How NOT to drive Code 3.

[usalsfyre]

If I suffer exangunating blood loss from a GSW to back there is nothing an ambulance is going to do to help me. If they insist on boardng me there's a very good chance they'll make it worse by screwing around onscene. In addition there's a good portion of trauma centers where the trauma staff is on 15 minute call at night. None of these folks run emergency lights.

I'm guessing your system runs emergency traffic to every call. This is just about the worst way of doing things. Emergency Medical Dispatch (EMD) ask a set of standardized questions and codes the call emergency or non-emergency based on the response. So you can be dispatched to lower priority calls non L&S. The problem with EMD is that there is a MASSIVE amount of overtriage built-in. So you run emergency to a whole lot of stuff that's not time sensitive.

Very little done in EMS is actually time sensitive, just like we very, very few lives. Most situations could stand another 10 minutes for a safer response. I would bet nationally the number of time critical patients with reduced morbidity/mortality is lower than the morbidity/mortality from code 3 accidents. If you don't care about the public, care about the fact that providers are regularly dieing for non-emergency situations.

I will also go on the record and say that I think public education will do bupkis to reduce the emergency vehicle accident rate. For one, I think the problem is mostly internal, and secondly the public is honestly not gonna care unless it's them.

 

[Veneficus]

I think a lot of that depends on where you live. In Tyler, there isn't a whole lot of traffic and the coverage is probably pretty good. Now try a city like Los Angeles, Dallas, NYC, Las Vegas, etc. The solution to abolishing Code 3 would be to build and staff more stations to increase non-code responses. How many taxpayers are going to support more government spending just to get rid of lights and sirens?.

I don't think this is the viable solution. I think that lay person CPR/first aid is the most cost effective method.

When you look at the results from places with a high out of hospital arrest to discharge rate, community CPR is present in every case.

I have only ever taught one first responder class, to school teachers, and it seemed they were quite happy to be able to do something.

In many European countries you must take a CPR class (at your expense) in order to qualify for a driver's license. Driving is not a right, there can be conditions attached.

Part of the problem is it is not economically even possible to increase the amount of responders to cover every block to try and reach a seriously ill person in a few miinutes. It goes back to EMS will have to get serious about prevention/ early recognition. It has been extremely successful for both police and fire.

In EMS there is lots of talk about prevention, but overall the programs are rather scarce and many are completely ineffective.

 

[Chimpie]

Let's keep the replies on topic and friendly please.

 

[Veneficus]

What does it say about someone with an arterial bleed?

Nothing.

How many arterial bleeds have you seen? How many have you saved? Some arteries can bleed for hours if not days if there is not immediate exanguinating hemorrhage. At the same time, without immediate aid, even smaller arteries (like in the testicles) can bleed a person out in minutes.

What does it say about someone who calls because he has chest pains, and enters cardiac arrest a minute or two before you arrive?

I have seen many who arrested just prior and just post arrival. In cardiac arrest the most common complication is arrhythmia, which is helped sometimes by early defibrillation. However, if it comes to an arrest, survival is decided by whether the infarct is transmural and if the fibrous scar can replace the dead tissue prior to a myocardial wall rupture. That is post emergency care.

For some time now survival to discharge neurologically intact is the measure of a "save." When it coms to arrests, they are few.

The point is that your argument is flawed because it assumes we can never get there in time, which is false. When a founding premise for an argument is false, everything built on it is flawed, to say the least.

It is not false, even in an MI tissue necrosis is measured in roughly 1/2 hour. The pt requires revascularization, either by medical or surgical intervention. Sometimes there is self resolution but it is rare.

The fact remains there is no evidence at all other than rare anecdote and prejudiced (if not wishful) thinking that demonstrates anyone arrives on time with any level of consistency to effect a better outcome past the ED.

The risk and consequences globally do not compare to the actual instances the few minutes saved actually help.

It sounds like you are rather new at this, and I would imagine the "hero complex" will be tempered over time, but I hope you don't have to go to a funeral or watch a coworker's life forever destroyed to save a few minutes that in the long run didn't matter at all.

There is absolutely no glory in being a disabled or dead hero when your loved ones pay the price for it. This is not a fantasy world where the injured hero is exalted and taken care of for life. The living ones are physically broken, depressed, often are financially crushed, lose families, and are largely forgotten by the people they "served" with.

A flag and a wreath doesn't pay for food on the table. Can't replace a lost parent in a child's life. They don't pay for housing or help with college. They do not council loved ones in time of need. They do not help the initial patient either.

Tell me, what career are you planning on after serving time for felony vehicular homicide if you kill somebody in another vehicle?

