Tag Archives: MPDS

Who says you have to be smart to be a doctor?*

Code 3 for leg cramps. I’ll let you read the call notes instead of repeating the radio dispatch. I copied and pasted the notes because I was unable to bring myself to type this garbage.

RP IN MEDICAL MOBILE UNIT
2 PTS
ONE WITH CRAMPS
OTHER WITH SWOLLEN LYMPH NODE

What. The. Fuck.

Because it’s second-hand info, it’s non-triaged. Because it’s non-triaged, MPDS says it’s Delta. So it’s lights and sirens.

I’m not MPDS so I’m not responding lights and sirens. I dare them to fire me. So we drive VERY SAFELY over to this location for this bullshit.

Apparently this is a mobile medical clinic for the unbelievably large homeless population that this city hosts. A county-run clinic. A county-run clinic that is now overtaxing a county-overseen EMS system. An EMS system that is stretched to the limit. Stretched to the limit by endless bullshit calls. Like this bullshit call. These two bullshit patients.

The physician in charge of the clinic greets us, and at least he’s not so stupid that he can’t see that I am not hiding my displeasure with him.

“You people couldn’t arrange a van or something to drive them and you had to call 911 for what is obviously not an emergency?”

“Well…”

“You’re a county program that is abusing the EMS system exactly like the idiots the county, your employer, is actively trying to discourage from calling 911? You know the hot new topic in public health is how to get people to stop calling 911 and going to the ED, right? So all along your transport plan for these patients is to call 911? Why even have this clinic then? Why don’t you just stay home and tell them to call 911 directly?”

*Obviously, I meet a lot of doctors at work – at hospitals, clinics, concerts, first aid stations, etc. Oh, and the EMS medical directors who do nothing but cause me headaches. Let me just say that the notion that only very smart people can be doctors was long ago shattered into a gazillion pieces.

This is insanity

Code 3 for unknown.

Fifty-seven seconds later, “M14, the reporting party is requesting cancellation.”

So why the fuck were we going code 3 in the first place? Anyone?

What a fucking ridiculous system.

If it’s not an Echo, GET RID OF RESPONSE TIMES.

NOW.

Meet Doug Gansler – he travels Code 3

What on Earth is a state Attorney General doing that is so important and time-sensitive that he needs to travel lights-and-sirens to his destinations?

Let’s for a moment assume this report is accurate, according to The Washington Post,

Maryland Attorney General Douglas F. Gansler regularly ordered state troopers assigned to drive him to turn on the lights and sirens on the way to routine appointments, directing them to speed, run red lights and bypass traffic jams by using the shoulder, according to written accounts by the Maryland State Police.

Here I write regularly about the dangerously stupid practice of responding lights-and-sirens to what nearly always turn out to be completely non-urgent situations, and yet we have an AG – not any kind of actual field emergency responder – running around town like an idiot because he’s impatient.

What. The. Fuck.

By the way, Mr. Gansler, we don’t drive on the right shoulder with lights and sirens. The right is the direction people are supposed to move toward when emergency vehicles running lights and sirens approach. Put two and two together, numbnuts.

I’m so glad that as the state’s top law enforcement officer, Mr. Gansler deems it OK to ignore laws that other people are expected to follow. It’s not like our roads are not filled with thoroughly distracted and/or drunk and/or high assholes without licenses and/or insurance who can’t control their vehicles anyway. Not to mention that he apparently has zero concept of risk, public safety, simple ethics, and what some people would call “just don’t be a douchebag.”

He’s also currently running for Governor, so I’m sure he’ll definitely be needlessly traveling lights-and-sirens everywhere if he’s elected.

I’d like some sanity please

Around here, law enforcement officers are nearly always allowed to independently determine their mode of response to a call based on the details. They seldom drive with lights and sirens. And it’s very rare to hear that they chose incorrectly.

In fact, they hold calls and stack them all the time. I’ve seen sergeants cancel responses just based on how stupid it sounds.* I envy them.

Furthermore, many law enforcement agencies don’t even chase anyone in vehicles anymore unless there’s a really, really good reason to chase someone down.

