, AAA, MI sorry you are harming patients.  The 1 or two minutes you might save if you arrive safely has no positive affect.  Again time to get current research.



What about areas like mine, where running code can get you there 15-25 minutes earlier?


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## jrm818 (Mar 2, 2009)

medic417 said:


> Please do some research grasshopper.  Yes there are studys out there that show even in trauma rapid transport does not impact survivorability.  As to CVA, AAA, MI sorry you are harming patients.  The 1 or two minutes you might save if you arrive safely has no positive affect.  Again time to get current research.



1 or 2 minutes..probably no notable difference in outcome except in extraordinary cases.  Who said we only save 1 or 2 minutes?  Yes i know research blah blah...that research wasn't the greatest quality.  Your location may be different, but in our location the difference L&S and not is considerably more than that depending on the time of day and local traffic conditions.

I'd still love to be told at least generally what the reason that L&S "harms" CVA or MI (or AAA) patients.  come on...give a "grasshopper" a hint at least  It's an interesting idea that I have not done research on this and am making things up out of thin air....although apparently there is some super evidence against rapid transport that I have missed....


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## jrm818 (Mar 2, 2009)

JPINFV said:


> How many drivers actually drive code 3 smoothly instead of doing the bat out of hell routine? I was talking to my normal partner on the phone (I've taken about a week and a half off from work for interviews) and he mentioned that he had a critical call and were transporting emergently and his partner that day, an EMT instructor and who has been in the field for years, ended up having to make a hard maneuver that resulted in my partner being slammed into the cabinets.
> 
> 
> As far as the sound, it's all about classical conditioning. You hear a siren (a neutral sound. It is just a sound in the end.) and see it associated with emergency vehicles. After years of this conditioning you no longer need to see the emergency vehicle to know that siren=emergency. The siren can be heard in the back, so the patient hears it, thinks emergency, and you get a stress response.



Look, I can't speak for anyone else, and I know there are people who drive like nuts, but honestly I am pretty good about driving smoothly L&S...and I know a couple of others who do the same.  This is an issue of community standards within EMS in terms of what it means to go L&S.  And I'm not an old grandma...I drive pretty fast...in my POV.  I just realize I have people in the back of my box, and drive accordingly.

Sure, stuff happens with people on the road.  A lot of that can be alleviated by not flying up behind people or riding them when they don't move over.  A lot more by going very slowly through intersections.  Sometimes stuff happens even when not going L/S


As for the stress response.  I daresay being in an ambulance in the first place is enough to activate a pretty good stress response.  The medic teling you you are having a heart attack/talking to the hospital and saying that/etc. will do the same thing.  I"m thinking the additional stress added by the siren is not so bad...especially since the public assumes that _everyone_ goes lights and sirens to the hospital.  Unless they've had a lot of experience with EMS, they probably don't appreciate that only severe things go with sirens.  Communication with the patient is probably just (if not more) of a factor in patient stress.  

and even if I grant you that there is a stress response, there isn't any evidence that I've ever heard of (could exist...have to admit I haven't looked) that stress (at the magnitude we're talking about here) is enough to change pt. outcome.  And even if that was a negative, it would need to be ballanced against the time savings of L/S and the positive effects on outcome of time saved.


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## medic417 (Mar 2, 2009)

ffemt8978 said:


> What about areas like mine, where running code can get you there 15-25 minutes earlier?



Can your partner safely and effectivly work?  If no then no.  How far are you traveling?  My short transports are 90 miles.  The difference between 80 and 85 is around 6 minutes, but the ride is much smoother at 80 and even smoother at 75.  Honestly if your patient is goning on a minimum of a 1hour trip another 15 minutes is not going to have any major impact on survivability.  Even the meds that everyone says we have to rush to the hospital to get, well first they should be on the ambulance, and second you are still in the window for administering it unless they delayed calling.  

We actually have some areas that we go under the speed limit in order to allow the person in the back to work on the patient.


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## VentMedic (Mar 2, 2009)

jrm818 said:


> I'd still love to be told at least generally what the reason that L&S "harms" CVA or MI (or AAA) patients. come on...give a "grasshopper" a hint at least  It's an interesting idea that I have not done research on this and am making things up out of thin air....although apparently there is some super evidence against rapid transport that I have missed....


 
Do you know what a stress response is? 

Do you really want the patient to also needlessly experience

Increased HR
Increased BP 
Increased RR
Glucose abnormalities

while also coping with any of the disease processes mentioned. 

This has been researched carefully for years and articles can even be found in THE JOURNAL: JEMS.



jrm818 said:


> . Communication with the patient is probably just (if not more) of a factor in patient stress.


 
While communication is important, this is a pretty naive statement. If this is the patient's first MI or CVA and the siren is blasting during his/her first ambulance ride, you can say pretty things to them all you want it will not change what they are feeling.

It is like preparing for a roller coaster ride. You know what is going to happen, but your body still responds to the ride regardless of how prepared you think you are.


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## ffemt8978 (Mar 2, 2009)

Our transport distances are 60-75 miles one way, to the nearest facility.  Two lane highways where the speed limit is 55 or 60.  For the most part, yes, we can effectively work at 85-90, although if we can't we ask the driver to slow down and take it easy until we complete whatever procedure we're doing at the time.

And yes, there are times we go under the speed limit if it is necessary to perform patient care.  But the reason we turn on the lights is that if we are 1 mph over the speed limit, then technically we need to be running code or the driver could (not likely, I'll admit) be cited for speeding.


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## medic417 (Mar 2, 2009)

VentMedic said:


> This has been researched carefully for years and articles can even be found in THE JOURNAL: JEMS.



And if it is such a simple thing to understand that it makes it into JEMS anyone that fails to understand must have problems.  I would like to see you post other articles from real journals but the big words might overwhelm some.


