Transport Times and Protocol Decisions

[ERDoc]

This is a topic where if you ask 10 people their opinion you will get 12 different answers. I've seen both sides of the coin while in the field. I've seen people whose head barely fit through a door they were so big that would stay and play on all scenes and then people who were so insecure in their skills that everyone was load and go. I think this is where the old art vs science of medicine comes in. You will never find a perfect answer. Prehospital RSI is debated in the literature and on internet forums ad nauseum. While the current evidence is leaning away from RSI, you do have to look at the current situation. It is one thing to load and go with an unstable airway when the hospital is 10 minutes away with competent docs waiting with airway equipment at the door versus being 90 minutes aways from a competent doctor at some form of trauma center. The first pt is probably better served by loading and going (which I would argue is supported by the current literature) while the second one is not going to make it half way to the hospital without a stable airway. As pointed out, the staff at the closest hospital will also affect your decision. A FM trained person who has never had to care for a difficult airway will shit bricks and probably butcher the airway (overgeneralization, I know) while your EM trained doc will be ready, tube in hand, chomping at the bit to get in there, with the scalpel only feet away, ready to go.

I feel bad for any of you guys who get reamed in cases like this. There is no right answer. I try not to criticize the EMS crews for things that don't make sense to me when they come in, unless it is blatant stupidity. I wasn't there and was not part of the thought process (of course I've been on both sides so I have a little extra knowledge of what happens in the field).

[Bieber]

So it came up on another thread, and I guess the point I was trying to make was that protocols can vary from jurisdiction and one of the factors is distance from a hospital.

It was stated that it should not matter if you are 5 minutes from the hospital or 30 but I disagree. If you are really close to the hospital are you really going to take time to sit there and set up say a dopamine drip? Or will you start a line and do a 12-lead and get them to the hospital quickly. I realize I have been out of the field for a little bit, but is the idea of load and go no longer around? I have seen areas who are 30 min + from a hospital have protocols that are far more extensive than urban protocols for the simple fact you have longer with the patient and can/should perform more interventions. If I'm 5 minutes from a hospital, starting antibiotics isn't realistic, but if I have a significant transport time with an open fracture or septic patient then I could see starting antibiotics.

Maybe my thinking is way off and I should just stick with nursing and bow out of the forum though.

Why delay treatment in order to expedite transport? Where's the benefit?

To your point in general... No, I don't agree with "load and go", however I do agree with recognizing when there are no (more) field treatment to be done and at that point there's really no sense in staying on scene. More and more, though, I'm starting to start more lines on scene and push more drugs on scene before I even move to the ambulance.

The way I see it is this: how long does it REALLY take to get things done? A good, thorough assessment with all relevant diagnostics? 10, 15, 20 minutes? An IV and drugs? Maybe 5-7 minutes? Patient movement, getting them packaged and ready to go? Another 5 minutes? Is delaying care and expediting transport so that the patient can be moved from point A to point B in order to receive that same care in another setting really better?

It seems that a lot of medics are reluctant defer treatment until the ER even with short treatment times. Just because you can do something does not necessarily mean you have to do it. I am not sure if it is just a matter of professional pride or what. There is nothing wrong with waiting until the patient is in a more controlled environment with better equipment or allowing a higher qualified provider to take over. Like systemet stated RSI is a great example of a procedure that should be deferred when ever possible.

Um, you're going to have to explain that one to me, 'cause I'm with Arctic on this one. It's not about doing something for the sake of doing it; it's a matter of giving clinically sound, medically indicated and patient appropriate treatment when it is needed or preferred in order to improve the patient's condition. Would you make a dyspneic patient wait to receive breathing treatments? Or a patient with a fracture suffer an unnecessarily long period of time to receive analgesia? Or obligate a patient with a compromised airway oxygen?

[island emt]

Nobody is advocating not providing appropriate care that is clinically sound and needed right now to correct life threatening medical problems.

Fixing a diabetic issue or giving pain relief before moving a pt with FX is common sense. Same as giving a nebulizer tx to a pt with bronchospasm.

It's the difference between starting an IV , doing a set of blood draws and a 12 lead on scene for a fall that has a possible fx to the wrist. They are doing things because they

can , not because it was medically indicated.

Instead of transporting to the ER 5 minutes away they are spending 30 minutes on scene doing everything their protocol allows.

We have all seen it and should know the difference in required care versus care because we can! or cookbook Paramedicine because thats how they were taught.

Monkey see this monkey do that!

[Bieber]

Nobody is advocating not providing appropriate care that is clinically sound and needed right now to correct life threatening medical problems.

Fixing a diabetic issue or giving pain relief before moving a pt with FX is common sense. Same as giving a nebulizer tx to a pt with bronchospasm.

It's the difference between starting an IV , doing a set of blood draws and a 12 lead on scene for a fall that has a possible fx to the wrist. They are doing things because they

can , not because it was medically indicated.

Instead of transporting to the ER 5 minutes away they are spending 30 minutes on scene doing everything their protocol allows.

We have all seen it and should know the difference in required care versus care because we can! or cookbook Paramedicine because thats how they were taught.