Looking toward the East Coast, a few years ago, FDNY – not exactly a bastion of ultra-progressiveness – stopped responding to a significant portion of their calls with lights and sirens. If FDNY can figure it out, everyone else should be able to figure it out.

Since we all work within the same legal framework, and driving with lights and sirens is very dangerous no matter what type of vehicle is used, and I write often about MPDS and how overly conservative it and the predetermined local responses are, why is it that I can’t choose my mode of response to what often sounds like total bullshit? Trading a few seconds for a much more dangerous ride to stupid calls doesn’t seem sensible at all, yet it is our norm.

We can constantly remind crews to use an abundance of caution, but that doesn’t take into account the unbelievably bone-headed behavior of the driving public in general. This seriously cannot be the way to do our work.

*And there are some really stupid calls.

The most important question not asked in MPDS

“I need to send the appropriate number of responders – how much does the patient weigh?”

“He’s 160 pounds.”

“OK, we’re only sending two people then.”

You saw it here first.

You didn’t know this?

Code 3 for sick person with a headache and abnormal breathing.

Abnormal breathing? MPDS and its “priority symptoms” are really annoying.

A disinterested firefighter waves us down a long driveway, flanked on both sides by dilapidated living units.

“We come here all the fucking time.”

It’s a 30-year-old woman with a headache. She’s carrying her baby in a car seat and walking toward the ambulance from her residence with the rest of the fire crew. Apparently the second adult woman who hands her the car seat can’t watch the baby.

“She can’t watch the baby?”

“We already went through all that with her.”

“Sorry guys. Just asking. Get in.”

This woman is flat, impolite, doesn’t want to answer questions and obviously has some sort of mental and/or personality defect. I keep the interactions to a bare minimum and taxi her to the ED.

She walks into the ED, and a few minutes later, the charge nurse approaches.

“Can she go to the waiting room so we can fast-track her through Quick Care and get rid of her?”

“Of course.”

“OK, walk her out there, and let me just get the doc to make sure she’s OK with this.”

As the patient plays on her phone, the ED attending comes over.

“What’s she here for?”

“Headache.”

“People call you guys for headaches?”

“People call us for all kinds of unbelievably stupid stuff. You didn’t know this working in the ED?”

Is MPDS really unreliable or do I just work in a shitty zone?

“M10, this is a Delta response for a 25-year-old male who is complaining of feeling shaky after drinking 4 Red Bulls.”

Or is it the people who specify whether the response is Code 2 or 3 who should re-think their policies?

Ever wonder just how accurate dispatch information is? What dying person are we driving to with lights and sirens? I happen to have 232 calls to show you. This is a relatively small sample size, but the data collection is ongoing. By the time I get bored, I may have a thousand calls logged. We’ll talk about the details in a second.

Thanks to this neat and simple graph-making tool at the National Center for Education Statistics, here are some of the numbers expressed in pie charts. Yes, it is for kids. A simple tool for a simple fool.

In June 2011, I wrote in total disbelief about how the CDC and ACEP claimed that only 8 percent of ED patients were considered “non-urgent,” the lowest level of acuity under their classification, which by extension meant 92 percent of patients should be seen within 2 hours.

That’s a weird classification, to put it nicely.

That very week, a quick tally of 19 patients resulted in me (and most normal providers, I’m sure) subjectively labeling 12 of them – 63 percent – “non-urgent,” as defined by normal English usage.

Over the past several years, as more agencies adopt the ubiquitous MPDS, I have noticed that the overtriage* based on common response models is quite significant. For those of you who aren’t familiar with MPDS, in the interest of keeping this post short, its main goals are to sensibly dispatch the appropriate type and amount of responders (or not dispatch anything at all) to medical calls based on pre-arrival information and to quickly sort out and dispatch units to the cardiac arrest calls. Think taxis for the least-serious Omegas and Alphas, and anyone with an AED for the non-breathing Echoes. One main feature of MPDS is that the determinants (Omega, Alpha, Bravo, Charlie, Delta, Echo) are set based on RPs’ responses to predetermined dispatch questions while individual jurisdictions are free to customize their response models (Code 2, Code 3, first response only, ambulance only, both, etc.) to the determinants. I like San Francisco’s old bus token idea.