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## VentMedic (Mar 2, 2009)

ffemt8978 said:


> Our transport distances are 60-75 miles one way, to the nearest facility. Two lane highways where the speed limit is 55 or 60. For the most part, yes, we can effectively work at *85-90,* although if we can't we ask the driver to slow down and take it easy until we complete whatever procedure we're doing at the time.


 
85 - 90 mph?!

On a two lane highway?!

In an ambulance?!


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## jrm818 (Mar 2, 2009)

medic417 said:


> Can your partner safely and effectivly work?  If no then no.  How far are you traveling?  My short transports are 90 miles.  The difference between 80 and 85 is around 6 minutes, but the ride is much smoother at 80 and even smoother at 75.  Honestly if your patient is goning on a minimum of a 1hour trip another 15 minutes is not going to have any major impact on survivability.  Even the meds that everyone says we have to rush to the hospital to get, well first they should be on the ambulance, and second you are still in the window for administering it unless they delayed calling.
> 
> We actually have some areas that we go under the speed limit in order to allow the person in the back to work on the patient.




Do tell, exactly what "work" are you doing with a CVA patient?  Sorry, there is barely anything that can be done in-hospital, never-mind Granted with an MI patient there might be something to be done pre-hospitally that will be a benefit.  Sometimes there isn't though. 

 NSR with ST elevation...what are you doing exactly?  Around here ASA, Nitro, maybe MS...and that's about it.  that takes what...the first 90 seconds of transport? 

And yes...my partner can work in the back when I drive L/S.  I don't go any faster than normal L/S...I just get to drive around traffic and through traffic lights.  

Obviusly our location is different than yours.  I wont tell you how to handle your territory, but around here the difference is between ~15 minute transport time and maybe 30-45 minutes if traffic is really bad.  That may very well make a difference.  Sounds like for you L/S means "faster than the speed limit" while for me L/S means "faster than traffic.  I might be convinced that in your system L/S isn't called for really ever.  That does not mean that L/S isn't needed anywhere.

What meds should be on the ambulance?  Tpa?  seroiusly?  lytics for MI maybe... just not the case in most places though

As for the "window" idea (i'm thinking CVA here...that's the evidence i'm most familliar with).  This is a huge pet peeve of mine.  It is NOT(!) the case that any old time within the 3 hour window is OK .  There is a good amount of research indicating that it is significantly better to arrive at the front end of the window than at the end.  the "window" is the absolute limit...but CVA's are truly time-dependent emergencies, and early arrival, CT, and tpa IS better.  I'll get on a soapbox here for a second...you owe it to your patient to get them to a stroke center as soon as safely possible if you suspect a stroke.  You may never know the difference...heck they may not....but time is brain cells...and they do not grow back.  

still waiting for even a hint towards evidence I didn't find in my non-research which suggests L/S transport is detrimental to patients (seriously...if it exists I want to see it)...


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## jrm818 (Mar 2, 2009)

medic417 said:


> And if it is such a simple thing to understand that it makes it into JEMS anyone that fails to understand must have problems.  I would like to see you post other articles from real journals but the big words might overwhelm some.



If this is directed at me you can go pound sand.  I know plenty of big words, never read JEMS, and you have no idea what my educational background is.  Just because we disagree doesn't mean I'm some moron who has never read a real academic journal or done a literature search.


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## VentMedic (Mar 2, 2009)

jrm818 said:


> ...you owe it to your patient to get them to a stroke center as soon as safely possible if you suspect a stroke. You may never know the difference...heck they may not....but time is brain cells...and they do not grow back.


 
You also owe it to your patient not to delay getting there by crashing.

Unlike TV, a stroke team does not magically appear out of thin air. They will be called while you are enroute and can be ready when you arrive. There is no need to try to shave off two minutes of time.

Seriously, you found nothing about L&S in your search?


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## ffemt8978 (Mar 2, 2009)

VentMedic said:


> 85 - 90 mph?!
> 
> On a two lane highway?!
> 
> In an ambulance?!



Middle of the desert, no cross streets, and visibility of 6-10 miles...yep.


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## medic417 (Mar 2, 2009)

ffemt8978 said:


> Our transport distances are 60-75 miles one way, to the nearest facility.  Two lane highways where the speed limit is 55 or 60.  For the most part, yes, we can effectively work at 85-90, although if we can't we ask the driver to slow down and take it easy until we complete whatever procedure we're doing at the time.
> 
> And yes, there are times we go under the speed limit if it is necessary to perform patient care.  But the reason we turn on the lights is that if we are 1 mph over the speed limit, then technically we need to be running code or the driver could (not likely, I'll admit) be cited for speeding.



I have no problem with the lights if you are truly running safely considering the top heavy brick we are in and the Medic can work w/o hanging on for dear life.  Honestly I am surprised your insurance does not stipulate no more than 10mph over posted limit.  But running full speed again is unecessary risk and again only saves you 5-15 minutes compared to 70-75mph.

The lights also seem to get the deer and elk to get out of the road.


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## ffemt8978 (Mar 2, 2009)

I've never asked what our insurance stipulations are...hmm, I might have to go look that one up.

I do know that we are self insured to a point, but I don't know what the point is either.

And for further clarification, most of our transport speeds are in the 70-75mph range...although we have done 90 on a few occasions.


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## medic417 (Mar 2, 2009)

jrm818 said:


> As for the "window" idea (i'm thinking CVA here...that's the evidence i'm most familliar with).  This is a huge pet peeve of mine.  It is NOT(!) the case that any old time within the 3 hour window is OK .




I will not do your research.  But I suggest you research your 3 hour post now as well as transport.


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## jrm818 (Mar 2, 2009)

VentMedic said:


> Do you know what a stress response is?
> 
> Do you really want the patient to also needlessly experience
> 
> ...



