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.