Why do urban EMS fear on-site treatment?

[BushyFromOz]

Man, some big ego's on this thread

I would be classed as a "stay and play" person in most cases, and with the exception of some clerly defined points in our guidelines such as penetrating trauma, there is no real excuse in my situation that precludes me from having a professional obligation to my pt to assess properly and begin supportive measures appropriate to the situation and then move to the vehicle.

Of course this is a fluid situation and is entirely dependent in the patients condition. If you tell me that the sicker the pt the earlier you should move them to the back of the truck to commence treatment, i would argue that those are the pts you should be assessing more thooughly and initiating care with before you move them.

One of my favourite people at work once chastised me for "wasting time" placing IV's in my chest pain pts before moving to the car. I wont argue that definitive care for this patient is in A&E. For the sake of 90seconds, getting that IV before we move gives us options if the pt craps out on us before we get to that back of the truck.

Hers my favourite line for explaining scene times

"Dont rush but dont waste time"

Yeah, we all love an oxymoron

[spenac]

Of course this is a fluid situation and is entirely dependent in the patients condition. If you tell me that the sicker the pt the earlier you should move them to the back of the truck to commence treatment, i would argue that those are the pts you should be assessing more thooughly and initiating care with before you move them.

One of my favourite people at work once chastised me for "wasting time" placing IV's in my chest pain pts before moving to the car. I wont argue that definitive care for this patient is in A&E. For the sake of 90seconds, getting that IV before we move gives us options if the pt craps out on us before we get to that back of the truck.

My cousin from way south I think we could work well together. I get tired of people saying lets get them loaded and roll. No I am going to take care of them where they lay so 1 they might get some pain relief. 2 As you mention they are prepped in case they crap out.

And I to agree definitive care is the ultimate answer but it does surprise me how often my patients have significantly improved because I went ahead and treated rather than just load and go and let doc figure it out.

[stcommodore]

One of my mentors in EMS made a point once about "bringing care to the patient." At the ALS level if we are not doing that in situations that permit it then we need to readjust our thinking.

[BushyFromOz]

My cousin from way south I think we could work well together.

Yes, imagine our babies!

[Steve Whitehead]

From my experiences with DPH medics in San Francisco in the 90s and with DG medics here in Denver, I think I could offer some insights as to why larger city medics tend to put a greater premium on scene time. I’m not offering these as the right or wrong way to do medicine, these are just some of the philosophies expressed to me by some very talented medics while they were encouraging me to work on faster scene times and more efficient care.

1.) Scene safety. The shorter your exposure to the scene, the better.

2.) A sense that the back of the rig is your area of control where the scene is the patients area of control.

3.) A desire to get the rig back in service as soon as is appropriately possible.

4.) An idea that fast and efficient medicine should be practiced on all calls to improve the skill for when it is needed.

I will say this. While I remain a stay and play medic at heart I took many of these lessons to heart and I think being trained in this way was helpful for me. Overall it improved my medicine. I have great respect for medics who come from big city, high call volume systems. The DG dudes I work with are some of the most knowledgeable and talented medics I’ve known.

One idea that I would refute is the idea that fast = sloppy. That may be the case in some regions, and believe me, I’ve seen my share of medics who race to the hospital to compensate for poor skills, but I never saw that with the DG guys.

The one remarkable thing I’ve noticed about most of the guys that came from that “knife and gun club” system is that they are just fast … like crazy fast. They are not sloppy. They just get a lot of stuff done really fast. And if you’re really sick, they’ll save your life. If you do die I guarantee you’ll die looking at a doctor.

Final verdict for me … if we can bring definitive care to the patient there’s no excuse not to do it, but there’s nothing wrong with doing good medicine fast.

One last point, Urban EMS providers don't "fear" longer scene times. They just don't prefer it. It's a matter of preference, not fear. The title of this thread slants the argument unfairly by implying that big city medics are afraid of something.

Thanks all.

[WolfmanHarris]

1.) Scene safety. The shorter your exposure to the scene, the better.

I grew up (well half the time) in downtown Toronto and spend a lot of time in the city. Unless American cities fit their caricatures from 1980's cop movies I don't see this holding a lot of water for the majority of calls. Are the majority of calls in these areas not still CP, SOB and all the usual medical fare? I just have some trouble buying this.

2.) A sense that the back of the rig is your area of control where the scene is the patients area of control.

Fair enough. But does that mean you need to be rolling trying to do everything in a moving vehicle?

3.) A desire to get the rig back in service as soon as is appropriately possible.

This is just potentially sub-par patient care being justified by covering for the failings of a sub-par system.