10 characters


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## medic417 (Mar 2, 2009)

ffemt8978 said:


> I've never asked what our insurance stipulations are...hmm, I might have to go look that one up.
> 
> I do know that we are self insured to a point, but I don't know what the point is either.
> 
> And for further clarification, most of our transport speeds are in the 70-75mph range...although we have done 90 on a few occasions.



Might double check insurance and state laws to make sure if the unthinkable happens you don't get hung out to dry.


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## medic417 (Mar 2, 2009)

jrm818 said:


> If this is directed at me you can go pound sand.  I know plenty of big words, never read JEMS, and you have no idea what my educational background is.  Just because we disagree doesn't mean I'm some moron who has never read a real academic journal or done a literature search.



Please do not allow your stress to cause you to start reading into posts.  I ask you please calm down as I never called you a moron.  If Jems is not your only source of Medical reading it obviously was not directed to you.  I do not want this thread locked or you to get into trouble for attacking.


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## jrm818 (Mar 2, 2009)

medic417 said:


> I will not do you research.  But I suggest you research your 3 hour post now as well as transport.



I never asked you to do my research.  There is a difference between giving me citations and giving warrants to a claim.

You siad "you are harming your patients."  I dont need citations, but the general idea of HOW L/S harms patients would be nice.  IE you could say "it causes a stress response."  or whatever it causes.  Sorry, I dont think many people are going to say "OK...well medic417 said it was bad on EMTLife.com so it must be so."  Give me a direction and I"ll do my own research....

the 3 hour refrence was simply because that is commonly taken to be the window for tpa.  Yes I know there is talk of modifying the window, but in a lot (if not most) of places 3 hours is still the limit.


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## VentMedic (Mar 2, 2009)

Originally Posted by *ffemt8978* 

 
_



I've never asked what our insurance stipulations are...hmm, I might have to go look that one up.

I do know that we are self insured to a point, but I don't know what the point is either.

And for further clarification, most of our transport speeds are in the 70-75mph range...although we have done 90 on a few occasions.

Click to expand...

_


medic417 said:


> Might double check insurance and state laws to make sure if the unthinkable happens you don't get hung out to dry.


 
You might also take another EVOC class and review what can happen for each additional 5 mph with a vehicle the size of an ambulance.  You put way to much trust into a piece of machinery.  The difference between 60 and 90 is very  significant if something happens that will cause your driver or that vehicle to want to stop.


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## jrm818 (Mar 2, 2009)

medic417 said:


> [...]I never called you a moron.  If Jems is not your only source of Medical reading it obviously was not directed to you.  I do not want this thread locked or you to get into trouble for attacking.



Then I withdraw the comment.  Too late to edit it.  I still think the shot about failing to understand and having problems is a cheap shot...even if not directed at me.


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## AJ Hidell (Mar 2, 2009)

jrm818 said:


> Which ones, and how would L&S hurt?


Vent laid it out for you very nicely just a few posts back.  Did you miss that, or are you intentionally refusing to acknowledge it?  Please tell us how you can justify, on any level, elevating the heart rate and blood pressure of an MI, CVA, or AAA patient.

Regardless, ever heard of Evidence Based Medicine?  That means we do things because they are proven by scientific and statistical analysis to be helpful, and without significant risk.  "What does it hurt?" is not a valid justification for any medical or operational procedure.  And neither is "well, I think...".  It's a lazy, unintelligent, and uneducated way to do things, and it puts your patients, your partner, the general public, and yourself at unjustifiable risk.


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## ffemt8978 (Mar 2, 2009)

VentMedic said:


> Originally Posted by *ffemt8978*
> 
> 
> 
> ...



We do mandatory EVIP on a yearly basis, and most of our ambulance drivers have CDL's with several years of experience driving.


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## medic417 (Mar 2, 2009)

jrm818 said:


> I never asked you to do my research.  There is a difference between giving me citations and giving warrants to a claim.
> 
> You siad "you are harming your patients."  I dont need citations, but the general idea of HOW L/S harms patients would be nice.  IE you could say "it causes a stress response."  or whatever it causes.  Sorry, I dont think many people are going to say "OK...well medic417 said it was bad on EMTLife.com so it must be so."  Give me a direction and I"ll do my own research....
> 
> the 3 hour refrence was simply because that is commonly taken to be the window for tpa.  Yes I know there is talk of modifying the window, but in a lot (if not most) of places 3 hours is still the limit.



Well lets see you could research by key words, but I am confident you know that.  You could even read just about all the EMS books, again I am sure you know that.  They say transport calm quite.  

Just because the hospital still goes by old data does not change the actual window, and many if not most are going to the much broader window with a preference for inside the 3.  


Point being you stress them by driving fast and L&S.  But by adding 1-15 minutes on the trip and all remaining calm you cause patient to decide hey they're calm I'm in good hands, they relax, BP and HR lower.  Wow less stress on the heart and blood vessels.  You just bought the patient more time than driving L&S every could.


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## medic417 (Mar 2, 2009)

http://www.youtube.com/user/ParamedicSafety

Ambulance crash videos.  Shows what happens in patient compartment.


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## jrm818 (Mar 2, 2009)

AJ Hidell said:


> Vent laid it out for you very nicely just a few posts back.  Did you miss that, or are you intentionally refusing to acknowledge it?  Please tell us how you can justify, on any level, elevating the heart rate and blood pressure of an MI, CVA, or AAA patient.
> 
> Regardless, ever heard of Evidence Based Medicine?  That means we do things because they are proven by scientific and statistical analysis to be helpful, and without significant risk.  "What does it hurt?" is not a valid justification for any medical or operational procedure.  And neither is "well, I think...".  It's a lazy, unintelligent, and uneducated way to do things, and it puts your patients, your partner, the general public, and yourself at unjustifiable risk.



Oh good lord.  I responded to Vent, as did I to JPINV when he brought up a stress response initially.  I'll give you the benefit of the doubt that I responded while you were posting....

