Lights and Sirens Response/Transport

[Bieber]

All right, ladies and gentlemen, the topic of this thread is simple (and I couldn't find another one like it after searching, but if there is one and I made a duplicate please let me know): what patients, if any, benefit from a lights and sirens response/transport? We know that under the best conditions we don't routinely save more than a minute of time driving lights and sirens, and that the risk to both us and the patient increases dramatically with lights and sirens response, so what justification do we have for it?

Some literature:

http://pdm.medicine....es-baptista.pdf (not a very large sample group, they retrospectively looked at 112 transports and compared them)

http://www.emsworld....-time-and-lives (cites a study that showed time saved by lights and sirens, while statistically significant, is not likely to be clinically relevant as well as a study done in Pennsylvania that provided a more stringent protocol for lights and sirens use and compared the outcomes of patients)

There WAS a study done that showed that response times, when under 4 minutes, resulted in an increase in good outcomes for critically ill patients (can't seem to find it now), however I think we all know that the likelihood of a universal 4 minute response time is pretty low.

Now, there ARE patients who do benefit from not dawdling on scene longer than necessary (AMI, CVA within the window of treatment, trauma or disease that requires surgical intervention, etc), and patients whose conditions are so critical that any delays in medical care can be detrimental (cardiac arrest, acute respiratory failure, etc), but aside from those few who benefit from every second saved between the time of onset and the time they receive medical care, are there any patients who benefit from the extra couple of seconds saved getting them to the ER? And is lights and sirens response appropriate for patients who don't fit inside this narrow range of conditions that might benefit from us arriving a couple seconds sooner?

I'd really like to hear from the docs and everyone else who's smarter than me (see, everyone), because maybe I'm forgetting some illnesses/injuries that are time sensitive (to the point that seconds or a couple of minutes makes a significant difference), or don't realize how time sensitive a lot of these injuries/illnesses are? What can be done with a couple extra seconds or even minutes for these patients that can make a significant difference in their condition?

Thanks, guys.

[Vorenus]

First of all, I actually believe I make more than one minute good with driving with sirens - surely not on country roads and maybe not in rural areas, but in a bigger urban city, definately.

Unfortunately, around here we don`t have a "Call category", like, say, the UK, where dispatch already gives you certain conditions concerning your driving to the pat.

So, unless obviously not life-threatening and not benefiting from a fast response, I drive with blue lights to the pat. After assessment, that`s a totally different question. I drive lots of pat. towards the hospital without sirens, since they wouldn`t benefit from it.

Edited January 17, 2012 by Vorenus

[Bernhard]

Scaring other cars out of the way by lights & sirens is only good for winning time at intersections, traffic jams and traffic lights (low speed!). On a free road, the signals don't help much (high speed!). That's essentially what I tell students: no need to risk something with high speed, you win time only at the low speed situations.

So, the main thing is addressed: our risk.

For patient care, there are patients who might profit by a minute faster response times. But they are rare - and I consider this a very theoretical part of the discussion, because the system looses more time in (remembering &) calling emergency number, taking and dispatching the call, getting the ambulance on the road, finding the target (street name, house numbering) and getting into the house/flat (5th floor without escalator?). So, next thing I tell my students: If the patient's condition really relies on every second, then he won't make it anyway. Again, no need to risk our health!

Basically I use lights & sirens to not wait on the traffic situations above. That saves me the minutes maybe lost elsewhere and with a lot of interceptions and traffic lights this sums up pretty high (see Vorenus' statement about city vs. rural setting). But no need to risk our health or the ambulance - reaching the patient is a key concept in EMS...

Next thing to save time is patient care. There is a discussion about this somewhere else, it depends on the situation, but I'm no friend of "stay & play" (playing is not what we should do in EMS anyway) nor "scoop & run" (running is another bad thing in EMS) but to "treat & go" (if I may call it that). Sometimes the "go" has to be much sooner than other times.

