Why do urban EMS fear on-site treatment?

[gvandellen]

I spent 3 months in Philly doing ride time and now I work 911 in a suburb of the city that has as much crime, poverty, and call volume per capita as the city. The only difference is we treat patients before we leave the residence. Why? I never started a treatment for asthma on a city pt because we never brought in o2. My precepts said we work out of the truck in our environment. Now as a medic right outside the city I have to remind myself that I'm not in the city and we treat pt's before we transport them to a hospital? Is this burnout, laziness, or an overworked system for city EMS workers? My first few weeks in the suburbs I wanted to walk pt's out to the truck but my mentor had me actually treat a pt on scene. I have to be reprogrammed to treating a pt and I find that sad. I have had 3 CHF pt's and all had no resp distress on arrival to the hospital. 3 minutes to scene, 10 on, and 3 min transport vs 3 minutes to scene, walk pt to truck, increase SOB, start treatments, sit by charge RN trying to get a bed for a pt in distress. Aren't we sent to help pt's not transport? Why is city EMS so different? Does having a distressed pt help you get a bed quicker so you can clear your call?

This isn't to attack city EMS, I understand your call volume, Philly even added more units to handle the call volume, I just want to know if you feel you are actually turning distressed pt's around vs just stabilizing them for entry to the ER.

[WANTYNU]

I spent 3 months in Philly doing ride time and now I work 911 in a suburb of the city that has as much crime, poverty, and call volume per capita as the city. The only difference is we treat patients before we leave the residence. Why? I never started a treatment for asthma on a city pt because we never brought in o2. My precepts said we work out of the truck in our environment. Now as a medic right outside the city I have to remind myself that I'm not in the city and we treat pt's before we transport them to a hospital? Is this burnout, laziness, or an overworked system for city EMS workers? My first few weeks in the suburbs I wanted to walk pt's out to the truck but my mentor had me actually treat a pt on scene. I have to be reprogrammed to treating a pt and I find that sad. I have had 3 CHF pt's and all had no resp distress on arrival to the hospital. 3 minutes to scene, 10 on, and 3 min transport vs 3 minutes to scene, walk pt to truck, increase SOB, start treatments, sit by charge RN trying to get a bed for a pt in distress. Aren't we sent to help pt's not transport? Why is city EMS so different? Does having a distressed pt help you get a bed quicker so you can clear your call?

This isn't to attack city EMS, I understand your call volume, Philly even added more units to handle the call volume, I just want to know if you feel you are actually turning distressed pt's around vs just stabilizing them for entry to the ER.

This is going draw some attention (If that is your purpose you will have succeeded)...

I think the folks you were riding with were not doing the right thing or in that case their jobs.

In NYC there is no acceptable reason NOT to treat the patient, unless its a GSW and you're in the ER already, or they're WARM and dead BEFORE you arrived...

What I'm saying is don't draw broad conclusions from limited experiences.

Don't "reprogram" yourself for the city, you're a paramedic, treat your patient.

as always IMHO

be safe,

WANTYNU

[Scaramedic]

I am going to leave the judgments about Philadelphia EMS to people who actually know the system. I have no clue what their system is like.

I have worked in some gnarly areas and I like to treat on scene. The only exceptions are critical pts where my interventions are limited, i.e. I can't perform surgery.

I also would be careful about casting the city in a bad light. It might just be the crews you worked with.

[WelshMedic]

Just a quick question vandellen, who do you work for now? I know the Philly area quite well and was just curious. Send me a PM if you don't to identify yourself any further.

WM

[p3medic]

All cities are not created equal. If thats the order of business in the city of brotherly love, so be it, but I assure you its not the case here, and hopefully not the case in most places.

[climbermedic]

I work in a suburb of Philly as well (who knows, possibly the same system as you) and I find that pt treatment on scene vs. enroute vs. transport only tends to depend on a lot of factors. Pt condition, scene factors, partner, etc. I will say that this particular system can be pretty high volume at times and covering your own local is a high priority. It's your patient, your treatment/interventions and your chart, treat your patients as you see fit, and if that's a problem for your partner/mentor then it's their patient.

[climbermedic]

Upon rereading your original post, I realized that I misunderstood a bit. I have no firsthand experience with Philly but I work with a few former Philly medics. The overriding factor in Philly seems to be call volume. I've heard that 20+ calls a shift is not uncommon. I think that type of volume is, no doubt, a recipe for burnout and I can see how it might influence patient care. I recently heard about a study that showed Philly's call volume far exceeds burnout levels. I guess until I've been exposed to that type of environment (as you obviously already have) you can't possibly make a judgement. I like being able to stabilize a patient on scene or enroute. I have had several patients that have presented stable and changed condition enroute. I guess that has much to do with being a new medic with a still developing sense of clinical judgement. Good luck to you in your new endevor.

[Dustdevil]

All I know about Philly EMS is what I hear, but this is indeed what most everybody says about them, so I don't doubt it.

While I appreciate those who are quick to jump in and say this doesn't happen in their big city, the fact remains that it is a big city culture thing. It's just that there are luckily many systems that are now well managed enough to have moved past that. I've seen it both ways in my experience. If I had to find a common denominator between such systems -- besides being urban -- it would be that most such systems are fire based. That doesn't really answer the question of "why", but it does kind of narrow it down. It all comes down to attitude and competent management.

If your administration doesn't know or care anything more about medicine than what they learned in their twelve-week paramedic school two decades ago, you can't really expect them to foster a culture of progressive professionalism within their organisation.

[FormerEMSLT297]

I worked in NYC for 10 years, We ALMOST always treated on scene, I rode with medics in a a suburb of DC they like to get the patient into the amb. before they start IV's, but they start resp treatment like albuterol, stuff like that in the house.

Everybody operates a little differently, I personally believe in getting the patient treated as soon as is practical...

I will not comment as to whether these medics you rode with are burned out you can draw your own conclusions.

[Dustdevil]

I will not comment as to whether these medics you rode with are burned out you can draw your own conclusions.

It is hard to write this off to burn-out. I've seen plenty of gung ho rookies doing the same thing. But -- and this is significant -- those rookies you see doing it picked that up from those who precepted them. So, while it may have started with the burn-outs, it quickly becomes ingrained in the overall culture as the burn-outs are replaced by monkey-see-monkey-do rookies whose primary professional concern is "fitting in" with all the old veterans they respect.

Again, I don't recall ever seeing this happen in a non-fire based system anywhere. Yes, I have seen individual providers within those systems doing it. Mostly those losers who are only there awaiting a call from the FD hiring board. But never seen a culture of load-and-go permeate a non-fire system.