Code driving

[daedalus]

You know, I am pretty good at letting people's arrogant or iggnorant behavoirs just roll off my shoulders. I like to think it matters little in the grand scheme of things. The other day my nextel went off, I answered and it was a dispatcher telling me that an ALS crew at Santa Monica UCLA orthopedic hospital was requesting a CCT unit to transport a premature infant to the main UCLA hospital in Westwood for an emergency cardiology consult and PICU placement. The infant was experiencing a bout of acute hypoxia sec. tetralogy of fallot. After picking up the baby, our RN and the ER MD decided on a code 3 transport to UCLA PICU. While driving, I had an asian man in a van refuse to yield the right of way, and as I passed him on the left instead he made a terrible face at me and than made a "SHHH" expression by bring his finger to his mouth, as if to tell me to turn off the siren. This makes me furious, as such I wished death upon him. I do not regret that thought.

It was a emergency, a new life struggling to hold on. I cant get over it.

 

[Bosco578]

You wished death upon him.....hmmmm....That's some cold S**t. Wow!

 

[Sapphyre]

Sigh, that's just one more reason why I hate driving in LA.

 

[VentMedic]

After picking up the baby, our RN and the ER MD decided on a code 3 transport to UCLA PICU.

Were the RN and MD not from a specialty team? Did they not have any lengthy experience with infants? Or was it an RN from a general CCT and a new MD or resident/Fellow?

Specialty teams pick critically ill infants up all from different parts of this country and others with many, many miles to travel. They rely on their expertise to get a child delivered safely and not L/S. I can not remember the last time our Speicalty teams used "Code 3".

 

[daedalus]

In LA county, most CCT transports receive verbal or written orders from the transferring MD to use lights and sirens. The last thing you want is to be stuck in LA traffic with a dying baby. We do not take chances when transporting critically ill people at my service.

 

[Ridryder911]

In LA county, most CCT transports receive verbal or written orders from the transferring MD to use lights and sirens. The last thing you want is to be stuck in LA traffic with a dying baby. We do not take chances when transporting critically ill people at my service.

I believe the point Vent was making, driving with l/s was not going to change or make any difference. In reality what difference if arriving to the hospital by four minutes earlier for what? You have an physician, neonate nurse (both specialist as well) what more do you want? The mobile unit should be able to provide the general care and surroundings of the initial care. Hence the reason why national trends and scientific research have made the move from flight service for neonate to ground transport.... no need for rapid transport to the hospital.

R/r 911

 

[MSDeltaFlt]

I do not have an opinion one way or the other in this matter. I do have a couple of points that might need to be voiced.

1. If you're driving L/S, it should feel as if you're driving without L/S. The only difference should be that it's brighter and louder. That's it. If it feels like you're driving code 3, then stop driving code 3. If those in the back are constantly hanging on to the Oh Sh*t bar like a couple of spider monkeys, then they're not taking care of the pt.

2. Of all of the Pediatric/Neonatal CCT's I've seen in my career, I'm yet to see one of them ever move their pt before each and every single duck was in a row. They have contingency plans for their contingency plans. They don't do a damn thing until they are good and ready.

 

[KEVD18]

id love to see a study done where an entire district kept track of their response and transport times for a month, then took the l/s's off the trucks and did another months worth of calls and then compared the data.

maybe its already been done and one of our resident never ending link list holders could point me that way.

 

[EMT-P633]

id love to see a study done where an entire district kept track of their response and transport times for a month, then took the l/s's off the trucks and did another months worth of calls and then compared the data.

maybe its already been done and one of our resident never ending link list holders could point me that way.

that would be interesting to know.

 

[JPINFV]

Maybe I'll stop seeing Boston EMS forcing cars into intersections against red lights then.

 

[KEVD18]

doubtful. the boys over at h+h are as close to being above the law in this state as is actually possible.

 

[VentMedic]

In LA county, most CCT transports receive verbal or written orders from the transferring MD to use lights and sirens. The last thing you want is to be stuck in LA traffic with a dying baby. We do not take chances when transporting critically ill people at my service.

Then those are not specialty teams which should be the ones transporting sick neonates and pediatrics. Those are just general run of the mill CCTs that have vague nothing for protocols and put warm bodies on the trucks. This infant was probably beyond their comfort level and thus a real specialty team should have been called as the American Academy of Pediatrics recommends.

Just because the sending doctor is crapping his pants when the infant is beyond his expertise does not mean his orders trump that of the rec'g facility's medical director. The medical director of the specialty team should be one that gives the orders and protocols by which experienced specialty teams follows.

As MSDeltaFlt said, an experienced Specialty team will do everything that they would normally do in the NICU/PICU before moving. Because of the nature of stabilization, this can take several hours before the team is even ready to depart with the infant to their base facility. That might also mean taking the baby, on life support if necessary, to the mother's room for a good-bye look. Then, depending on the location, since many of our transports are from other countries and the islands, the whole transport may take up to 24 hours. As our attorneys have told us there is no way we can justify L/S considering there could be 4 minutes saved by not stopping by the mother's room.

