The Curious Case of Diesel Bolus

Any prehospital provider who has spent any time on social media forums has invariably read this as an answer to [insert any scenario here]:

"DIESEL BOLUS!"

The inference of this "solution" of course being to simply drive really fast to the hospital for definitive care. Reading this makes many experienced clinicians head hurt as the sole solution for whatever scenario lay in front of them. And the inference is that the provider isn't thinking through the situation and taking the easy way out. We roll our eyes every time we read this answer and classify that provider into the category of "simpleton". And we either challenge them, ignore them, or provide some degree of sarcasm against the answer (guilty as charged).

Then a few weeks ago I came across this post (I have eliminated the author because calling out isn't the intent of this post):

"SADS - Sudden Ambulance Death Syndrome - critically ill patients who deteriorate quickly (/go into arrest) in the back of or on the way to the ambulance. Stabilize. Your. Patient. On. Scene. Before. You. Move. Them."

This is kind of like the opposite of the diesel bolus. The inference here obviously being do whatever you can to stabilize your patient on scene before getting out of whatever setting you're in. This seemed to be approached with a lot of fanfare and support from various folks who took the time to add their thoughts. I see a problem with this concept. Not that I disagree with the statement specifically. But that the reality is it's actually not that much more intelligent than "Diesel Bolus!". Bear with me before lighting your torches.

Both those statements are essentially false dichotomies (or false dilemmas, whatever language you're used to). It premises the fact that we should be in one court or the other when it comes to patient care. But the reality is that sick patients are complex creatures and should not be lumped into any specific category.

If I have a motorcyclist who is struck, unresponsive, with an unstable pelvis and abdo bruising and hypotensive (and I have no access to anything but normal saline), I'm going to quickly manage the airway in a BLS fashion, put on a pelvic binder, and I'm going to get the hell outta dodge. I'll do any further interventions such as advanced airway and judicious fluids enroute. Even though we know that the "Golden Hour" in trauma is a bit of horseshit (1,2,3) it turns out the answer to this guys problem is actually diesel bolus, because there is nothing I can do to fix this patient and they need an OR.

And if I have an elderly patient who is GCS 3, with no obtainable blood pressure, in a third degree heart block at a rate of 24, simply trying to get to the hospital quickly will potentially result in death when I have the capability to treat that immediately in their living room with either transcutaneous pacing and/or pressors. The answer in this case is to indeed stabilize before transporting.

Essentially each statement will be right once in a while depending on what case sits before you. Once in a while the Diesel Bolus guy is right. Once in a while the Stabilize guy is right. But for the most part the truth sits somewhere in the middle. Medicine has always been and will always be a grey area that we need to be able to recognize and adapt to. We need to stop putting patient care into a specific algorithm or a corner because very rarely do they fit entirely into those scenarios. Ultimately this goes back to the concept of "Stay and Play" versus "Load and Go".

"Should I stay or should I go now? If I go, there will be trouble. And if I stay it will be double. So come on and let me know, should I stay or should I go?" ~ The Clash

These are the terms that need to be vanquished from the vocabulary of Paramedics. On every single call you need to examine your patient, your vital signs, and prioritize what you can do. And once you figure all that out the more important decision becomes what to do now and what you want to do later. You also need to take into account your receiving facilities and their capabilities. In short the concept of load and go vs stay and play needs to die. I'll simply reference this tweet I made some years ago on the matter:

Stop putting patients into corners, algorithms, and fancy catch phrases. They deserve better than that. They deserve the most evidence based and timely care each and every call. No offence to The Clash, but I'm thankful they stuck to singing.

Now if you'll excuse me, I have a Spotify playlist I need to listen to.

References:

1) Emergency medical services intervals and survival in trauma: assessment of the "golden hour" in a North American prospective cohort. Ann Emerg Med 2010 ;55:235-246

2) Is total out-of-hospital time a significant predictor of trauma patient mortality? Acad Emerg Med.2003 ;10:949-54

3) Helicopter emergency medical services (HEMS): impact on on-scene times. J Trauma 2007;63:258-62