Monkey see this monkey do that!

Uh...

I really don't think we're not talking about the medic who is so stupid that they're doing blood draws and a 12-lead for a wrist fracture, that's not the scenario that was given in the OP nor the tone of the thread at all based on the responses so far. My understanding is that we're talking about medics who are providing either prolonging scene times to provide critical interventions when it may be conceivably be quicker to just transport or medics performing non-critical, non-life-saving but still clinically indicated interventions instead of simply "deferring" them to the hospital.

There's no reason to delay or defer clinically indicated medical care if there are competent providers to administer it present.

There is no reason to give non-clinically indicated medical care regardless of how competent the providers administering it are.

If we're talking about medics giving care that isn't medically indicated, I will support you 100% in denouncing that practice; as I would denounce any provider giving care that isn't indicated.

If we're talking about medics giving care that some people would rather they defer to the hospital, with no justification why except for vague excuses of "controlled environment" or "just because you can do it doesn't mean you should", then no, I don't support that at all.

[Mateo_1387]

No right or wrong answers huh? It seems things like risk vs benefit, confidence, protocol, and the like come to play in determining scene times. I am sure administrations also play a large roll in this question. I seem to view it like this. We are supposed to be the professional on scene, we are called to respond by the public for our services to be rendered. There is an expectation that our emergency services are completed. I also try and think of myself as a part of the continuum of care, in that what I do is going to be the beginning of the patient's treatment which will continues as they move through the system. With that being said, I do not agree with providing slack care based on distance from the hospital. Maybe you have heard the saying that goes along the lines of "respond to the call, do not react to it". Rushing to the hospital just seems like a reaction. Prioritizing treatments in a timely manner, stabilize the patient as best as possible for transport, and making the move towards definitive care with sound reasoning is how I think it should be done. Because you can pawn your work off to the hospital based on distance, should not be your primary reason for scene time.

I tend to see in my area that EMS personnel are prioritizing scene time over patient care. I think a great deal of the problems stems from our administration and their priorities of load and go and the other part being a lack of efficiency in performing on the scene. For instance, are you the provider that waits to be told what to do on a call, even in cases where you may not be the leader of the call, or do you jump in and get things done? Even worse, are you that provider holding the clipboard? Tell me, what does that do for the patient?

I do try and keep scene times in mind without compromising patient care. Practicing efficiently on a constant basis I think helps when you get that critically ill patient that needs definitive care, but also needs the primary and timely care you provide.

I also see this issue as an ethical dilemma, in that we are supposed to provide a certain level of care to all patients. Arctickat brought up the legal term nonfeasance, Not performing indicated actions to certain population groups (in this case distance from the hospital) has usually been frowned upon. Anyone else see it similarly?

[Spock]

Pennsylvania has state wide protocols but individual medical directors have some latitude in how far medics can go with their treatments. My service seldom has longer than a ten minute transport timeI to either a level one trauma center or a hospital with a cath lab. It seems this all goes back to the old "load and go" versus "stay and play" argument. Even with our short transport times our crews usually minimize on scene treatments. Our QA standards require a scene time of 20 minutes for medical and 10 minutes for trauma patients. It is rare to find these levels exceeded and it is usually related to difficult extrications.

The bottom line is to do what is best for the patient in each situation. I've seen plenty of people that were supposed to be competent at airway management butcher an airway. Life isn't easy and no matter how good you think you are at managing an airway the next one might be a very humbling experience.

[Bieber]

Spock, out of curiosity, is that 20 minute standard inflexible or do field providers have some discretion in it? If not, what do you guys do with cardiac arrests or, say, a hypoglycemic that is taking a while to work on?

[triemal04]

With this particular topic, like several others, knowing what actually will happen in the ER (the ones you go to) is pretty vital before you should be taking a stance one way or another.

What I mean is, how long will that particular ER take to actually get the same intervention/medication done/administered if you don't? It often isn't as simple as some people think; (not neccasarily anyone here but way to many that I've talked with) you drop someone off at an ER and -poof- they magically have all the needed treatments on board. A doctor is still going to have to make it to the patient, do an eval, give some orders, the nurse will still have to pull the meds from a pixis (or maybe call pharmacy), labs/x-rays/ct's/central access/ultrasound/other things may need to be done first depending on the hospital protocol, etc etc etc. While in a truly emergent situation things will happen faster and some of the standard things like actually waiting for a MD's order may not be needed, there really aren't that many true emergencies. While the overall medicine is the same (hopefully anyway) how things are done in a hospital are very different than how they are done in the field, and it seems like not everyone always understands this.

This is leaving out that some ER's are just plain slow at getting things done. And that some are uber-quick.

[TruckEMT]

The idea of Load-and-Go is not so dead. I work in a small city where we are never more then 10 minutes out of the hospital. When stationing the nearby mountain, we sometimes run 20-30 minutes out of the city to meet up with a bls truck inbound to the city. We see both the lengthy stays and the 2-3 blocks from the ER situations. We adjust our ways based on this. I don't think I've ever really ran into issues, and we RARELY remain on scene for longer then necessary, and by necessary I mean however long it takes to get them on the litter...