Specialty team members have several years of experience in their profession and are educated/trained by their attendings and medical directors. Their protocols are extensive and they rely on expertise, NOT diesel. The same can not be said for many CCT teams. Thus, children should get the best team for the job and not a "just haul arse" crew regardless of the titles in the back.

 

[Bosco578]

Then those are not specialty teams which should be the ones transporting sick neonates and pediatrics. Those are just general run of the mill CCTs that have vague nothing for protocols and put warm bodies on the trucks. This infant was probably beyond their comfort level and thus a real specialty team should have been called as the American Academy of Pediatrics recommends.

Just because the sending doctor is crapping his pants when the infant is beyond his expertise does not mean his orders trump that of the rec'g facility's medical director. The medical director of the specialty team should be one that gives the orders and protocols by which experienced specialty teams follows.

As MSDeltaFlt said, an experienced Specialty team will do everything that they would normally do in the NICU/PICU before moving. Because of the nature of stabilization, this can take several hours before the team is even ready to depart with the infant to their base facility. That might also mean taking the baby, on life support if necessary, to the mother's room for a good-bye look. Then, depending on the location, since many of our transports are from other countries and the islands, the whole transport may take up to 24 hours. As our attorneys have told us there is no way we can justify L/S considering there could be 4 minutes saved by not stopping by the mother's room.

Specialty team members have several years of experience in their profession and are educated/trained by their attendings and medical directors. Their protocols are extensive and they rely on expertise, NOT diesel. The same can not be said for many CCT teams. Thus, children should get the best team for the job and not a "just haul arse" crew regardless of the titles in the back.

Very well said! I agree 100%. Besides the last thing the little one needs is to be tossed around in the isolet.

 

[marineman]

KEV, the service I'm riding with tracks and charts all call response times both emergent and non-emergent. In our area the last report I read was 2:31 saved on a one way trip with blinkies and whoo-whoo's.

 

[mycrofft]

Two shots...the driver is the captain, and when code 3 helps.

The person who trumps both MD's is the driver of the vehicle. She or he knows the degree of emergency and what the actual realtime driving conditons are. If the driver causes harm in the treatment compartment or triggers a MVA, the driver is accountable. If the driver slowpokes (or, more likely, takes a wrong turn) and the case is affected negatively, then the driver is also responsible. I suppose it could be argued that, if the driver were a competent practitioner, he/she could actually refuse the job (and probably get fired) if the transport promised harm to the patient.

Code three is a request for right of way. A motorist may be legally cited for not giving right of way, but the warning devices are a request. I can't speak for areas outside my experience, but in Calif and Nebraska the literal law was that code three meant you could override stop signs and signals when it was safe, but only within the posted (safe) speed limit, and under that if conditions require for safety. You could not override train crossing safeties (one did near Hasting Neb once and the train tore the modular apart), cross active runways without permission, etc.

We get into what Dr Ziv Ayal taught us as the "Triage of Time". If thirty seconds one way or the other is going to decide a critical pt's outcome, if you are any distance away from defintive care, that pt is most likely to have a negtive outcome in any event. Don't kill the crew or the pt on the way.

PS: You like rude drivers? Try riding the tailboard at about 75 mph and a car pulls up to within four feet of you and starts honking!

 

[VentMedic]

The person who trumps both MD's is the driver of the vehicle. She or he knows the degree of emergency and what the actual realtime driving conditons are.

NOT on a Specialty transport. This is one of the best reasons why specialty teams should have their own trucks and their own drivers. They then wouldn't have to contend with a L/S trigger happy adrenaline junkie in the front. The driver would know what the team is capable of and what they may be attempting as they care for the child.

We get into what Dr Ziv Ayal taught us as the "Triage of Time". If thirty seconds one way or the other is going to decide a critical pt's outcome, if you are any distance away from defintive care, that pt is most likely to have a negtive outcome in any event. Don't kill the crew or the pt on the way.

That may hold true for teams that have limited knowledge, skills and scope of practice. It does NOT hold true for specialty teams stabilizing an infant with a cardiac defect, on mobile ECMO or a flight team (or quality ground CCT) charged with the responsiblity of getting a patient with several pieces of technology attached safely to another hospital. In those cases, haste makes waste and serious mistakes can be made.

Even the long distance tranports can have great outcomes. Our physicians and nurses talk to the sending hospital's staff to assist in ideas for stabilization until the team arrives. Once the team is there, their protocols and abilities will not be much different than in the NICU/PICU. The only exceptiom may be for a surgical requirement and often with children, we have enough good meds and technology to buy some time with the right people at the controls.

The practice of Critical Care medicine in transport should take a very different level of critical thinking and not just a knee jerk impulse to haul arse.

 

[scottmcleod]

I do not have an opinion one way or the other in this matter. I do have a couple of points that might need to be voiced.

1. If you're driving L/S, it should feel as if you're driving without L/S. The only difference should be that it's brighter and louder. That's it. If it feels like you're driving code 3, then stop driving code 3. If those in the back are constantly hanging on to the Oh Sh*t bar like a couple of spider monkeys, then they're not taking care of the pt.