I seriously doubt you have a realistic view of what you are part of.

Police, Fire, and EMS departments all over the world have been trying to make response safer for at least 2 decades.

Here is a link, as well as a copy of a post by the person who compiled the list:

http://www.emtcity.com/index.php/topic/17318-2009-ambulance-crash-log/


EMS Personnel Injured: 191

EMS Personnel Killed: 5

Patient Injured: 39

Patient Killed: 9

Passenger in Amb injured 3

Passenger in Amb killed: 2

Other Vehicle Injured: 119

Other Vehicle Killed: 20

Pedestrian Injured: 3

Pedestrian Killed: 4


"No there is not a breakdown. I read every accident posted on the emsnetwork's website (http://www.emsnetwor...e-crashes.shtml) and compiled the numbers myself. I can tell you that the death numbers are probably much higher, as many of the injured people were reported critical at the scene (often flown), but there was no follow-up if they died or recovered later, unless you were interested in searching for all of those stories, and knew everyone's name (occassionally you would see a follow up story if multiple people died from the same accident over a 2-3 day period, but you know that many probably died in ICU two weeks later, and the obituary is all that made it to the newspaper). The overall numbers are also low, because this data only represents the crashes that made the news (as you are aware, many do not). I did not categorize by L&S or by who was at fault; my recollection was that it was about 50/50 for L&S versus not, and about 75/25 the other driver's fault versus the medics (other driver did not yield or was drunk more often). When it was the medic's fault it was usually during a critical transport or enroute to a critical call, that the accidents occured, so you can surmize that they were probably driving emotionally and not defensively."

 

[JJR512]

If I suffer exangunating blood loss from a GSW to back there is nothing an ambulance is going to do to help me. If they insist on boardng me there's a very good chance they'll make it worse by screwing around onscene. In addition there's a good portion of trauma centers where the trauma staff is on 15 minute call at night. None of these folks run emergency lights.

The GSW to the back was but one example. I don't yet have the experience to state definitively when getting there faster definitely helped improve patient outcome, but I don't need to, because you do. You've already stated that it's made a difference in a very small number of calls. It doesn't matter how small the number is; any small number is >0, and that was my point. It's wrong to say it never makes a difference and is therefore absolutely unnecessary. So that argument is flawed. Period.

I'm guessing your system runs emergency traffic to every call. This is just about the worst way of doing things. Emergency Medical Dispatch (EMD) ask a set of standardized questions and codes the call emergency or non-emergency based on the response. So you can be dispatched to lower priority calls non L&S. The problem with EMD is that there is a MASSIVE amount of overtriage built-in. So you run emergency to a whole lot of stuff that's not time sensitive.

I'm still new in my current county, still doing ride-alongs. I don't actually know the policy, but I do recall one incident when a Paramedic Unit and Paramedic Engine were dispatched to, if I recall correctly, an unknown medical problem at a convenience store. The ambulance went out emergency, and the engine went out non-emergency. So no, not everything always goes out emergency.

As I said earlier, a neighboring county was experimenting with dispatching units non-emergency if that was determined to be appropriate by the EMD. I was a member of a station in that county just before they started trying that. I don't know how it's been working out for them. Hopefully it's been working out good. You see, just as you don't believe that completely eliminating code 3 responses is probably the best solution, I don't believe that always responding code 3 is necessarily appropriate, either. But I think we all know we've gotten some pretty bad info from the dispatchers; there's plenty of threads here to prove that. So they need to get better training. If they can tell pretty conclusively that an emergency response isn't needed, fine. But if they're not sure, if there's any doubt, then for now, I'd prefer to sticking with the emergency response.

 

[JJR512]

It sounds like you are rather new at this, and I would imagine the "hero complex" will be tempered over time, but I hope you don't have to go to a funeral or watch a coworker's life forever destroyed to save a few minutes that in the long run didn't matter at all.

I was skimming over your reply to see how many other people had posted while I was writing my previous reply, and this caught my eye. After this, I decided not to read the rest of what you wrote. You lost me here. You don't know me, but you want to accuse me of having a "hero complex"...fine, I won't bother to read the rest of the crap you wrote. You want my attention? Fine, present an intelligent argument that bears in mind what Chimpie just wrote.

All I really have to say to you is what I've said in pretty much every post since I jumped in. You took one specific scenario, said that when those exact circumstances are met an emergency response would never help, so therefore an emergency response is absolutely unnecessary. And that's a crap argument, sorry to say it like that but I've grown tired of repeating the nice way I've been saying it so far so I'm going to change it up a bit this time.

