Pre-decisions, Part 2

In the fictional scenario from Part 1, I asked the questions whether the patient should be a STEMI alert and whether she should be transported emergently.  Check the scenario to catch up if you haven’t already done so.

For me, the STEMI alert question is easy – this patient is not a STEMI alert in my EMS system.  An alert requires ST elevation plus cardiac-type symptoms in the absence of exclusion criteria.  This patient had no symptoms whatsoever, so the alert is out of the window.  If the patient was having a posterior MI with ST depression in V1-V3, I couldn’t alert either (there being no ST elevation) – even though I know the patient is having an MI and needs a cath lab.  Remember, however, that the STEMI alert is shorthand communication meant to replace the whole description of a specific type of MI.  Nothing is stopping me from describing another type of MI - saying something like, “Prepare for an MI.  This isn’t a cardiac alert because X criteria is missing, but I am positive that this is an MI…” Usually, the response by the hospital is the same as it would be for a formal alert.

So the bigger question is whether or not to transport the patient in this fictional scenario emergently.  I think it is important to think through your decisions before you are making them under pressure.  At least come up with a framework to help make decisions before you’re under pressure in the middle of a stressful situation.  So let me explain how I do it for emergency transports.  The process is the same for all other decisions – whether to start an IV, what to bring into a call, when to give analgesia, etc.  There are dozens of decisions on every call, and they all need to be pre-decided to some extent.

My first step is to think about the pros and cons (or, if you prefer, the costs and benefits) of the decision.  In the case of emergency transport, the theoretical benefit is that the time to hospital is possibly shorter.  I don’t think it is usually greatly shorter, and the amount of time saved is based on geography, distance to the hospital, traffic patterns, and such.  The subset of patients, even really sick ones, that have a positive effect from getting to the hospital more quickly is pretty narrow, too.  The cost is increased danger (ambulance crashes and wake wrecks), increased roughness (faster is rougher in the back of the bus), and increased patient anxiety (which I think is minimal, but theoretically could exist).  The specific setting you find yourself in will dictate if the benefits outweigh the costs.

Cost.

Next, brainstorm every reason to transport a patient with lights and sirens.  It doesn’t matter whether the reasons are obviously dumb or not.  It is helpful to list them all out, even the blatantly dumb ones.  My complete “reasons to transport emergently” list:

• Obvious threat to life or limb – These people are making a solid attempt at dying in front of you.  This includes cardiac arrest, airway compromise, unmanageable hemorrhage, etc.
• Likely threat to life or limb – These people aren't necessarily circling the drain, but their disease or injury is not especially compatible with long life.  I would include things at the level of gunshot wounds to the torso with normal mental status and vital signs here, along with myocardial infarction and resolved airway issues (post successful intubation), etc.
• Potential threat to life or limb – There is really no obvious threat here, but there could be.  This level includes patients from severe mechanism crashes, for example.
• Possible threat to life or limb – Now we are getting to the theoretical end of the range of life threats.  And I suppose it is possible for a phalanx fracture to release a teeny little fat emboli that ends up in a lung causing a pulmonary embolism, right?
• Time-dependent intervention I can't give – I am thinking of emergent caths and surgical interventions.
• The protocol demands it – My agency’s protocols never say to transport with the lights and siren, but a different set of protocols might.
• Boss expects it – Not just a supervisor, but a Medical Director, a preceptor, or even a partner may have expectations of emergency transport.  Those expectations can influence our transport decisions.
• Send message to hospital/Improve reception – Nobody likes to get ignored for several minutes after arriving to the ED, getting sent to a small back room, and waiting five more minutes to give a nurse a report.  Transporting emergently ensures I get a big room and a lot of attention immediately.
• Send message to quality assurance staff – I want the QA folks to know that I was taking this patient seriously.
• Send message to "lawyers" – I want to avoid getting sued.  So if I transport with the lights and siren, any problems are harder to put onto my shoulders.
• About to get off shift – Listen, we all want to go home on time.  We have lives and things to do.  The daycare center will call the cops and claim that I abandoned my child if I’m not there by 6pm.  I can’t drive this patient to the hospital in the flow of normal traffic.
• Have to poop – If the choice is lights and siren versus going home to shower and change, isn’t the emergency transport warranted?  I’m not talking about a little discomfort – I’m talking about serious issues like diaphoresis, weeping, barely restrained panic, and negotiating with your own body parts. 
• Wang Rule – The ‘Wang Rule’ holds that any traumatic injury to a person’s genitals warrants an emergency transport.  Solidarity [thump your chest with a fist].  If it were my joint that was bleeding, I’d want to hear the siren.
• Bill at higher rate – The financial viability of your agency is important.  Emergency transports are reimbursed for more money.  Doesn’t that make good financial sense?
• To run the next call – Some small EMS systems only have an ambulance or two.  If there is one more emergency call than you have ambulances, does it make sense to transport the earlier call emergently as a part of the emergency response you’re about to go on?

That is a pretty complete list.  Now go through the list and ponder the logic behind each item.  For which do the benefits outweigh the costs?  Is each grounded in good medical care, logical, consistent, legal, and defensible?  If not, mark it off your list.  The result is your pre-decided reasons for transporting emergently.  Some are indefensible - getting off shift on time.  Some are probably illegal - billing at a higher rate.  Some just aren't grounded in logic and science.

For me, the final, defensible list includes obvious life/limb threat, likely life/limb threat, time-dependent intervention, and have to poop.  I would discuss the ability to run another emergency call that was holding, but that doesn’t really come up in my system.

Going back to our original scenario and the emergency question transport, I don’t think that this patient falls into my emergency transport rationale.  Her ECG is certainly abnormal and very concerning, but she has absolutely no complaints and her vital signs are normal.  In addition, this is an issue that has been troubling her for days.  The distance to the PCI facility is short.  I think she has a potential life threat and I would certainly be monitoring her closely.  All of those combine to result in a non-emergency transport for me. 

There are two main points about that last paragraph.  First, doesn’t that sound like a good answer to give if I were called into a boss’ office to explain that decision?  Reasonable, logical, thoughtful.  Nice.  Second, your threshold to differentiate between likely and potential life threats may be different.  Your list of pre-considered reasons for emergency transport may be different.  Your confidence in your abilities may be different.  Your reassessment may indicate that the patient went from potential to likely life threat and the time has come to step it up – you’re not locked into a transport mode.  All of that is okay.

The important point that I am trying to make is that your decisions be thoughtful, reasonable, and considered.  It is hard to consider all of the factors when you are also orchestrating the scene, caring for the patient, and making a to-do list in your head.  As much as possible, do it in advance.  Don’t make decisions based on gut feelings, habit, or what you think other providers in your agency would do.  Think them through.