I never said "what does it hurt" as a justification...it was an actual question.  Acutally..I wanted to know what evidence you were basing the claim on.  Nor did I ever say "I think," rather, I've said multiple times "evidence (that scientific stuff) shows improved outcomes with shorter onset to treatment times."  My opinion is based on my interpretation of the literature I have seen on the issue.  

I resent the implication that I am somehow lazy or uneducated, and there is no need for that to be in your post at all.  I provided warrants for all my claims, which included my interpretations of scientific studies which I have acutally read.  Quit assuming....

EDIT:

Sidenote scientific rant.  nothing is EVER "proven" in scientific studies.  hypotheses are supported or refuted.  evidence changes, and so do ideas about best practices.  That happens all the time.  As a result there are differing interpretations of evidence, and people can disagree about what the evidence says....


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## VentMedic (Mar 2, 2009)

This is all the hand holding you are getting. I just did a quick search and found several good articles. 
http://scholar.google.com/

Working in EMS and on Specialty transports for several years, I also have experience that tells me what patients go through. It's not rocket science, just a little commonsense.


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## AJ Hidell (Mar 2, 2009)

jrm818 said:


> I resent the implication that I am somehow lazy or uneducated, and there is no need for that to be in your post at all.


It did need to be there, because it is the very foundation of this entire discussion of the original post.  Whether it applies to you personally or not is entirely up to you, not me.  But whether it applies to you or not, to choose procedures with no basis in proven evidence is indeed, lazy, unintelligent, and uneducated.  Regardless, we are talking about a decision making process as a whole, not any individual person.  But if the shoe fits, wear it.


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## UrbanEmt (Mar 2, 2009)

Lights and sirens give me a headache.  I dont like headaches.

We dont use them unless its justified, it rarley is.


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## VentMedic (Mar 2, 2009)

ffemt8978 said:


> Our transport distances are 60-75 miles one way, to the nearest facility. Two lane highways where the speed limit is 55 or 60. For the most part, yes, we can effectively work at 85-90, although if we can't we ask the driver to slow down and take it easy until we complete whatever procedure we're doing at the time.


 
This is where we would consider a helicopter especially if the patient meets the criteria that requires you to run L&S at 90 mph for the transport.


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## ffemt8978 (Mar 2, 2009)

VentMedic said:


> This is where we would consider a helicopter especially if the patient meets the criteria that requires you to run L&S at 90 mph for the transport.



HEMS is my preferred ALS transport, but since there is only one helicopter in the center part of the state, and the next available one has a 75 minute ETA there are times we're stuck transporting via ground.


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## DR_KSIDE (Mar 2, 2009)

VentMedic said:


> PDs do have very strict rules for running L&S fortunately or it would be one noisy mess if they ran L&S to ALL of their calls.
> 
> The other article I posted involved the FD.
> *Redundant Response Under Fire in Florida *
> ...



I would have to disagree, but I am not looking to go head to head against you Vent, just want my opinion heard. Be it some departments probably do have policies, but most that I have seen, worked for and with, leave the discretion WHERE it should be, with the officer or the driver. Our FD in the town I currently work, they don't seem to get out much so they pretty much run L&S to everything, most of there calls just happen to be code 3. Again, when it comes to our EMS, its left up to the discretion of the driver and the crew, and the same with our PD, it is always up to the officer. People talk about liability and such, which will always be there in the sue happy society that we live in, but what it comes down to is the training and education that you give your people before you clear them to drive your vehicles♠, you can't just let the rookies get behind the wheel and go. I believe that everyone should go through some sort of EVOC course, but even then it doesn't prepare you for every scenario, but at least it gives you more of a feeling to what you are capable of and how your vehicle will handle with you behind the wheel. 

Note: I am both and officer and a EMT/Driver, I also have been through and helped teach multiple pursuit courses and defensive driving courses. I also teach the driving portion of EVOC for our dept and EMS and in the spring our FD will go through our course. If your dept is looking for a course the try I will send you a basic EVOC course and layout.


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## medic417 (Mar 2, 2009)

http://www.medscape.com/viewarticle/582754

Good article on Trauma and scene times.


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## VentMedic (Mar 2, 2009)

DR_KSIDE said:


> I would have to disagree, but I am not looking to go head to head against you Vent, just want my opinion heard. Be it some departments probably do have policies, but most that I have seen, worked for and with, leave the discretion WHERE it should be, with the officer or the driver. Our FD in the town I currently work, they don't seem to get out much so they pretty much run L&S to everything, most of there calls just happen to be code 3. Again, when it comes to our EMS, its left up to the discretion of the driver and the crew, and the same with our PD, it is always up to the officer. People talk about liability and such, which will always be there in the sue happy society that we live in, but what it comes down to is the training and education that* you give your people before you clear them to drive your vehicles*♠, you can't just let the rookies get behind the wheel and go. I believe that everyone should go through some sort of EVOC course, but even then it doesn't prepare you for every scenario, but at least it gives you more of a feeling to what you are capable of and how your vehicle will handle with you behind the wheel.
> 
> Note: I am both and officer and a EMT/Driver, I also have been through and helped teach multiple pursuit courses and defensive driving courses. I also teach the driving portion of EVOC for our dept and EMS and in the spring our FD will go through our course. If your dept is looking for a course the try I will send you a basic EVOC course and layout.


 
So what part do you disagree with? I stated PD has policies and do not run L&S to everything. Is that not true?  If I want to file a complaint about the dog next door barking all night, are you as an LEO going to respond L&S to take my complaint?

In the article referenced, *all* vehicles respond L&S if they are dispatched by 911 regardless of the emergency. I don't agree with that. 

Why do you think I am looking for a basic EVOC course? EVOC is a requirement for all who drive ambulances in my state. 