Why don't you ask me what my favorite brand of chocolate is. The answer is Hershey. I guess that means everyone's favorite brand of chocolate is Hershey, at least going by the kind of logic you used to conclude emergency responses are absolutely unnecessary.

 

[adamjh3]

I was skimming over your reply to see how many other people had posted while I was writing my previous reply, and this caught my eye. After this, I decided not to read the rest of what you wrote. You lost me here. You don't know me, but you want to accuse me of having a "hero complex"...fine, I won't bother to read the rest of the crap you wrote. You want my attention? Fine, present an intelligent argument that bears in mind what Chimpie just wrote.

All I really have to say to you is what I've said in pretty much every post since I jumped in. You took one specific scenario, said that when those exact circumstances are met an emergency response would never help, so therefore an emergency response is absolutely unnecessary. And that's a crap argument, sorry to say it like that but I've grown tired of repeating the nice way I've been saying it so far so I'm going to change it up a bit this time.

Why don't you ask me what my favorite brand of chocolate is. The answer is Hershey. I guess that means everyone's favorite brand of chocolate is Hershey, at least going by the kind of logic you used to conclude emergency responses are absolutely unnecessary.

You provided specific examples in which you thought the circumstances warranted an emergency response. Vene rebutted to those specific examples. How is your argument style an different than his?

As far as this topic goes, we shouldn't be dispatching six medics code 3 to a stubbed toe or busted lip which seems to be the norm around here, but rather pushing for quality call-taking and proper priority dispatching by EMDs.

Certainly eliminating L/S responses all together is unrealistic at this point due to public perception of what we do. Changing that view will take years, if it ever happens. And judging from the attitude of many in the field, it may never happen.

I will admit I'm still very new to this field, and I only work BLS, but running code is one of my least favorite things to do. It's difficult enough to drive the ambulance under normal, non-emergency conditions, the stress of running code 3 much greater than I ever thought it would be.

 

[LonghornMedic]

I was thinking through my career of 8 years. Short by most standards. However, in that time, I have worked in EMS systems that averaged over 120,000 calls for service a year. In that time I have seen only 3 Code 3(fire and EMS) deaths. None of which were EMS personnel. The civilian deaths were all found to be the fault of the civilian drivers who failed to yield. The most critical injury was paraplegia to a FF(who was going to a fire and not a medical call) who was not wearing a seatbelt in direct violation of the law and department policy. The only on duty death was a Medic involved in a head on MVA when a truck lost control and entered the ambulance's lane. They were returning to the station when it happened.

Even the numbers presented earlier still seem low in comparison to the millions of Code 3 responses each year. In my 8 years, I've had one collision. I was returning to post and it wasn't my fault. I've had some close calls running Code 3, but so far(knock on wood) no collisions.

Interestingly enough, I find that law enforcement agencies have had many more fatal collisions. I think it has to do with smaller vehicles that are harder for the public to see, that can accelerate quicker and go faster. LEO's appear to not wear seatbelts as often as we do for what they describe as "tactical reasons."

Getting back to EMS. I think many here have very good points. Having a more involved citizenry is a wonderful dream. But reality is they aren't. How many times have you gotten the notes for a cardiac arrest where bystanders are refusing to do CPR(compressions). And do EMD's overtriage? No. They merely do their jobs like we do. They are going off a set of standardized flipcharts that dictate the response. Should it be revamped? I don't know. I do know that they are definitely not perfect. I've been on plenty of non-Code 3 "BLS" responses that were anything but BLS. Luckily all 911 responses get an ALS response. The system is far from perfect, but what system is perfect? What next? Non-code fire department response to house fires? Because it is "only property." Non-code police response? Because most of the time the suspect is already gone. I could go on and on. But if we focus our efforts on good, quality training throughout a career, I think we could cut down on many preventable collisions.

 

[Veneficus]

What next? Non-code fire department response to house fires? Because it is "only property." Non-code police response? Because most of the time the suspect is already gone. I could go on and on. But if we focus our efforts on good, quality training throughout a career, I think we could cut down on many preventable collisions.

Because of the nature of the problem, with both law enforcement and the fire service, the threat to life and property increases with time. A fire exponentiates in size by the minute, which increases the potential loss of life. Law enforcement has figured out the hard way that with an active shooter, or somebody who may potentially become violent, more lives are saved by rapid intervention.

EMS has quite a different circumstance, it is talked about often. EMS deals with individuals. A person having an MI affects that person, possibly the mental or physical health from stress response of a limited family group. With the increased risk of a L/S response, EMS is what is directly escalating the threat to the public.

