Clinical scenario: Patient with a traumatic amputation
You are dispatched to a factory for a report of a man with his arm caught in a hydraulic press
Medic 7, respond Priority 1 with Engine 4 to 8450 Southern Terrace. The caller is reporting a worker who has an arm injury from an industrial accident.
You arrive in front of a factory where metal car parts are stamped and the foreman leads you into a work area. The foreman tells you that the factory’s third shift just started when the accident occurred.
The engine crew arrived on scene shortly before you and they have successfully extricated the patient from the hydraulic press. Prior to removing him, they placed a commercial tourniquet around his arm and bleeding is currently minimal.
The engine captain introduces the patient as Steven. He has been working at this factory for some time and when he tried to remove an extra piece of metal from the press, his arm was caught and crushed.
Your primary assessment reveals that Steven is conscious and alert with a patent airway and adequate — though rapid — breathing. Steven has a strong radial pulse in his left arm, but his right arm has been severed around the middle of the forearm. The fire department reports that the amputated portion of the arm is not salvageable. Steven’s bleeding is controlled now.
Vital signs are:
- BP: 100/66
- HR: 128
- RR: 24
- SpO2: 97%
Your service area has a level III trauma center 15 minutes away and a level I trauma center 35 minutes away.
Now that you have completed your primary assessment, you must decide what Steven’s transport priority should be. In considering that, think about the following questions:
- What is your initial impression of Steven’s presentation?
- Is the care which has been provided so far adequate?
- What are the risks and benefits of transporting Steven with lights and sirens?
5 questions to guide EMS transport decisions
Many EMS providers will remember being asked to decide in school about whether their patient required that they "load and go." The idea being that there were patients who were either so sick or required specific, time-sensitive interventions that EMS should scoop them up and immediately transport to the closest hospital.
The implication was that these patients would be transported with red lights and sirens active. Code 3 or Priority 1 transport – depending on your part of the country – has been slowly decreasing in frequency as an overall percentage of transports.
Risk mitigation strategies like Just Culture and analysis of transport times are beginning to show that more judicious use of RLS may be appropriate. There are still patients, however, who will benefit from emergent transport and one of the first decisions an EMS provider must make after completing a primary assessment is whether the specific patient requires that mode of transport.
An important idea to understand when making a transport decision is that your patient’s status or severity can be completely decoupled from transport mode. As you will see later on, there are critically ill patients who may not require red lights and siren transport and there are more stable patients who do require that transport mode.
Some EMS systems have protocol-driven guidelines for transport decision while others rely on the discretion of the EMS providers themselves. In either case, the following questions can help you decide if your patient needs emergent transport.
1. IS YOUR PATIENT GOING TO DIE?
This seems like a basic question, but what you really need to determine is the level of time-sensitivity of the patient. The question could easily be re-worded to "Is your patient going to die before you get the hospital?" This question is asking you to make a judgment on whether the patient requires a specific, time-sensitive intervention that cannot be provided in the prehospital setting.
As an example, think of a patient going to the cardiac catheterization lab with a STEMI. There is really no definitive treatment that can help this patient in the field; she needs to get to the hospital in a timely fashion.
While not the only question you need to answer when determining if RLS is appropriate, knowing whether your patient needs immediate, lifesaving treatment can help determine if the remainder of these questions need to be asked at all. In the case of the injured auto worker, a crushed and amputated extremity is certainly a condition which requires immediate intervention.
2. WAS YOUR PATIENT STABLE? HOW ABOUT NOW?
Along the same lines of time-sensitivity is patient stability. This question represents the balance of the first question and focuses on the patient’s presentation rather than the anticipated hospital treatment. This step asks you to determine if a patient is "big sick or little sick" and whether you can do something to improve that level of severity.
In the case of our injured press operator, when he was experiencing uncontrolled hemorrhage from his crushed extremity he was not stable — or at least wouldn’t have remained stable for long. The fire department placing a commercial tourniquet on his arm, however, improved his situation significantly.
By the time you arrive on scene, his bleeding is largely controlled and his vitals are stable. While he was at risk shortly after his injury, an argument could be made that he is currently stable, but still critically injured.
3. WHERE ARE YOU GOING?
Destination decision has a lot to do with transport mode as well. In many EMS systems, there are guidelines for which receiving facility should get which patients, generally divided by some sort of trauma triage criteria or based on hospital specialty programs. Transporting to hospitals in the center of an urban area may require RLS transport more frequently due to increased traffic, whereas an outlying hospital in a suburban or rural area, or one right off a highway, may be better suited to non-emergent transport.
For the patient with a traumatic extremity amputation, you were asked to make a destination decision based on a nearby level III trauma center and a further away level I trauma center. While it is true that a level III trauma center can provide stabilizing services for a patient and then transfer them to definitive care, Steven appears to be relatively stable and likely does not require massive transfusion or stabilizing treatment beyond what has already been provided.
What he does need is specialized orthopedic and possibly vascular surgical services meaning that the level I trauma center is the more appropriate transport destination. If available in your service area , a level II trauma center can also provide the same specialized surgical services as a level I trauma center. Since many level I trauma centers are in urban areas, you should determine whether that setting is more likely to require RLS transport based on the questions below.
4. IS YOUR DECISION SAFE?
Safety, of you, your partner, your patient and the public, should be top of mind when deciding how best to transport your patient. As any seasoned emergency vehicle operator can tell you, civilian drivers tend to make interesting decisions when they suddenly see flashing lights behind them. These unpredictable behaviors increase the possibility of a collision when transporting with RLS active.
As a result, the transporting crew needs to weigh the risks of using RLS against the other questions in this article. Additionally, factors like weather, time of day and day of week all need to be considered before deciding. In Steven’s case, his injury occurred during third shift – nighttime – making it less likely that significant traffic delays will impede your transport to the hospital.
5. WHAT IS THE POTENTIAL BENEFIT?
It was often thought – and in some cases is still taught – that utilizing RLS expedites transport to the hospital. While there are few high-volume studies addressing this question directly, some EMS systems have taken steps to decrease the number of RLS transports due to insufficient time savings in a given system.
While RLS results in negligible time savings for many transports there are cases when it can prove beneficial. For instance, RLS can assist in navigating a crowded intersection during the morning or afternoon commute. An ambulance may be able to more effectively get through traffic backing up from an accident when RLS are active. Given the time of day of Steven’s injury, however, it appears unlikely that RLS transport will result in any specific benefits.
You and your partner load Steven onto the stretcher and into the ambulance. Your partner starts an IV and administers pain medication. Based on Steven’s extensive injuries, the decision is made to transport to the level I trauma center downtown. Given the time of day and the fact that Steven’s bleeding is controlled and his vitals remain stable, your partner asks you to transport priority 2 – without red lights and sirens – to keep from stressing Steven out and reducing the risk of an ambulance collision. She does suggest, however, that you keep an eye on traffic as there is a basketball game tonight and there may be backups near the hospital exit.
Ultimately, Steven loses his arm but is doing well in rehabilitation and is expected to be discharged home soon.
Listen for more
Examining red lights and sirens data with Jeff Jarvis, MD
Reduce unneeded red lights and sirens responses, while targeting time-critical emergencies
This article was originally posted March 24, 2017. It has been updated.