4.) An idea that fast and efficient medicine should be practiced on all calls to improve the skill for when it is needed.

I'm not sure i follow here. Is this advocating using skills unnecessarily on patient's that don't require it as practice for those patient's that might in the future?

Final verdict for me … if we can bring definitive care to the patient there’s no excuse not to do it, but there’s nothing wrong with doing good medicine fast.

I agree.

[akroeze]

DocH, I think what they are trying to say is that you should treat every call like the person is acutely ill (speed wise) even if they aren't that way when the time comes that you have a serious patient there is no problem in acting quickly since it is what you are used to.

[MontvilleFire39]

Patient care can't and should not be defined as rural vs urban but based upon the situation at hand which are dynamic and not black and white.

Per SOP, at a minimum I am required to take a jump bag, o2, and monitor into all EMS calls. Some do, some don't but it is a punishable offense and the potential to get in a ringer is there.

As far as treatment on scene goes, I often prefer to treat the patient on scene but inthe ambulance for crew safety reasons. If somehing goes negative on scene you can quikly take off. In questionale at best neighborhoods scenes can change rapidly. In the upstairs bedroom of a house with a patient on the monitor and 02, you can rapidly exit the scene. It is a judgement call and depends on the neighborhood, amount of people on scene, and amount of personel on scene. If we are on scene with a first responder company it prvides more eyes to be looking at the overall scene which is hard to do as a treating paramedic.

One of the biggest traits of a high quality paramedic is being able to rapidly and appropriately decide if they can effectively initialy manage a patient on scene or if the patient is in need of a higher level of care than afforded by the EMS crew thus prompting them to rapidly transport and treat as much as possible enroute.

[HERBIE1]

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.

Depends on far more details than you are providing. What were the scenes like? Safe? Tons of bystanders? Unruly? Potential for problems? Surroundings? How much assistance did you have? Irate/upset/interfering family or friends?

Yes, some of it is burnout, some of it is things you may not be aware of- previous problems in these areas, who knows. If it's simply trying to get back in service for the next call- that's silly. You can only treat one at a time- except for MCI's of course. The point is, we have a lot of toys to use, but time and place.

From my experiences with DPH medics in San Francisco in the 90s and with DG medics here in Denver, I think I could offer some insights as to why larger city medics tend to put a greater premium on scene time. I'm not offering these as the right or wrong way to do medicine, these are just some of the philosophies expressed to me by some very talented medics while they were encouraging me to work on faster scene times and more efficient care.

1.) Scene safety. The shorter your exposure to the scene, the better.

2.) A sense that the back of the rig is your area of control where the scene is the patients area of control.

3.) A desire to get the rig back in service as soon as is appropriately possible.

4.) An idea that fast and efficient medicine should be practiced on all calls to improve the skill for when it is needed.

I will say this. While I remain a stay and play medic at heart I took many of these lessons to heart and I think being trained in this way was helpful for me. Overall it improved my medicine. I have great respect for medics who come from big city, high call volume systems. The DG dudes I work with are some of the most knowledgeable and talented medics I've known.

One idea that I would refute is the idea that fast = sloppy. That may be the case in some regions, and believe me, I've seen my share of medics who race to the hospital to compensate for poor skills, but I never saw that with the DG guys.

The one remarkable thing I've noticed about most of the guys that came from that "knife and gun club" system is that they are just fast … like crazy fast. They are not sloppy. They just get a lot of stuff done really fast. And if you're really sick, they'll save your life. If you do die I guarantee you'll die looking at a doctor.

Final verdict for me … if we can bring definitive care to the patient there's no excuse not to do it, but there's nothing wrong with doing good medicine fast.

One last point, Urban EMS providers don't "fear" longer scene times. They just don't prefer it. It's a matter of preference, not fear. The title of this thread slants the argument unfairly by implying that big city medics are afraid of something.

Thanks all.

Good post. May I also add that in certain cases- bad trauma- load and go is the only way. You do whatever you can enroute, but they need an OR- that large bore IV will probably do little for them. For a sick cardiac, we can definitely make a difference and at least in the first few moments, we do exactly what an ER does. Obviously they have more help, MD's, more toys, and more meds, but our first line, immediate care is ACLS and the same as an ER. In this case, extended scene time is OK and I've been told this by every doc I've spoken with.

Depending on transport times, the acuity of the patient, and the level of skill of the provider, what can be done enroute to the ER also varies widely.

[medic82942003]

I worked in Flint MI for 3 months, the first time I took the 02 in with the moniter and drug box- my

partner looked at me like i was crazy. There attitude is bad there. Unless the person is a code they

say its dangerous to stay and play. high crime areas.