The fault of the person when injury or death occurs is really a nonissue. If a firefighter is paralyzed for life, does it really matter whos fault it is? Will his/her benefits be better? Will it keep the family together? Will He go back to the career he wanted and struggled for?

I am not suggesting there is no reason for a L/S response. Only there are no medical reasons. If there are no medical reasons, it eliminates only EMS from employing it. If you consider that even in large scale disasters, the medical response is often secondary, and in an epidemic or pandemic, (the largest medical emergency) EMS response is moot. It is logistics that solve these incidents, not transport to definitive care.

I do not support the idea that Police, Fire, and EMS are expendable employees. That a certain level of "acceptable losses" has to be the norm.

As just food for thought, we know the amount of accidents compared to total L/S response is less than 1%. Let's just estimate high and say that the L/S response makes a difference in 1% of cases. Now compare that to the injury and death in that less than 1% of responses. That equals dozens of deaths and hundreds of injuries, for an almost unappreciably low number. But rather than take it out to the 10x-5 number or greater, why not just call it "0" and be done with it?

Now does it suck if you or a close family member are that <0.00001% ? Sure it does. But the question goes back to how many providers are we going to deem "acceptable losses" in order to make such a small difference?

Not only myself, but the people who argue against L/S response in EMS or its significant reduction, are looking out for providers. From day one you have been taught that your safety is #1. Unfortunately, you are taught safety starts at the scene. That is not true. If you are going to be killed, chances are it will be responding to or from it, according to the numbers.

 

[usalsfyre]

JJR512, we'll agree to disagree. You seem fairly inteligent, so please do one thing for the next few years. Drive with your head and not your b@lls. There's no reason " a little more aggressive" or "push a little harder" on any code three response. Driving beyond your normal limits is asking for trouble.

LonghornMedic, I've been to plenty of calls dispatched as low priority that turned out not to be as well. Which is exactly why I think every patient needs a competent paramedic assesment. But did any of those pts die because the call was undertriaged? I'll bet the number of times that happens pales in comparison to how often you run priority to calls that do not constitute a life threat. I don't blame the dispatchers themselves, they read scripted questions word for word and code the call based on responses. I blame a seriously gutless system that gets the vapors at the thought of anyone possibly trying to blame them for a death that was likely inevitable due to poor lifestyle choices.

Also, while my current location is Tyler, I started out south of the Potomac in the DC metro area. Lots if people, traffic, stop lights, ect. I don't recall running emergency making that much of a difference. Could just be my colored memories though, it's been 6 years since I was there.

 

[JJR512]

You provided specific examples in which you thought the circumstances warranted an emergency response. Vene rebutted to those specific examples. How is your argument style an different than his?

I'm not sure exactly what you're referring to here by argument style. I thought I stipulated that each of my points could almost surely be rebutted by those of you with more experience than my own limited amount. However, since one person has already said that an emergency response did make a difference in at least one occasion, then no amount of point-for-point rebutting is going to change the fact that it is not true that an emergency response is never helpful and therefore absolutely unnecessary.

As far as this topic goes, we shouldn't be dispatching six medics code 3 to a stubbed toe or busted lip which seems to be the norm around here, but rather pushing for quality call-taking and proper priority dispatching by EMDs.

In Maryland (at least in the non-rural areas), it's common for multiple units to be dispatched on calls. Here's one example that should make you happy. I was recently riding as an observer on a Paramedic Engine. The Paramedic Unit and Paramedic Engine were both dispatched to a medical call at a convenience store (if I remember correctly, an "unknown" medical call). The ambulance left Code 3 first. The engine went normal. I don't know if that was SOP, the EMD's discretion, or the engine driver's discretion, though.

 

[JJR512]

JJR512, we'll agree to disagree. You seem fairly inteligent, so please do one thing for the next few years. Drive with your head and not your b@lls. There's no reason " a little more aggressive" or "push a little harder" on any code three response. Driving beyond your normal limits is asking for trouble.

I'm not likely to be driving the FD ambulances for at least 1.5 years (due to mandatory time as an aide, then lead provider required first), but I appreciate the advice. It's already well-incorporated. I think it was in this thread in which earlier I mentioned I used to drive for a hospital-based critical care transport service, and I was known as a very unaggressive, cautious driver. I don't think it needs to be any more stressful than regular driving. So I happen to have blinky lights and annoying noises coming from the vehicle, so what? Some people will get out of the way. Some won't. It doesn't need to bother you if you don't let it. It's all in the mind. I know I can drive safely if I focus on driving, and not be silently (or not so silently) cussing out all the dumbasses that don't get out of the way.

 

[JJR512]

One other thing...

