Fair Enough

A few days ago I promised I would try to write something true about lights and sirens response in EMS. I believe I have come up with something, but first I want to outline a call this morning.

The horn goes off. The call is for an unresponsive at a nursing home, history of diabetes. Code 3 response, which in our town is lights and sirens. The dispatcher tells us it is a pass from the commercial company. As I head out to the ambulance, I hear the same call go out to two police units. Code 3.

Our driver today hasn’t worked for awhile and is excited about the call. I caution her that passes from the commercial company are rarely as serious as they sound. I explain that the fact the nursing home called the commercial company and not 911 is a good indicator that the call is not serious. I also tell her that the call takers are not medically trained, and are taught to simply follow a medical dispatch algorithm. Sometimes the wrong choice of words will initiate an emergency response. I cite the recent example of the psychiatric patients who got in a verbal dispute with a nurse over watching television, triggering a difficulty breathing code three response because the nurse’s answer to the question whether or not the patient was breathing normally was that the patient was not breathing normally because she was agitated. We arrived to find the patient smoking a cigarette.

Two police cars are parked outside the home. We unload our stretcher with equipment piled on it and enter the lobby. There is no one there to direct us to the proper wing. We were given no patient name or wing, just the nursing home address. “Which way did they go?” I ask an old man in a wheelchair. He points to the right and also to the left. “They split up,” he says.

Then a nurse arrives looking quite puzzled. She asks us who we are here for. I say we don’t know. She says the only one going out is Mr. Brown. She leads us down the hall to the left, and to a room where an elderly man is sitting on the side of his bed laughing with a visitor. “This can’t be him,” I say, “Our patient is supposed to be unresponsive. Plus there should be officers here.”

“I don’t know then,” she said, “We can ask at the nurse’s station.”

We wheel our stretcher further down the wing and ahead I now see two officers standing at the desk in a very heated argument with a nurse who is looking at them like they are from outer space.

The gist of the matter is they are angry that they came lights and sirens and no one was there to direct them to the room. Plus the patient was obviously not unresponsive. The man we saw laughing evidently is our patient. The nurse just shakes her head and says she didn’t call 911. She called the commercial company and told them it was not an emergency. The man had had a brief hypoglycemic episode four hours earlier and come around after drinking orange juice. She had put a call in to the doctor and he had called back four hours later to tell her to send the man to the ED to look into why his sugar has been on the low side in recent days.

This mismatch between the patient acuity and dispatch response obviously happens in our town all the time, and it is a disaster waiting to happen. Some day someone is going to get killed in a wreck because public response vehicles – two police cars and an ambulance are being sent lights and sirens to a non-emergency. How did it happen and how can we prevent that fatal accident from happening?

This is all about liability.

The nurse calls the doctor to report the episode. The man’s sugar only went down to 78, but he was a little woozy from it, and it has happened a couple times lately. Fair enough.

The doctor who is probably at home or perhaps playing golf, says oh, hell, send him to the ER. He probably figures to cover his butt in case the man has any problem. Pawn it off to the ER. Fair enough, I guess.

The nurse calls the commercial service for transport. It is after all four hours after the incident and it is just for an evalve. The commercial service call taker is trained to follow an algorithm. When the nurse says the words altered mental status to describe what happened, the call becomes a priority, which by state ruling has to be passed to the local 911 holder. The commercial service by using EMD and employing a strictly algorithm controlled response protects itself from liability. The company is in business, and this is clearly a smart business practice. Fair enough.

I should add to our list of players and factors the EMD algorithm and the science or lack of science behind it, as well as the companies profiting or not profiting from its use and proliferation. Let’s believe everybody is trying to do what is right. Fair enough.

The 911 police receive that call and dispatch two police cars along with the ambulance because the police are the first responders and have to go to all the calls because it is a state regulation, and because the town doesn’t do its own EMD, it has to go to all the calls, even ones at nursing homes and doctor’s offices where the personnel there have more medical training than they do. Regulations are regulations. They were written with good meaning, but clearly not with anticipation of scenarios like this. Fair enough.

So here we are. We started with “This is not an emergency…” and ended up with two police officers and an ambulance crew going lights and sirens and ending up shouting at a disbelieving nurse.

I promised I would write one true thing about lights and sirens.

Here it is:

If the system is going to pass the liability down to the cops and EMS field people, then I guess we’ll have to take it on our backs.

Therefore:

It is our job, duty and responsibility to exercise all due regard to arrive at the scene safely, and to not endanger other people with our response.

Like they teach us in class. Our safety comes first. And we can’t let contracted response times, misguided EMD protocols or our own desire to do good, get in the way of that principle.

Fair enough.

***

Ambulance Crash Log

“Sixteen of the 32 protocols performed no better than chance alone at identifying high-acuity patients.”-Comparison of the medical priority dispatch system to an out-of-hospital patient acuity score.
Acad Emerg Med. 2006 Sep;13(9):954-60.
Feldman MJ, Verbeek PR, Lyons DG, Chad SJ, Craig AM, Schwartz B.

6 Comments

  • Anonymous says:

    Our squad rules state that all 911 dispathces should be responded to RLS, unless deemed by the crew to be safe to run “cold”. Many times we are provided the exact information we find on scene but many times we don’t and shouldn’t risk a 3min run vs a 5min or greater in the latter. A very wise medic also said that in regards to those who ask for “no lights” that they called 911 and will get lights for a few reasons. 1st Ability of the unit to mark to other responders the location if they can’t find it. 2ed Safety to the traffic way. 3rd In the event the crew is target for some sort of assault the police can locate the unit easily, similar to the 1st.I agree and disagree with it but feel that a safe responce is the most important thing for the safety of the crew and patient.

  • Anonymous says:

    I think it disgusts all of us who have gotten past that initial adrenaline rush of going lights and sirens

  • Anonymous says:

    i think it disgusts all of us who have gotten over that initial adrenaline rush of going lights and sirens

  • eddie says:

    Very nice :)Maybe we exchange links?http://mragowskiemolo.blogspot.com – my blog.If so then write me on mail, or speak in comments.

  • Anonymous says:

    I work for a service kind of like the commerical service you describe here. In several instances, we have had a government-run hospital call us on a code 3 to transport a patient from their ER to the more advanced hospital in the city. Imagine what that looks like: an ambulance running lights and sirens to the back door of one hospital only to pull out and drive granny style to another hospital a mile away.Since we get so few code 3 calls, perhaps 1 in 50, it’s fun while it lasts. However, the last time I did have some issues with traffic acting really bizarre. It’s always a crap shoot.

  • Lucian says:

    We have EMD where I work, but no priority codes and no triaging. That is, if I happen to be on duty and staffing an ALS truck, and someone stubs their toe (I’ve had that call before), then we get sent, ALS and all, running lights and sirens to the call. Depending on where the call occurs in our district, we may or may not get a fire engine to first respond. In the majority of my district, the FD is an EMS agency, but only responds to MVC’s and unresponsives/CPR calls. In a small portion, a different department responds to every 911 call, no matter how basic it may be.There have been times where I have elected to go without RLS, but this is against our squad’s SOP…we also have a bad habit of transporting non critical patients on what I like to call “Priority 2” which is RLS but obeying the speed limit (basically using the opticom to get green lights and to get cars to move) because the hospital is 20minutes away at best, and often times we’re the only medic unit in the area.I just hope I dont get killed one of these days…Stay safe!LAM

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