When will we stop running code?

[ffemt8978]

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

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

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

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

 

[RocketMedic]

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

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

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

 

[ffemt8978]

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

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

 

[Aidey]

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

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

N=1

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

 

[Rialaigh]

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

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

 

[DrParasite]

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

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

Also, feel free to be respectful.

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

 

[DrParasite]

N=1

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

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

 

[Aidey]

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

 

[RocketMedic]

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

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

 

[Tigger]

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

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

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

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

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

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

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

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

 

[Veneficus]

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

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

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

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

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

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

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

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

Fully agree. Life is imperfect though.

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

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

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

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

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

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

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

American Ambulance Association is definately too biased to do it.

 

[DrParasite]

Why should these regional variances exist?

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

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

 

[usalsfyre]

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

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

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

 

[Hunter]

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

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

 

[TransportJockey]

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

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

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

 

[mycrofft]

5=4

 

[Tigger]

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

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

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

 

[bigslaank]

Illinois

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

 

[medic17]

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

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

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

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

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

Lights and sirens.

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

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

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

 

[NomadicMedic]

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

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

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