On the way to hospital I rarely use lights & sirens. The patient is in most caring hands now in the ambulance, we have a lot of good stuff to keep them alive and stable. Sure, there are cases where time to OP room is essential: hemodynamically instable/internal bleedings, perforated thorax or abdominal injuries, non-manageable respiratory insufficiency, raising intra cranial pressure, severe hypothermia. We simply can't fix or even stabilize those conditions, so we have to win another few minutes by passing through intersections, traffic jams and traffic lights without much delay. They'll loose those minutes in hospital anyway, so we have to hurry (that was cynical and I have to admit that hospitals improved a lot meanwhile).

The above conditions may be an indication for fast HEMS organization especially if there is a better trauma center somewhere else further away and ground loading/driving time is much more than HEMS'.

So, the answer is more complex than a simple yes/no/why/when.

Efficiency is the key. That includes team & resource management and other things that can be prepared (Does the team know what to do when, why and under who's responsibility? Is your bag stuffed in such a way that you have and find what you need? ...?). It involves a lot of organizational stuff, pre-call (times from accident to starting the ambulance, making sure to reach scene without much hassle, concept for door-to-scalpel-time at hospital) as well as in-call (treat & go, notifying target clinic, organizing HEMS early enough to make sense out of it, ...).

And so i tell my students: Safety before speed! Lights & sirens may outrule the traffic laws but not the laws of physics and they sure do not improve the average level of dumbness in the world.

(there is a statistic by German National Traffic Authority: as far as I recall, risk for an accident is about eight times higher with L&S on)

[HellsBells]

I agree with a lot of what Bernhard is saying.

Lights/siren help us get through traffic jams and intersections for the most part, otherwise they don't help much. I take exception with the statement that only a few minutes are saved by an L/S response though. In urban centers during rush hour a L/S response can make a good 20-30 min difference easy. That said, when traffic is at a low ebb, it makes little difference. Also, as Bernhard states, low speed is key, particularly when your transporting the sick pt to hospital. There is nothing worse than an inexpeirenced rookie driving like a manic, tossing the attendent to and fro in the pt compartment. Not Cool.

Edited January 23, 2012 by HellsBells

[DwayneEMTP]

I think that we all agree that L/S are a bad idea on a regular basis. But a couple of things come to mind for me...

First, I wonder if any of the studies have been done in areas where emergent transport triggers the the traffic signals ahead, clearing the intersections ahead of the emergency vehicles? I've ridden once, I can't remember where, maybe Denver, where they had this and it seemed to make a huge difference over L/S alone.

Also, in some of the places that I've worked, L/S had a larger impact on my ER response than on the traffic en route.

I'm not exactly sure of the dynamic, but I've called in with patients, for example, a gunshot wound (rural service), "This is Dwayne, I'm en route with a 22 year old male GSW, 90% traumatic amputation to left humerus secondary to 12 g gunshot wound, significant loss of blood prior to EMS arrival, pt has thoracic damage to effected side, unknown depth of those pellet wounds. Pt is unresponsive at this time, B/P 66/0, resps 36, intubation imminent, yadda yadda yadda..."

We arrive at the ER to...nothing. Wheel the pt inside to find two nurses hanging out by the radio, doc is in bed, RT/Xray haven't been notified, nothing. They see my pt covered in blood and freak out saying, "Why didn't you tell us that he was critical!!!" Really? That radio report failed because I didn't say the word 'critical'?

Another pt with really bad asthma as well as some end stage pulmonary pathology, I can't remember what flavor. Tripoding, pale, diaphoretic, RR around 40, L/S silent in all fields...Keeps repeating, "No intubation...no...matter...what....no....intubation." to every question that I ask him. His wife verifies that he is refusing intubation regardless of the situation. Anyway, to make a long story short, I do my immediate treatments, which I have no faith are going to work, load him up, and though I don't believe that another minute or two will make any difference but having learned my lesson with the GSW, run in emergent. Low and behold, half the friggin' hospital is there upon my arrival...

