Priority Transport

[OVeractiveBrain]

In fact, dustdevil, i think this is quite an appropriate forum. ALS providers are expected to make more severe decisions in care, including transport. If i asked in an EMT forum, I would get a different answer. If i posted in a rural forum, that would get one, whereas an urban would get another. In fact, this issue is a source of major contention amongst ALS providers (even within some of our posts here). It is sometimes viewed as "old versus new" or "inexperienced vs experienced." Im trying to a)get the subject out and discussed, dissuade providers from giving in to these misrepresented assumptions and c) find out what individuals would do in their own situations.

For example, I do not transport priority for a stroke unless Ive defined them as a candidate for fibrinolytics (normal baseline, <65 yo, new onset [protocol says <6. i stick with <4], obvious deficit in speech, hemiparesis, or any change in cranial nerves / mental status with 3+risk factors, and inclusion/exclusion criteria) while another provider may choose to transport anyone exhibiting the signs and symptoms of stroke. The difference in choosing a medication for an arrhythmia and a priority for a transport is very small; they are both part of a clinical impression and decision making. (By the way, my decision for stroke patients was based on a recent CME where I learned that most Stroke Patients get a hospital course of "wait and see what happens and hope we can take care of them after", that cath procedures for cardiac patients are not available for stroke patients, and that 6% of patients that receive fibrinolytics suffer hemmorage and worsening symptoms, and thus facilities are hesitant in the administration of the drug despite "time is tissue").

One impetus for this post was that I often listen in to priority patches, to see what people are bringing in. Sometimes its an ALS provider throwing out BLS decisions, "difficulty breathing on oxygen." Great, why are you on a 1? Obviously this may be a result of poor patching, not poor decision making, but i find it interesting how and why people choose priority patches over flow of traffic. It also happens to be a hot topic in EMS education, one particular facet of this website that I enjoy. The learning.

Another important topic is that different providers have different criteria for what constitutes "hemodynamically unstable." As fiz pointed out, we do have limited knowledge and tools for the formulation of a diagnosis. TO be honest, if some one is hemodynamically unstable, I keep it simple: electrical, pump, tank. When dumbed down so simply. the problems become easier to fix. If I am to transport a medical case priority 1 its because the cause is unfixable (ACS with compromise) or I cannot discern the underlying problem. That usually involves fluid, ascertaining the electrical system, and checking for hemorrhage. Only after a failure to improve patient condition to stable (though often still symptomatic) do i then upgrade to a one. Other providers may find that the patient deserves a priority one, and they will get done what they can enroute, and allow a more sophisticated clinician make decisions based on data obtained by the medic. Neither is wrong, and Id like to understand the motivation of both.

That is to say, I make my transport decisions after formulating an impression, a plan, and see what the response is to my treatment.

That being said I have hustled the fire department to get a patient out of her room and into my truck. I often allow the FD to assume control of the scene (since they are first responding paramedics in their territory). This girl was 24 years old, renal insufficiency (though still able to maintain urinary output), supposed to be on dialysis but has skipped it for a month, now complaining of N/V, Dizziness, and intense anxiety when seated upright. She has no palpable radial or brachial pulse, and auscultation reveals a heart rate near 150. I dont get acutely emotional, so when I stress urgency, my partner knows it means now. Getting her into my bus, on a monitor with some fluids, was when I could calm down (sinus tach with poor PO intake and vaginal bleeding for 3 days). My initial urgency was fear of an electrolyte imbalance and the start of some ventricular dysrhythmia (yes i did not have my monitor, and the FD had taken theirs down without putting her on it...) You could say I was "on a one" until further data changed my mind; we were 5 minutes away and I was able to get her stable without the use of the hospital. Her crit was 20, by the way. Thats when I was taught to use the conjunctiva as an indication for low H&H (the whiter the conjunctiva of the eye, the lower their value). Had I been 20 minutes away at 5pm driving through the 91-95 interchange (literally 30 minutes to go 1 mile) I probably would have taken her in on a one, despite her stability. Thats why I want to discuss the topic here. Flush out the grey area.

This is somewhat in contention to fiznat's advocacy: I dont need special equipment or knowledge to diagnose the problem. In fact, i dont even have to diagnose at all. In unstable patients, its my job to stabilize them. In my mind, some one who remains with a reduced GCS but maintains perfusion, color, sp02/ETc02, is symptomatic, but stable. I am very lenient when it comes to what is considered unstable (That is, the level of symptomy that is the cut off for unstable is probably more symptomatic than many others would allow). Obviously, I had my own beliefs on priority transport ion generating the post. I had hoped for a little more discussion (thanks Foster) or for some one to take an alternative stance. Im pretty sure no one is going to say "Priority Transport for every ALS patient" nor will some one say "Priority Transport is NEVER indicated." Especially for reasons already discussed about safety. Again, Im looking to fill in the cloud of that grey area, get people's own thoughts or simple protocols about the subject.