It should involve a little more than just educating someone to drive an ambulance. This thread is also being discussed from the medical aspect. Are you (not in the personal sense) so uncomfortable with the patient care you provide that you must run real fast to the hospital? Yes, this may be true at the BLS level but even then L&S are not always warranted. However, if you are a competent healthcare provider, you should be able to assess and provide the necessary level of care to get the patient to the hospital safely while initiating the needed medical care.


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## jrm818 (Mar 2, 2009)

VentMedic said:


> This is all the hand holding you are getting. I just did a quick search and found several good articles.
> http://scholar.google.com/
> 
> Working in EMS and on Specialty transports for several years, I also have experience that tells me what patients go through. It's not rocket science, just a little commonsense.



Thanks for removing the personal shot (serious).

I didn't need any hand holding.  I'm familliar with google scholar...just as a for instance...type in "'lights and sirens' stroke"  The first page of results has one vague reference to transport with L/S...every other article on the first 2 pages of results deals with dispatch priority not transport with or without lights and sirens.  The closest to a mention of ambulance transport time is just listing net time with patient, the effects of prehospital recognition on stroke, and the fact that pt.s presenting with stroke-like symptoms to an ED get CT's faster than pts comming by POV.

The point is, there is no good research that I've yet seen which directly addresses the use of lights and sirens transport with stroke patients.  

There is (decent to good) evidence that early treatment = better outcome in strokes.  Insofar as in many locations L/S will reduce transport time by signifigant amounts, it is logical to assume that absent any other intervening factor (eg stress...see below), L/S will improve outcomes.

Stroke team activation is obviously important.  no they don't materialize, but in a properly setup system, they are ready when the ambulance shows up.  Door to CT times are important...but if you don't hit the door for 40 minutes instead of 15, than patient outcome may well be worse.

So from the premise that L/S decreases onset-treatment times, which is good. L/S is a good practice, unless there is a signifigant evidence supported detriment to such transport.  Accident rates are certianly valid, but proper driver training and re-enforcement can reduce those risks.  In my case I' don't drive like a nut, so i don't think the increased accident rate is an accurate representation of the risk to me and my patient individually.

I understand the stress response arguments - they would be an intervening factor that _might _outweigh the time saved by L/S driving.  I don't agree that they do based on everything I know about the effects of stress on strokes.  I will readily grant (and already have) that stroke outcome is worsened by stress responses - especially the inflammatory, hyperglycemic, and hyperthermic variety.  

The argument that L/S increases stress is not enough.  This issue is more complicated than that, and the quantity of stress matters.  I've seen the data for time to treatment, I want to see the data (actual numbers, not generalizations) for stress responses.  I don't believe such data exists specifically applied to L/S transport.  There is a lot of animal data about stress and stroke outcome, but it is mostly chronic or subacute stress prior to stroke.  I knew about this data already, and spent the last hour or so looking again to confirm that...I didn't find anything too specific to the issue at hand.  

There is data which indicates that there is a stress response to stroke regardless of psychological stress (which is what L/S is).  Thus we are not comparing stress from L/S to an unstressed CNS, rather the incremental additive stress form L/S transport to the stress that already exists from the physiological response to stroke, underlying pathologies and disease processes, possibly a freaked out family, psychogical disturbance due to strange neurologic symtoms (e.g. not being able to talk is pretty darn stressful), stress from the arrival of an ambulance, quick moving providers, phone conversatoins with all kinds of medical gibberish, going in an ambulance, exposure to a hospital, etc.  

I find it hard to believe that hearing  a siren in the back (when the patient likely expects a siren to go with an ambulance anywyas) is going to make that much quantitiave difference in net stress levels.  In the absence of data (and for this, I will ask for citations.  I've looked, and found nothing on point about stress increases in patients (plenty about providers) when brought by ambulance), we are left to guess...and that's my guess.

So, from my perspective...for all you evidence based types out there
decent-good evidence supports decreasing onset to treatment times
good evidence says stress is bad in a stroke, but thats prior chronic stress, acute stress almost certianly is bad, but exists anyways
little-no evidence that L/S has any effect at all on overall stress levels

To me that adds up to the evidence pointing to L/S (in systems where it make a signifigatn difference in transport time) as possibly helping outcomes until more evidence clearly demonstrates a detriment.

Fire away...i may not answer anymore tonight.  Tomorrow is another day...


Note: I realize I'm not paying any attention to MI's AAA's or the other things I mentioned.  I'll admit I'm not nearly so familiar with that data, and I don't have time to debate each condition individually, so i picked strokes as my example condition.  I got blasted for advocating strokes to L/S too, so I figured it's as good a condition to defend as any...


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## jrm818 (Mar 2, 2009)

medic417 said:


> http://www.medscape.com/viewarticle/582754
> 
> Good article on Trauma and scene times.



Can you post a citation?  Curious what this is.  Link doesn't work for me the way I log into things...


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## AJ Hidell (Mar 2, 2009)

Okay, you're getting way too hung up on the term "stress", without seeming to understand exactly what it means.  I understand that the understanding of physiology taught in EMT school -- as well as most paramedic schools -- is painfully inadequate, so this is of no surprise.  However, regardless of your educational background, your common sense should kick in to compensate here.

Again, do you not understand the dangerous and potentially fatal effects that increased heart rate and increased blood pressure can have on your MI, CVA, or AAA patients?  Do you really believe that a few seconds or minutes of time saved could possibly negate that risk?  Do you think it is okay to increase the rate of their bleed, or the damage of their infarct just to get them to the hospital faster?  That's like the guy I pulled over for speeding once who claimed it was because he was in a hurry to get to a gas station before he ran out of gas.  Does that make any sense on any level?  No!  Use your head!


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## trevor1189 (Mar 2, 2009)

*my opinion for what it's worth*

It looks like Pennsylvania is proactively trying to decrease L&S response to less than 50%. According to the PA BLS Protocols updated 11/1/2008. 

