I Need An Emergent Ambulance. But Not Really.

A while ago I ran a call that got me to thinking. (I hate that.) My agency provides bike medics equipped with AEDs and the first-line accoutrements of ALS care. They’re usually employed where patients are harder to get to: sporting events, concerts, downtown events with road closures, and those kinds of events. Anyway, I was at one of those affairs and responded to an adult female with an asthma attack in the stadium stands.

Most stadiums that hire me to ride a bicycle don't look like this. Unfortunately.
Source

I rolled up after an extremely frustrating series of 20-foot rides followed by impatient trackstands* through the crowded concourse to find nobody in the seat I was dispatched to. I checked with the disembodied voice on the radio and wandered around a little, before finally finding the patient out in the concourse a few sections away from where she was supposed to be sitting. She appeared to be tachypneic but with deep breaths and had a slightly fast heart rate (104 or something). She couldn’t speak due to an almost constant cough, and I saw no manual spasms. Breath sounds were hindered by the loud ambient noise that comes with working a patient in a stadium crowd, but I think she had inspiratory stridor in her upper airways. Each time I put my head near her ear to shout a question, she would answer with a cough. My partner put a neb in her face and I was down with that plan.

To be frank, though, I kind of got a hyperventilation/anxiety vibe from her. She had a history of asthma, so that was still on the table. Also on the differential diagnosis list were all of the other pathologies that cause tachypnea: pulmonary embolism, allergic reaction/anaphylaxis, and so on. I didn’t have enough information to rule anything out. So I didn’t blow the patient off. But I did feel an anxiety vibe coming off of her. 

I stepped away to get my blood pressure cuff off of my bike and bumped into two people who were in the way. So I may not have been positive about what the patient's problem was, but I was positive I was sick of working up this patient in a crowd: “Dispatch, can I get an emergency ambulance to…” The transport ambulance’s response time was about the same as the time it took me to find a wheelchair and roll the patient and her neb outside. So as the ambulance was being put into park, I was loading the patient into the back of their bus. The extra hands provided by the crew made quick work of the patient. In short, she did have some slight wheezing and hand numbness. Her sats were great and she had an end-tidal CO2 of 45 with square waveforms. In the end, we still didn’t have a firm delineation between asthma and anxiety. The patient was driven to the hospital.

So here is the part of the call I was thinking about: I called for an emergency ambulance even though I was fairly confident that the patient wasn’t critically ill. My intention was that she would be a nonemergency transport. The most important reason I called for the bus with lights and sirens was that I was sick of dealing with the patient in a crowd. I knew she would be transported, so why delay the handoff? Especially because I was sure the patient was non-critical, but not positive (if the difference makes sense at all). My confidence in the patient’s level of illness could have been misplaced due to the noise and crowds.

A friend and coworker recently had a street call with two patients. The patients couldn't easily be transported together, but they were both nonemergency situations. So he and his partner called for a second (nonemergency) ambulance. The nonemergency response to take the second patient took almost an hour. Assigned ambulances kept getting diverted to emergency calls. I see both sides of this coin. On one side, nonemergency ambulances which are assigned to transport a patient with a medic already on scene should be reassigned to emergency calls without a medic on scene. On the other side, we shouldn’t have to wait close to an hour for another ambulance to transport my patients.

It made me think of the times where I got all fired up at the fire department. It is pretty common for them to call for an emergency ambulance – for neck pain, for “mechanism” (when the car involved in the crash is still driveable), for patients with several weeks worth of chest pain, and so on. It riles me up every time. But wait - didn’t I just do the same thing? Should a firefighter have to wait for an hour (with their giant red vehicle blocking a lane or two) for a nonemergency ambulance? What if they are sick of working up a patient in a crowd?

That is what we call cognitive dissonance, ladies and gentlemen. Cognitive dissonance is the intellectual discomfort or tension you feel when two beliefs you hold oppose each other, or when existing ideas are refuted by new evidence. Cognitive dissonance makes me uncomfortable, as it should. I probably ought to work through the dissonance and figure out the most rational, defensible answer to the issue. But that seems like a lot of mental stress and discomfort. 

In the end, I decided I need to give firefighters a break when they call for me emergently and I find a nonemergency patient. Cognitive dissonance temporarily terminated...

*Bike medics are cooler when they don't put their feet down...