[Dustdevil]

In fact, dustdevil, i think this is quite an appropriate forum. ALS providers are expected to make more severe decisions in care, including transport. If i asked in an EMT forum, I would get a different answer.

If only it were that simplistic.

The reality is that, these days the lines are blurred. This isn't the "Paramedics Only" forum. This is the ALS forum. Paramedics are BLS providers just as EMT-Bs are ALS providers. Consequently, half the answers you receive here are from EMTs, and half the answers you would have received in the BLS forum would have been from Paramedics.

And, of course, you are talking about transportation. ALS is a level of care. Care and transportation are not the same thing. That's why the book is called "Care and Transportation of the Sick and Injured."

To address your [inappropriately placed] question, I would agree with your belief that running hot to your patient, and then transporting much more judiciously is the prudent way to go. This nonsense of lay idiots with flip charts attempting to assess and prioritise patient conditions by telephone is simply ludicrous. Less than half of the time is their assessment anywhere near accurate. Arm pain and toothache turns into AMI. Full arrest turns into fainting. Headache turns into sepsis. Seizure turns into shivering. Passing judgment on a patient's condition before they have been properly assessed is just bad policy.

On the other hand, in most systems, there is simply way too much hot running to the hospital. These guys are running on emotion, adrenaline, whackerism and insecurity. There is a tendency to run hot with any patient whom you have run out of options for, even if their condition is not critical. They do it because they lack the education to properly assess their patient's condition and needs. They do it because they lack the medical sophistication to provide for those needs. They do it because they are emotionally out of control. They do it simply because everybody else does it. They do it because it's fun. They do it because they can.

A very wise man once said here on EMT City that a good first step towards improving the quality of people attracted to EMS would be to remove the lights and sirens from our vehicles. That was an excellent point, and I believe a very valid point.

I would be interested in seeing a statistical analysis of "Code 3" transport collisions to see what percentage were Basic units and what percentage were Paramedic units. I theorise that this occurs much, much more frequently with Basic units. And if this is so, it is a very significant argument against BLS systems.

[JPINFV]

I would be interested in seeing a statistical analysis of "Code 3" transport collisions to see what percentage were Basic units and what percentage were Paramedic units. I theorise that this occurs much, much more frequently with Basic units. And if this is so, it is a very significant argument against BLS systems.

I think it's understandable that BLS units transport l/s more often. Simply put, a life threatening emergency that can either be ruled out or fixed by a paramedic can not always be ruled out by a basic. Hence seeking the nearest ALS, which includes the local ER. Of course, this is also a perfect argument for having ALS on scene for any call going to an emergency room.

[OVeractiveBrain]

In fact, the national registry TEACHES emts to identify "life threatening injuries" and penalizes them for NOT transporting lights and sirens (a critical fail). When I teach EMTs, particularly on the medical assessment stations, I tell them the "national registry" answer and then "my take." It is because, inherently, the EMT education does not teach towards symptomatic / asymptomatic stable / unstable, it teaches possible devastating injuries (which they define as SOB, CP, N/V, etc) and to then activate a medic and transport priority one. Experienced EMTs may still believe in that policy, and others may have adopted a level of confidence (aka, knowledge base beyond the EMT curriculum) to know that the black and white picture of the national registry is not necessarily the street (or correct) way to do it.

With experience and advanced education, we, as paramedics, can make more informed decisions. Just as we can make more informed decisions on treatment options (EMTs put on a NRB at 15lpm regardless, only if the patient cannot tolerate an NRB does the EMT curriculum teach NC, whereas paramedics can titrate oxygenation, for example). I do wish that the emt curriculum was stronger in its delineation between symptomatic (no need for urgent transport) and unstable (need for urgent intervention).

[katbemeEMT-B]

It would be interesting to see some statistics as to whether BLS or ALS are involved in more accidents. Along with that would have to be included traffic flow (interstate, highway, city street, etc.), rural service, urban, or city, what type of service (private, hospital, or government owned), call volume, and education of those involved. This would be the only fair analysis. Maybe I will do something like like for one of my research papers when I go back to school this fall.