You can check out guidelines for L&S response in PA here: http://www.dsf.health.state.pa.us/health/cwp/view.asp?a=170&Q=231878

By clicking the "Statewide BLS Protocols Effective November 2008" link and looking at pages 16-18 of the pdf file.

I agree that an ambulance shouldn't be flying down the highway L&S going. At least where I live, bumpy roads = not fun for people in the back of the ambulance. But I also think that ambulances should be able to use lights and sirens to proceed through lights instead of sitting there waiting if time is sensitive. Where I live, people do pretty good about getting out of the way for emergency vehicles and even blue lighters. I also think something to consider is resources. If you live in a small town, with limited EMS personel and equipment the longer it takes for the ambulance to get back in service the longer the next patient might have to wait. If there are only one or two ambulances available and both are out it seems like they should be trying to get back in service and available as quick as safely possible. 

But, what do I know. I'm not even an EMT yet. 

Just my 2 cents.


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## jrm818 (Mar 2, 2009)

AJ Hidell said:


> Okay, you're getting way too hung up on the term "stress", without seeming to understand exactly what it means.  I understand that the understanding of physiology taught in EMT school -- as well as most paramedic schools -- is painfully inadequate, so this is of no surprise.  However, regardless of your educational background, your common sense should kick in to compensate here.
> 
> Again, do you not understand the dangerous and potentially fatal effects that increased heart rate and increased blood pressure can have on your MI, CVA, or AAA patients?  Do you really believe that a few seconds or minutes of time saved could possibly negate that risk?  Do you think it is okay to increase the rate of their bleed, or the damage of their infarct just to get them to the hospital faster?  That's like the guy I pulled over for speeding once who claimed it was because he was in a hurry to get to a gas station before he ran out of gas.  Does that make any sense on any level?  No!  Use your head!



Actually I think the view of stress I'm taking is a bit more complex that what you assume.  Especially in the case of CVA, which is addressed above, stress in the form of increase HPA activation, local and generalized inflammatory factors, local as well as systemic vasoactive factors are important.  Heart rate and BP are just the sympathetic responses (I'd even venture to say that the most important symp. response may be glucose mobilization in the context of cva, rather than the ones you mention...hyperglycemia is bad juju for strokes)...but the effects of stress on infarct size and the cellular reactions to infarct involve responses to a lot more than just raised blood pressure.  A lot of the problems in stroke comes from local dysregulation of the vascular system anyways...I dont know how much difference arterial blood pressure alterations make given that semi-decoupling of vessel pressure in the brain from systemic pressure.  When I say "stress" above I'm referring to all of these processes...sympathetic, inflammatory, HPA and secondary cellular-reactive, etc.

I think I made it clear that I understand that stress is bad...both the local and inflammatory version and the sytemic sympatho/adrenal version. My point is that these are not only psychologically mediated.  The physiological stress of CVA (or whatever) alone will cause a lot of these processes.  You get a stress response even in the absence of psychologicla stress.  

Much of the psychological stress is innate to the emergency condition.  In order for you  make this "common sense" arguement that L/S is bad for people, it needs to be clear that the increment of stress which is caused ONLY by L/S transport, and not by the other circumstances, contributes significantly to the overall level of stress (measured either by catecholamine activation , HPA activation, inflammatory response, whatever "stress" you choose) to such an extent that removing the L/S unique stress changes patient outcome.    I simply don't see the data for that argument.  

Read that carefully...I will happily grant that stress in pretty much any form is bad for these patients.  But dealing with the emergency is stressful...if there is an intervention like L/S transport that can be performed with only a relatively small increase in stress but a relatively larger positive effect on outcome, it seems justified.  The question is simply how much stress does L/S add, and how much benefit does L/S bring.  There is data for the second part of that...not so sure about the first.  without data we can only speculate on the added stress of L/S...and I simply don't think its that big of a deal given the magnitude of the stress response that is unrelated to hearing a siren.  In the absence of data we are all free to speculate...

As to the difference made by seconds...of course seconds don't matter for almost any condition.  I'm talking about cases where L/S makes a difference of 15 minutes or more.

In that case...can it change outcomes?  Yes, I think it can. And the difference between your "common sense" argument against increasing stress and mine is that there is _evidence _that demonstrates better outcomes the sooner CVA is treated (assuming they can be treated).  How much difference?  for an individual patient..who knows.  but in general, I feel pretty confident speculating that less transport time can acutally result in signifigantly improved outcomes.

And again, i realize I'm ignoring MI and AAA.  I don't have time to address everything, so for consistency I'm sticking with strokes.


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## Ridryder911 (Mar 3, 2009)

I think you can't see the forest for the trees. Simple. Hook up the monitor and closely monitor the blood pressure. Now, proceed with l/s and without. Research has demonstrated even experienced emergency providers blood pressure and pulse rates increased as much as 25%. Remember, these were experienced providers. 

Now, let's use common basic hemodynamics. Increased HR X Increased SV X Increased TPR = Increased cardiac output and increase ICP and vessel pressure. Just watch a CVP and art line. 

Now, how much time is really saved? What difference is 4 minutes really going to save? There is more questions as if with l/s actually save time? And if so, really how much, if it is performed safely? As well, more and more centers have increased their door to option from three hours to six hours. 

L/S are for usually reserved for those that do not know what to do. There is those very, very few times that I respond back with l/s. Triple A that has a code brown, Cardiac Arrest that occurs with a code brown.... okay there is something related here. 

R/r911


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## AJ Hidell (Mar 3, 2009)

jrm818 said:


> Much of the psychological stress is innate to the emergency condition.  In order for you  make this "common sense" arguement that L/S is bad for people, it needs to be clear that the increment of stress which is caused ONLY by L/S transport, and not by the other circumstances, contributes significantly to the overall level of stress (measured either by catecholamine activation , HPA activation, inflammatory response, whatever "stress" you choose) to such an extent that removing the L/S unique stress changes patient outcome.    I simply don't see the data for that argument.