For instance, for the data that I’ve collected, responses to Omegas and Alphas are Code 2, the rest are Code 3. This is a fairly common setup in other jurisdictions.

In the United States, because the typical staffing configuration in most emergency response jurisdictions only consists of engines, trucks and ambulances, and because the typical disposition options with which most oversight agencies (and their lawyers) are comfortable are “transport” and “no transport,” in practical terms, the only real noticeable result is the increase in Code 2 responses in place of the riskier yet not more fruitful Code 3 responses, which isn’t a bad thing. It just doesn’t go far enough.

Judging by the details involved in the implementation of EMS systems as well as MPDS, there are plenty of signs out there that even many EMS jurisdictions and the people who think they know enough to make decisions do not understand the purpose of MPDS, which is exacerbated by the fact that most administrators have absolutely no or pathetically little time working in actual field-level EMS capacities, but this seems to be the norm and not something that will go away anytime soon.  It’s the Dilbert principle as applied to EMS.

A common way jurisdictions misuse MPDS is how they use determinants to establish response time standards. For example, 20 minutes to Alphas, 15 to Bravos, 12 to Charlies, 10 to Deltas, 8:15 to Echoes.

Really? With the exception of Echoes, I’m wondering if this is set up for the sole purpose of generating fines for late responses. Based on what I’ve seen and done, there is no way anyone can convince me a Delta is 2 minutes more serious than a Charlie, and a Bravo is 5 minutes more serious than an Alpha.

Worse, units get re-directed from Bravos to Charlies, Charlies to Deltas, etc. This is colossally stupid. The only diversions should be to Echoes.

We once were dispatched to a Bravo for someone who fell off a horse on the outskirts of town, and nearly 10 minutes into the call, less than a half mile from it, we were re-routed to a Delta for chest pain on the other side of town because we were the closest unit. I tried to insist on continuing to the Bravo but was overruled by dispatch. We turned around, and after about 6 minutes, we were canceled by fire, implying total bullshit. We then were put back on the Bravo since we were still the closest unit, and drove back to the original call. There were several factors at play here, but none of them was common sense.

Anecdotally, my co-workers are quite often upset when they are dispatched Code 2 to a call and they find a patient legitimately sick. Frankly, I’m not much bothered by this. There has not been any substantial evidence demonstrating the benefits of shorter response times (or transport times) in the form of clinical outcome in any cases other than salvageable out-of-hospital cardiac arrest. On the other hand, I am more unhappy about being dispatched Code 3 to a call and finding some complete bullshit. There certainly have been plenty of actual negative outcomes of unwarranted Code 3 responses, usually in the form of wrecks. This is not an easy problem to solve for the simple fact that (a) callers are notoriously unreliable and sometimes downright dishonest, and (b) it is difficult to definitively determine (a) over the phone.

Objective:

  • Quantify patient acuity as determined by MPDS and response modes
  • Evaluate patient acuity as observed on scene
  • Compare the related distributions

Initially there were suggestions to include information on first responders’ (or lack of) actions and interventions. I did not include this because ultimately this project was about MPDS and response modes. We hardly ever went to any good calls, and I spent most of my time writing paperwork and not providing any treatment anyway, so I can hardly expect first responders to provide any treatment either, let alone single them out for the lack of treatment.

I also did not include details on interventions. The main reason is that there simply aren’t many interventions to record. Seriously, look at the shit calls we went to. Besides, I think that subjective acuity is sufficient to express the disparity between MPDS, response modes and actual disposition.

Inclusion criteria:

All 911 calls for medical assistance during which a patient presenting with a complaint of illness or injury is found.