I do know that I work for two separate services. The BLS service (205 calls/year) we only run hot MAYBE 5 times/year. It takes a pretty unstable patient for us to run to the hospital l/s. In the last year we ran l/s for an advanced CVA, kid that torched himself, cardiac arrest, seizing infant lasting longer than 5 minutes, massive overdose that we started transport as routine but she tanked on the way so we upgraded.

Being a rural system with no ALS backup other than air care, we continually educate ourselves. I say we do it ourselves because we only get reimbursement for any education that is required to maintain our stated and national registry. The rest is at our expense.

As far as accidents, we have only had one and that was quite a few years ago when a driver smashed up the truck (turned out he was well beyond drunk). They have now instituted regulations to avoid that and things have been great. I will say that in the my county and the neighboring county which we also service part of, there are two ALS services and five BLS services. The ALS services have a much higher crash rate than the BLS. I don't think it's a matter of ALS - vs - BLS, I believe it's demographics. They are in cities with a high traffic concentration and also service the interstate. Accidents are bound to happen.

Hey Dust, thanks for the idea on a research paper. When I get it finished I will post my results.

[Dustdevil]

As far as accidents, we have only had one and that was quite a few years ago when a driver smashed up the truck (turned out he was well beyond drunk). They have now instituted regulations to avoid that and things have been great.

LOL! I'm sure I am misunderstanding that statement, but it strikes me as funny. They didn't have regulations against drunk driving before the accident? And the state law didn't stop him from driving drunk, but this new departmental regulation will? Heck, you could establish a "no alcohol use at any time by any member" policy, along with random breath-alcohol testing, and still end up with drunks behind the wheel.

There are more people to blame for that guys crash than just him alone. His partners should have noticed the problem and refused to respond with him, as well as calling the police.

[katbemeEMT-B]

LOL! I'm sure I am misunderstanding that statement, but it strikes me as funny. They didn't have regulations against drunk driving before the accident? And the state law didn't stop him from driving drunk, but this new departmental regulation will? Heck, you could establish a "no alcohol use at any time by any member" policy, along with random breath-alcohol testing, and still end up with drunks behind the wheel.

There are more people to blame for that guys crash than just him alone. His partners should have noticed the problem and refused to respond with him, as well as calling the police.

Yep, I guess I didn't explain it real well. Sorry. It does make it sound kind of funny. They fired him and have now implemented a no alcohol ten hours before shift policy. The crews used to respond from the bar. Gotta remember. At that time we were as small town as it gets. We have come a long way baby. We only have three members that were on at the same time as this idiot and two of them are retiring soon. We are all serious about our jobs and would not blink an eye at turning a fellow crew member in for violating the no alcohol policy. We remind each other that it's not just them at risk, but our patients and ourselves.

Sorry for the confusion Dust. At least I made you laugh this morning.

[Medic26]

I can realisticly say that less than 1% of my patient transports are emergency mode, even cardiac arrest patients since we are doing the very same treatments the ER will be doing. MI's, no lights on them either unless they become "unstable". CVA is no L & S per protocol unless the patient is crowding the 3 hour window and that 2 minutes you save might help. We did a "time study" at my full time service about 5 years ago, involving distance traveled measured in miles and response time between the two modes. Time saved was less than 1 minute on our average response time of around 8 minutes. So you can see where the risk of crashing is not worth the gain. Furthermore, I have seen very few providers who have been "trained" enough to drive properly in emergency mode......even ones with 10+ years on the job. One of my part time services uses L & S all the time on transporting patients........way overkill and saves minimal time but these guys have done it for years and you can't change "the old way".

[firemedic54]

Priority transport in our system is closely monitored. While there are times when priority transport is deemed appropriate in some cases, being able to justify a priority trans. on a seemingly"stable" pt. then getting into an accident enroute to the hospital could be tough sledding. We are required every year to take a road course test that tests the drivers' skills in everything from parking to slalom to accident avoidance. Basically it's the drivers' that are going to have to answer up to a higher authority if they wreck a truck and are found at fault.

[cloe911]

I currently work for a BLS transport who RARELY does anything code3. But when we do, it seems the company is divided, half want to go as fast as the diesel can flow and the other half use it with a feather touch to ensure a "speedy, get there faster and alive" trip.

I personally agree with the later in almost every situation. But I do want to point out the there will ALWAYS be the one in a million (ie. AAA) injury/illness that requires surgery an hour ago, which makes the speed a required thing.

We have the lights and sirens for that one in a million chance, but I think far to many tend to "abuse" it or simply do not fully understand it's repercussions.