When I was working for commercial ambulance companies, I'd frequently get to various hospitals in Baltimore City. From time to time I would see city ambulances arrive Code 3, but the patient walks out of the ambulance and into the ER with the providers. One day I was with a coworker who used to work for the Baltimore City FD, and asked him about that, and he said that their call volume is such that they need to get rid of patients as quickly as possible, because it's extremely likely that the instant they clear, they're getting another call. So the longer they spend transporting even a Priority 3 patient, that's longer that the next patient, who might be worse, has to wait.

Is this a legitimate excuse to drive Code 3 pretty much all the time? No. But it's a sad fact that the conditions exist that practically necessitate it. Baltimore City, I suspect like many urban areas, has had lots of budget problems lately, and has resorted to rolling station shutdowns and overall downsizing, etc., so it's only getting worse.

 

[looker]

One other thing...

When I was working for commercial ambulance companies, I'd frequently get to various hospitals in Baltimore City. From time to time I would see city ambulances arrive Code 3, but the patient walks out of the ambulance and into the ER with the providers. One day I was with a coworker who used to work for the Baltimore City FD, and asked him about that, and he said that their call volume is such that they need to get rid of patients as quickly as possible, because it's extremely likely that the instant they clear, they're getting another call. So the longer they spend transporting even a Priority 3 patient, that's longer that the next patient, who might be worse, has to wait.

Is this a legitimate excuse to drive Code 3 pretty much all the time? No. But it's a sad fact that the conditions exist that practically necessitate it. Baltimore City, I suspect like many urban areas, has had lots of budget problems lately, and has resorted to rolling station shutdowns and overall downsizing, etc., so it's only getting worse.

Why are the not utilizing private ems as back up for code 3 respond to 911 calls? There are plenty of private ems that run both bls and als and can handle such calls.

 

[JJR512]

Why are the not utilizing private ems as back up for code 3 respond to 911 calls? There are plenty of private ems that run both bls and als and can handle such calls.

If they can't afford to pay their own guys, I suspect they can't afford to pay other companies, either.

 

[Sandog]

Below are links to a few articles that seem relevant to this thread. The articles appear to support the argument against L&S.

http://www.emsworld.com/publication/article.jsp?pubId=1&id=2027

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

Below is a small quote from one of the articles.

Conclusion

We conclude that in the setting in which this study was conducted, the 43.5-second mean time savings with warning L&S does not warrant use of L&S during ambulance transport, except in extremely rare situational or clinical circumstances.

 

[looker]

If they can't afford to pay their own guys, I suspect they can't afford to pay other companies, either.

That type of system need to be reworked. Backup contractors should pay the city for any 911 call they get. The private company makes money when/if they do transport and bill the patient that they transported.

 

[CAOX3]

Below are links to a few articles that seem relevant to this thread. The articles appear to support the argument against L&S.

http://www.emsworld.com/publication/article.jsp?pubId=1&id=2027

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

Below is a small quote from one of the articles.

"The citywide speed limit is 35 mph unless otherwise posted. The city has population of 46,000"


Ok Im of the belief that not many EMS complaints are time sensitive but a city with 46,000 people doesnt really seem like a fair sample study group. I mean some areas have populations over a million and that can balloon to double that during work hours, it can take thirty minutes to go a mile.

What then?

L/S is a neccesary evil in some areas where a citys overburdened infrastructure dosent allow flow of traffic driving.

 

[JJR512]

That type of system need to be reworked. Backup contractors should pay the city for any 911 call they get. The private company makes money when/if they do transport and bill the patient that they transported.

That is a good idea to have the private company bill the patient, but not one that I feel would work in practice. In Baltimore, taxes pay for the municipal services. People calling 911 and receiving services through municipal agencies do not get billed for those services. But if you happen to be the patient that needed emergency services during a busy time and the city had to get an outside contractor to fill in, are you going to be happy that you're now being billed for a service that you expected to be free, and pay taxes to make it free?

Especially consider the fact that part of the reason why the municipal services in Baltimore are overwhelmed in the first place is due to many people in the lower socio-economic tears abusing the system because they know it's free. They don't have primary care physicians, don't have health insurance, can't afford a taxi, so they call 911. We all know how this works. Good luck getting money from them. They might have Medical Assistance if they're lucky, and maybe the private company can collect from them, but that's taking money from the government's left hand because its right hand is empty. That's not helping the problem, it's just redirecting it.

 

[bstone]

Back to the original topic, I watched the entire video. They needed to make stops at red lights and ensure the peripendicular traffic was clear, but other than that they did fine. They did a lot of rolling stops, which is pretty much par for the course.