Words to live by.

"It's not your emergency" from one of my old instructors comes to mind.

Bringing calm to an otherwise chaotic situation is the job of emergency services. The most experienced paramedics get calmly (but with focus) out of their rigs, even on calls that would freak out most people.

 

[JPINFV]

The person who trumps both MD's is the driver of the vehicle. She or he knows the degree of emergency and what the actual realtime driving conditons are. If the driver causes harm in the treatment compartment or triggers a MVA, the driver is accountable. If the driver slowpokes (or, more likely, takes a wrong turn) and the case is affected negatively, then the driver is also responsible. I suppose it could be argued that, if the driver were a competent practitioner, he/she could actually refuse the job (and probably get fired) if the transport promised harm to the patient.

Are you seriously going to tell me that the EMT-B driver, in all 110 hours of his educational experience, know how better to judge if a patient is having an acute emergency than a physician with 8 years of education and at least three years of residency training? I seriously doubt that who ever is driving a critical care team even views the patient's file, especially if the team is made up of a combination of physicians, nurses, and RTs.

Furthermore, are you seriously going to tell me that you would refuse a transport because the patient 'might be harmed' during transport and leave the patient at a hospital that is unable to care for the patient (hence the reason for a critical care transport)?

Code three is a request for right of way. A motorist may be legally cited for not giving right of way, but the warning devices are a request. I can't speak for areas outside my experience, but in Calif and Nebraska the literal law was that code three meant you could override stop signs and signals when it was safe, but only within the posted (safe) speed limit, and under that if conditions require for safety. You could not override train crossing safeties (one did near Hasting Neb once and the train tore the modular apart), cross active runways without permission, etc.

How can it be a "request" AND be legally actionable? Don't get me wrong in saying that the emergency driver needs to drive with due regard in terms of both safety and how his driving is going to affect patient care, but emergency lights are anything but a request.

In addition, in terms of California emergency transport exemptions:

21055. The driver of an authorized emergency vehicle is exempt from Chapter 2 (commencing with Section 21350), Chapter 3 (commencing with Section 21650), Chapter 4 (commencing with Section 21800), Chapter 5 (commencing with Section 21950), Chapter 6 (commencing with 22100), Chapter 7 (commencing with Section 22348), Chapter 8 (commencing with Section 22450), Chapter 9 (commencing with Section 22500), and Chapter 10 (commencing with Section 22650) of this division, and Article 3 (commencing with Section 38305) and Article 4 (commencing with Section 38312) of Chapter 5 of Division 16.5, under all of the following conditions:
...
Chapter 2 Traffic Signs, Signals, and Markings
Chapter 3 Driving, Overtaking, and Passing
Chapter 4 Right-of-Way
Chapter 5 Pedestrians’ Rights and Duties
Chapter 6 Turning and Stopping and Turning Signals
Chapter 7 Speed Laws
Chapter 8 Special Stops Required
Chapter 9 Stopping, Standing, and Parking
Chapter 10 Removal of Parked and Abandoned Vehicles

Essentially, if you are in an emergency vehicle that is showing a forward facing "burning red light" (you can add more lights, but EVERY emergency vehicle in California has a forward facing steady red light somewhere on it) and sounding a siren as necessary, the only law you have to follow is:

Section 21055 does not relieve the driver of a vehicle from the duty to drive with due regard for the safety of all persons using the highway, nor protect him from the consequences of an arbitrary exercise of the privileges granted in that section.

We get into what Dr Ziv Ayal taught us as the "Triage of Time". If thirty seconds one way or the other is going to decide a critical pt's outcome, if you are any distance away from defintive care, that pt is most likely to have a negtive outcome in any event. Don't kill the crew or the pt on the way.

If the patient is likely to have a negative outcome regardless of the 2 minutes saved by transporting a specialty team code three, then why drive code three to begin with when there is a high probability that it will disrupt patient care?

 

[Buzz]

I've been noticing a lot of people with complete disregard for our ambulance lately. Perhaps its because the past few priority 1 responses I've driven were at least 10 minutes long. I work nights now, but the last day shift I did, we were responding to a dyspnea call. I counted 20+ cars that sped through the intersection we were trying to cross... including 1 car in the middle lane that stopped and the driver looked at us. The driver then started moving again a second later.

I've only ever transported three patients with lights and sirens on. All three of them were a code before we cleared the hospital... The most recent one needing a secure airway that we couldn't give her because of the extent of her injuries (trauma patient.. Roof of her mouth caved inward, I assumed an NPA was contraindicated at that point...). Being that I ride a basic rig, their chances of survival were probably greatly improved by the few minutes saved by transporting like that.

 

[VentMedic]

Ipods and cell phones....

Ever try to get the attention of one of your own co-workers who have these things stuck in their ears? Or even try to give report to one of them at a nurses' station during a pt pickup? And that is on the job. Now imagine all those people speeding around in their cars wearing the same devices and paying the same amount of attention.