Why do urban EMS fear on-site treatment?

[zippyRN]

number of factors here

top two as to why there is a resistance to doing more than the bare minimum on scene

1. risk of being bawled out by receiving hospitals " why did you spend 20/30/45 minutes on scene when the transport time is only 5/10/15 minutes ?" especially if they are providing your medical direction or any aspect of OLMC or QA ...

2.(lay) management pressure to reduce total call time and therefore increase the number of Jobs per shift - so scoop and run esp if transport times are short has become the norm to stave off pressure over scene times - especially when people start bandying 'platinum 10 minutes' and 'golden (s)hour ' about ...

add in laziness of not taking adequate equipment in and trying to sometimes inappropriately ambulate the patient to the vehicle ....

[46Young]

I'm not going to read through all 11 pages, but I will offer my own experiences. When I worked in NYC as a paramedic in the 911 system for a voluntary hospital, we treated most patients onscene. We had multi floor walkups, elevators to deal with, long trips through apartment buildings, etc. Medics are only dispatched ALS job types, so our pts were typically significantly ill. We weren't prepared to deal with the liability of having a pt circle the drain on us while carrying them out, having done notheing except a quick 3 lead, L/S and O2. You could treat a sick pt onscene and then leave as soon as the pt is secure in the back, or txp downstairs right away and then treat in the back with my medic partner. Having two medics means that two medics are supposed to treat the pt. The time spent is the same, but the pt gets what they need that much sooner if you treat onscene.

If I'm working a street job, then I'll have a mental picture of what I can squeeze in during txp. I'll do everything up to tha tpoint onscene, and then do the rest on the way to the hospital.

Down south, most homes have an easy egress and 4-6 providers onscene, so removal to the bus carries much less risk. Txp times can typically be longer than it was in the city, so we'll do mostly everything in transit.

[Bieber]

I'm doing my FI in a county with a large urban city (where all of the posts on my preceptors rotation are located) and a large rural area as well. I've had a little bit of rural experience at some of our posts (we're on a three post rotation) where we respond further out in the county, but most of my experience has been in the city. I'm not a paramedic yet, and I haven't worked in a rural setting (though after I get my paramedic I plan on working both at the service where I'm doing my FI and also at a smaller, rural service as well) but I can offer my limited take on things. Or at least, the reasons why I do most of my treatments in the truck.

First of all, because that is the way I've been instructed. Perhaps not the noblest of reasons, but true nonetheless. I have my own quirks to patient care, and I have my own way of doing things, but I was taught to run calls the way my preceptors run them and so I generally follow their template; not solely because they want me to, but also because I agree with their way of doing things.

Second, why I agree with my preceptors and also prefer to do my treatments in the back of the truck, is for a number of reasons. Now, I don't withhold all treatment until we get to the truck, for example I like to get an initial 12-lead on cardiac patients on scene, put my patients who need the monitor on the monitor, get a blood sugar (if I think it could be a sugar problem, otherwise I get it off the IV needle) and place them on O2 and get my first breathing treatment in if necessary, but I prefer to do most everything else in the truck. I usually save the on scene IV for code blues or symptomatic tachy/bradyarrhythmias because I don't want the line getting yanked while we're moving the patient, and because most of the time we can get them to the truck within a reasonable amount of time if they really need an IV stat (not a lot of high rises where I am, and those that are around I've never gotten a call at).

Also, the vast majority of my patients need three things: an IV, a monitor, and a paramedic to monitor their condition. Most of their conditions are either non-life-threatening, but require vascular access and monitoring, or aren't so acute that I expect their condition to deteriorate in the time it takes me to get them out to the truck. Now, that's not necessarily always the case, my fourth patient on my first day of field internship as a difficulty breather who went from respiratory failure to arrest in about the time it took us to walk all ten feet from the front door to them. In that case, I probably would have preferred to run the code on scene (I'm in favor of not transporting codes, however that's not currently what the service advocates), but we scooped her up, bagged her to the ambulance and took care of things there. Thus far, that has been the only patient I have had who has deteriorated that quickly on me, and even then we were able to manage her long enough to get her into the truck.

The final reason, and this is really an operational/administrative issue, but one I (and certainly others as well) have to deal with, is that scene times are closely monitored and it's my perception that dawdling around for too long can attract unwanted attention. And that's not necessarily bad in se, we're a very busy service and there's a lot of pressure for trucks to have a quick turn around, lest we get short on manpower, but all the same, I wish it wasn't necessarily pushed so fervently. Also, along the same lines as the first, is it becomes an issue of both billing and the continuum of patient care if you treat the patient on scene, they decide they feel great and don't want to go to the hospital, and refuse transport. Not to say they can't change their minds en route, but I think there's less of a willingness to do so when we're already going and also when they find out that we're not a taxi service and they only get two destinations: the hospital, or right where we are when we hit the brakes. I'm not a fan of making patient care decisions based on finances, but at the same time, that same policy DOES also help to discourage patients who decide they're fine after they've been converted from their new onset of a-fib from not going in for further eval at the hospital.

Anyway, that's my take on it, such as it is. To clarify, I'm not saying either way of doing things is wrong (I'm a student, I have no opinion), and I think what's most important is patient care. To me, it seems more like two different styles of doing things. If anything, I'm kind of surprised it's not reversed. The folks with 30 minute transport times have a plenty long transport to do everything they need en route, while those of us in the city are often scrambling to get everything done in the 10-15 minutes we spend with the patient. I'd almost expect urban EMS'ers to do what they need on scene and for those out in the boonies to be loading and going and getting things done en route.