So here I think, and in many things, we can't rate any one intervention on only one criteria. Again, not having looked at the studies, is there more to any of them than, "L/S have been shown to save 5 seconds/2 miles traveled, is this time savings significant when pt M/M is considered?"

Is there an educational value to people being exposed more to L/S? Perhaps more people would react intelligently instead of freaking out if they had more exposure?

Is the danger from running L/S inherent in them, or is it the effect that they have on the drivers of the vehicles that is part/all of the issue? Would add'l training mitigate this issue?

Is there a possible psych effect of some patients that may be beneficial? Hell, I don't know, I'm just pulling these things out of my ass...but maybe it makes the point.

I wouldn't be opposed to l/s being removed from emergency vehicles with the exception of police cars, but then I still like being stuck with patients...

Again, I'm not advocating for L/S use, but wondering instead of once again we're looking at a tunnel vision view of a larger equation.

As well, this may sound snipey, but I think it's valid. Regardless of the safety issues involved, I would be willing to bet that Fire will be one of the biggest proponents for continued emergent response to everything as it's such a massive advertising vehicle for them. "Look at us! Saving another life!" I know it sounds facetious, but it's really not meant to...

[Kiwiology]

As well, this may sound snipey, but I think it's valid. Regardless of the safety issues involved, I would be willing to bet that Fire will be one of the biggest proponents for continued emergent response to everything as it's such a massive advertising vehicle for them. "Look at us! Saving another life!" I know it sounds facetious, but it's really not meant to...

Don't lie Dwayne we know you're a facetious bastard .... man, what are we going to do with you?

Light and sirens are used here but not very often. We can use the red lights alone and not have the siren going, which is most often what we do and a quick blast of the siren approaching intersections or when driving through red lights.

There is little (read: any) value in lights and sirens transport and it's way more dangerous than it is good.

[JakeEMTP]

It is very rare that I will transport a pt. L/S to the hospital. I will however respond to the call L/S. No offence to the dispatchers out there, but you don't always have the information that is required. If it's a SOB call, it might require a more emergent response because we/you/us don't really know the extent of the pt.'s distress.

STEMI's and CVA's (depending on onset of course) get a emergent trip to the hospital. Life threatening trauma will also get a expedited trip.

I think though, being 25 - 30 minutes from the hospital, dictates whether a emergent or routine transport is warranted. We've also had severe asthma pt.'s like Dwaynes who we've managed with Neb's, solumedrol and Mag and on occasion CPAP. We have the tools to manage the majority of our pt.'s, Trauma Red pt.'s require a surgeon, not a paramedic. Sure we can control most bleeding, pain control and airway compromise, but the reality is, they need a higher level of care and we will expedite our on scene time and transport priority.

I'd would also be in favour of removing L/S from ambulances. It would detract a great number of wackers from entering our profession.

:edited fro spelling.

Edited February 5, 2012 by JakeEMTP

[HellsBells]

Here is a link from a recent study on the subject.

http://www.calgaryherald.com/news/calgary/Ambulance+response+times+critical+patients+survival+study+finds/6080857/story.html?id=6080857

[Bieber]

Good discussion from everyone so far. Dwayne, you brought up some interesting points about the possible non-time-related benefits of lights and sirens transport, and while I won't discount them and I agree with you that we don't want to get tunnel vision on either end of this issue, we've still got to consider safer alternatives if one of the roles of lights and sirens is just getting folks at the hospital to get moving when they need to be. HellsBells, thanks for sharing that study.

[ERDoc]

Since we are on the topic of L&S, I have a question for all. You are dispatched to a rural hospital for a confirmed STEMI going to the big academic center for a cath. VS are stable (don't worry about specifics). Do you respond to the sending facility with L&S?

If one of the mods wants to make this a new topic, feel free to do so.