It's a fallacious argument to make.  What you are saying is, since other things cause stress, there is no reason to avoid any of them.  That's like saying since our house could be destroyed by a tornado, there is no reason to reduce our risk of fire.  It's a nonsense argument.  If the sympathetic response were the only "stress" we had to worry about, you'd actually have a better argument.  But, since you admit that it is only one of many stressors, it is more important than ever that we reduce as many of those as possible.

Regardless, we can only prevent those stressors that we ourselves induce.  Since WE induce the stress of a code 3 run, WE are responsible for preventing it.


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## jrm818 (Mar 3, 2009)

Ridryder911 said:


> I think you can't see the forest for the trees. Simple. Hook up the monitor and closely monitor the blood pressure. Now, proceed with l/s and without. Research has demonstrated even experienced emergency providers blood pressure and pulse rates increased as much as 25%. Remember, these were experienced providers.
> 
> R/r911



Like this study? (acutally the first I've found to address this issue on point.  The authors claim it actually is the first..I believe them)

Emergency medical service transport-induced stress? An experimental approach with healthy volunteers  Resuscitation, 2001

I'll summarize the results:

Found that transport down stairs is more stressful than the transport to the hospital while going L/S in dramatic fashion.  They measured Epi NE HR and BP.

EPI and NE increased signifigantly for transport in a stair chair, EPI increased significantly for transport in the ambulance, although EPI in transport was significantly less than EPI while going down stairs.  

NE increased in the stair chair, and was acutally _lower _than control during ambulance transport (I don't like the authors explanation for this one, although it probably hurts my argument.  I think the decrease is prob. due to the secretion of EPI rather than NE from the adrenal medulla now that the HPA axis had time to stimulate the conversion, and thus the decrease in NE doesn't represent a decrease in stress....but who asked me)

HR went up a bit during transport...much more during stair chair.  BP changed overally by 4+- 2 mmHG, but wasn't plotted across the time points.

Overall the _least _stressful part of the whole experience was transport in an ambulance going L/S with intentional speeding, hard breaking, and u-turn making.

To me that supports what I've been saying.  Will there be in increase in stress?  Sure, but it is NOT unique to L/S, and removing L/S probably won't result in very much clinically relevant decrease in stress.  

Plus..these were healthy volunteers with no other sources of stress.  With a real patient I feel like the stress from transport will be overshadowed by the stress from their emergency..but there's no data to support or refute that.


the time window extension argument:

fine...tpa can be given at longer time points.  It doesn't matter, my argument was never based on tpa vs. non-tpa (although it could have been I suppose) - outcomes are still better the earlier it is given (and that was mostly studies using the 3 hour time limit).  It is not true that outcome at 6 hours is the same as outcome at 3.  The cliche time= cells is right on in this case.


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## Sasha (Mar 3, 2009)

You can't avoid transporting down the stairs, unless you toss the patient out of the window or there is an elevator.

You can avoid the unncessary stress of a lights and sirens transport.



> Plus..these were healthy volunteers with no other sources of stress. With a real patient I feel like the stress from transport will be overshadowed by the stress from their emergency..but there's no data to support or refute that.



Put yourself in your patient's shoes. What do you think when you see an ambulance just lazily driving along? "Oh, it must not be that bad!" but when you see a truck screaming down the highway towards the hospital, you think "Yegads! An emergency!", right? 

So, if you were a patient and the paramedic decided for a L/S transport, what does that tell you about YOUR condition? Do you start to get worried and stressed?



> Plus..these were healthy volunteers with no other sources of stress.


You miss a key factor in the study, in my humble opinion. The volunteers knew they were healthy, nothing wrong. The patients don't know what's going on. The unknown can be quite a stressful thing.

Can you provide a link to the study?


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## jrm818 (Mar 3, 2009)

AJ Hidell said:


> It's a fallacious argument to make.  What you are saying is, since other things cause stress, there is no reason to avoid any of them.  That's like saying since our house could be destroyed by a tornado, there is no reason to reduce our risk of fire.  It's a nonsense argument.  If the sympathetic response were the only "stress" we had to worry about, you'd actually have a better argument.  But, since you admit that it is only one of many stressors, it is more important than ever that we reduce as many of those as possible.
> 
> Regardless, we can only prevent those stressors that we ourselves induce.  Since WE induce the stress of a code 3 run, WE are responsible for preventing it.



Strawman argument.  I never said we should not avoid stresses.  We should.  But if an intervention has positive outcomes, those positives are weighted against the negatives of increasing stress.

The presence of other stressors does not make L/S unique stress more potent.  The opposite in fact...the system can only modulate within certain limits...as stress increases due to non-L/S factors,  whatever system we are talking about will get closer to its upper limit.  At these limits it takes very large changes in stimulus to get measurable effects.  

For example...you see a hungry bear...HR and BP go way up.  Bear pulls out a gun.  HR and BP might go up a little more....but the increase will be less than it would if you had seen a gun pointed at you sans bear because they were both pretty high to begin with.

In the same way the effect of L/S transport will likely (although maybe not...again...no data) be overshadowed by the other stresses going on...like being brought down stairs on a stair chair.  If we were really worried, we would start sedating our patients prior to transport.

OK that really is it for the night.  Its been fun...back tomorrow maybe..


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## AJ Hidell (Mar 3, 2009)

You seem to be seeing individual points here, but failing to do the math to add them up in context.  The math is simple here; less = better.  And if you add stress, you had better have solid, proven justification for it.  You do not.

This whole argument is sounding just like those who continue to argue that MAST pants are good because they maintain BP to the hospital.  You're basing your argument on empirical data that is not scientifically validated as helpful.


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## VentMedic (Mar 3, 2009)

jrm818 said:


> Like this study? (acutally the first I've found to address this issue on point. The authors claim it actually is the first..I believe them)
> 
> Emergency medical service transport-induced stress? An experimental approach with healthy volunteers Resuscitation, 2001
> 
> ...