Exclusion criteria:

  • Canceled en route
  • Canceled on scene by first unit on scene
  • Unable to locate
  • No complaint of illness or injury
  • Psych holds and self-committals

As you well know, these incidents make up a sizable portion or our responses. I did not record the numbers, and sometimes I wish I did. Every canceled or excluded call means that any response was for the most part unnecessary in the first place. As for the psych calls, well, fuck them. What a fucking waste of time and resources. If it’s not some guy who wants a place to crash and a sandwich to eat, it’s another guy who’s going for the fourth time this week because he’s “going to kill himself” again. If it’s not those guys, then it’s the guy who’s trying to get out of an arrest, and he knows how to play the system. From the perspective of ambulances, fuck all those psych calls. If you didn’t actually hang yourself or slice the shit out of your wrists, go the fuck away. When are we going to grow a fucking spine and get rid of these fucking calls?

Methodology:

Of the information recorded, some of the relevant data are used:

  • MPDS card, determinant, subcode
  • Response mode
  • Chief complaint as reported to the call-taker
  • Chief complaint on scene, provider impression and relevant information
  • Poor historian(s)
  • Drugs
  • ETOH
  • Psychiatric component
  • Frequent 911 caller
  • Subjective acuity
  • Disposition

Subjective acuity is categorized into “Very Minor,” “Minor,” “Urgent” and “Emergent.” It’s just what I decided to label these patients, based on their presentation, their history, my experience and common sense. Their meanings are very plain. It is nothing like what the CDC and ACEP did. In all of these cases, my subjective acuity was broadly in agreement with how the ED decided to manage them, in terms of resources assigned. The EDs use triage categories more in line with what the CDC and ACEP use than my subjective ones, but in many instances this has more to do with theory than practice. For example, “chest pain” may automatically be triaged as something more serious even if it’s been ongoing “for 2 years.” As nosy as I am, I made quite some effort to follow up unofficially just to see what patients ended up with. I don’t remember any ED finding something that made a patient more acute than I rated, but if that happens in the future, I fully intend to adjust the subjective acuity I assign a patient.

To give you a better idea of this so-called subjective acuity, while dependent on specific cases and presentations, and not absolute, here are some examples:

Very Minor – no complaint, toothache, not feeling well for days, obvious death, etc.

Minor – abdominal pain, vomiting, anxiety, s/p seizure, etc.

“Urgent” and “Emergent” are self-explanatory and do not interest me much since they are not the source of our collective aggravation, anger, eye-rolling and dash-pounding.

I also want to point out that the main description of these subjective categories is best defined by the most reasonable and least self-centered way to go to the ED. For example, a few years ago when I ended up needing emergency surgery, I found a ride. Just because someone ends up being diagnosed with a legitimate entity doesn’t mean at the time this person called 911 it was absolutely necessary for us to respond Code 3. In fact, far from it. Studies typically use discharge diagnosis as the typical measure of patient acuity, because it is objective. However, I think there is some value in using such subjective measures as providers’ impressions. Seriously, how often do we get patients who elicit, from EMS to RN to PA to MD, a continuous chain of eye-rolling, accompanied by, “This is bullshit.”?

Findings (no shit, Sherlock):

  • MPDS and common response models produce significant overtriage
  • Large majority of 911 calls for medical assistance are mind-numbingly routine
  • Please keep all of this in mind when you drive to a call

Less obvious findings (based on this relatively small sample size):

  • Alphas tend to be quite accurately triaged
  • The ratios of Very Minor/Minor to Urgent/Emergent are quite similar in Bravos, Charlies and Deltas, implying there is no practical difference in these determinants. Given that most jurisdictions dispatch different equipment traveling in different modes to scenes depending on whether it’s Bravo, Charlie or Delta, and given that units are often re-directed from Bravos to Charlies and Charlies to Deltas, this seems pointless. I think we’re dicing these calls too fine by differentiating between Bravos, Charlies and Deltas.
  • Charlies and Deltas have similar respective breakdowns to the overall breakdown in acuity.
  • Deltas include all the “unknown medicals,” “non-triaged medicals,” PD requests, etc. The lack of information automatically makes these calls Deltas, but there were very few legitimate patients found as a result of these dispatches. This makes no sense when contrasted with medical alarms, which usually have no information as well, and are basically “indoor unknown medicals.” These calls are automatically categorized as Bravos, but they are in essence no different from the Deltas.
*Other overtriages: Patients who meet trauma center criteria and the use of spinal immobilization, but those are entirely separate posts.