 
To read medical literature one has to understand its weaknesses as well as its strengths. That study was done on healthy individuals and even the authors themselves admitted that "who wouldn't relax" even if it was in the back of an ambulance after the climb down the stairs. Since these were healthy individuals they did not have the additional stress of disease processes and the anticipated stressors of the trip to the hospital.

Try this article:
*Effects of Emergency Ambulance Transportation on Heart Rate, Blood Pressure, Corticotropin, and Cortisol* 
_K Witzel_

If you have university access, it is in the Annals of Emergency Medicine.

Or, try this one:
*The influence of the mode of emergency ambulance transportation on the emergency patient's outcome.*
Eur J Emerg Med. 1999 Jun;6(2):115-8

*Witzel K*, *Hoppe H*, *Raschka C*.
Department of Surgery, Herz-Jesu Hospital Fulda, Germany.
Emergency transport by an ambulance can cause considerable psychical and physical stress for patients. We determined the haemodynamic and endocrinological values of 54 healthy volunteers subjected to one high speed emergency transport and one smooth transport. There were significant differences in all measurements: heart rate (p < or = 0.001), blood pressure, cortisol (p < or = 0.01), prolactin, somatotropine and ACTH between the two modes of transportation. We hypothesize that the additional stress of high speed ambulance transport particularly in patients with acute cardiac disease may result in additional morbidity.
PMID: 10461554 [PubMed - indexed for MEDLINE]


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## triemal04 (Mar 4, 2009)

AJ Hidell said:


> You seem to be seeing individual points here, but failing to do the math to add them up in context.  The math is simple here; less = better.  And if you add stress, you had better have solid, proven justification for it.  You do not.
> 
> This whole argument is sounding just like those who continue to argue that MAST pants are good because they maintain BP to the hospital.  You're basing your argument on empirical data that is not scientifically validated as helpful.


I'm not going to argue that the use of a siren doesn't increase stress, or that being tossed around in back won't either (of course, even while driving code 3 that shouldn't happen; that it does is a great indicator that someone needs more training and/or needs to be fired).  And the studies that have been cited have shown that pretty well.  But that isn't neccasarily the end of it.

While the bodies responce to stress can make multiple problems worse, as shown in a couple studies, none seemed to take into account the things that we should be doing to help alleviate both the stress responce, and the initial problem.  (granted, this can't be done for everything).  An MI for instace...nitrates, beta blockers, morphine/fentanyl...all can help to decrease the bodies natural responce to both the stress of the event, and whatever increase there is from hearing a siren.  It's definetly not perfect, but I believe it can be effective.  

Really the only time we should be going code 3 to the hospital is if the issue is one that we can't correct in the field, only sustain to one extent or another, and will lead to, at minimal permanent disability and very likely death.  At some point it does either become use a means of rapid transport and try to mitigate any additional problems caused by that, if any, or transport normally and allow the problem to continue to worsen.  Either way has it's pluses and minuses, and for both it's knowing when and why to do it that is the hard part.  

And going code 3 to save a few seconds is ridiculous.


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## ffemt8978 (Mar 4, 2009)

Something else to consider...

In town, the only place that code 3 driving gains you time is at the most dangerous part of your trip...intersections and against the light.


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## firecoins (Mar 4, 2009)

ffemt8978 said:


> Something else to consider...
> 
> In town, the only place that code 3 driving gains you time is at the most dangerous part of your trip...intersections and against the light.



that is true.  Intersections and heavy traffic are the 2 places where it is effective.  I don't even use them for jobs late nights when there is almost no traffic at all.  What's the point?


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## ffemt8978 (Mar 4, 2009)

No point, other than this is a discussion about driving code.


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## JPINFV (Mar 4, 2009)

Here's something else to think about in terms of intersections. How much of the time it takes to stop, clear the intersection, and snake your way through any traffic stuck and stopped inside the interseciton? Now how much time does it take to just sit behind the limit line and wait for the light to change? The difference is probably a few seconds. 

I've always wondered, given enough money to insure 100% of lights can be preempted (e.g. opticon), what the difference between l/s, opticon without l/s, and regular transport.


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## firecoins (Mar 4, 2009)

JPINFV said:


> Here's something else to think about in terms of intersections. How much of the time it takes to stop, clear the intersection, and snake your way through any traffic stuck and stopped inside the interseciton? Now how much time does it take to just sit behind the limit line and wait for the light to change? The difference is probably a few seconds.
> 
> I've always wondered, given enough money to insure 100% of lights can be preempted (e.g. opticon), what the difference between l/s, opticon without l/s, and regular transport.



l&s at an intersection probably saves us 45 second to a minute.  We have long lights here.  

opticon w/o l&s would work.


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## mycrofft (Mar 5, 2009)

*Heck, code 3 doesn't work here a lot of the time.*

Between air conditioners, heaters, sound systems, cell phones and tinted windows, many drivers do not know you are coming.

The difference between driving thirty and sixty in city traffic means higher lateral G force on turns, rougher ride crossing speed bumps and potholes, and thirty more miles an hour in combined speed accidents with careless drivers. Your hapless partner is immobilized at times trying to stay upright. I once saw a MICU nurse drive a Bristoject Epi needle into her upper lip when my otherwise good partner/driver took us across some RR tracks in a Caddy and she had just unsheathed the needle. (Remember, this was in Bedrock and Barney Rubble was out dispatcher).

I only remember reading one mention above about inclement weather. Since safe drivers lower their driving speeds in icy wet snowy foggy dusty conditions, look to your ER mortality reports for those periods and see if more people die because drivers went slower. (Betcha there is no difference regarding cases experiencing this "delay" of care).


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## medic417 (Mar 5, 2009)

Where do most ambulances crash runnig L&S?  Is it at the intersections that they rush thru to save a few seconds?


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