Short Transport times

[NREMT-Basic]

They way I look at it is that EMS is a continuing spectrum from field to hospital. If we get things done in the field, great. If we get the patient to the hospital really quickly and provide necessary care enroute, that's good too. I mean, if you are 3-5 minutes away from the hospital, and you have a critical asthma patient who needs intubation, and well, you just can't get the tube, I think it is the more responsible thing to control the airway using BLS techniques and get to the hospital where a respiratory therapist can give it a shot in a controlled, well lit environment. EMS works on a time/procedure factor. If it will be quicker to start a life saving procedure in the field, do it. If it will be quicker to get the patient to a hospital to have them do it there, it is in the patient's best interest to do that. This attitude of "if you didn't do the skill in the field, you are just lazy/incompetent/etc. etc." needs to stop. Too many providers are putting their egos above patient well being.

Very well said Asys. I know medics who are gonna that line started, it doesnt matter if we are two minutes out. I also know medics who "extend" their time with their patients by sitting curbside at the scene starting a line, taking two sets of vitals, filling out parts of their PCR, making a nice long report to the ER. We are pre-hospital emergent care. Not diddle around so you can do as many of the things you ever learned as possible---care.

Of course there is the reverse side of the coin. I also know medics who insist on getting that line started because they know if their patient doesnt have a line, they are coming in the ambulance entrance and going through the ER and right into the waiting room where they will get a wristband and sit for 9 hours. So in some cases the medics are doing it out of a belief that the things they do will get the patient in a room and perhaps actually seen by an MD sometime this millennium.

[WelshMedic]

This is an interesting question as it raises a number of issues:

1) Should we extend our scene time to assess the pt fully or just accept the fact that we are primarily there to transport people to a higher echelon of care?

2) Is it safe to perform invasive skills in a moving vehicle?

3) Who are we starting that IV for, the patient or the hospital?

To answer 1), I can remember as a new medic that I would try to be as thorough as possible with every patient and get my documentation just right on scene too....was that the right thing to do? No, in retrospect. I probably didn't jeopardize any one's health as I never stuck around long with a critical trauma; but I came to realise that even though we have a neat bag of tricks available to us, it isn't always appropriate to use them. I find leaving time to talk and reassure my patients can have a far more therapeutic effect than any IV.

To 2), just think about this for a second: sticking a pt in a moving vehicle is leaving yourself open to a needlestick injury and decreasing your chances of getting a hit. I don't care how good you are, bouncing down the road at 60mph causes enough vibration to significantly lessen your chances. I have seen this too, during a ride-along. The pt was a woman with COPD and although sick, certainly not critical. The medic decided to transport emergently and then missed three IV attempts before giving up. Would it have been such a crime to spend a few minutes on scene to secure that IV? Doing so would have meant being able to give corticosteroids and therefore making a start on the definitive treatment for the pt.

To 3), there are nursing staff that will bitch on you even if you bring them all in with a needle , but the decision should be made on an individual basis. What do I want to acheive with my IV? Is the patient dehydrated or hypovolaemic? Go for it! Do I need to give medications? What are you waiting for? But what about the rest? There is a significant infection risk with an IV started prehospitally versus one started intramurally. So much so that some services are limiting IV starts to the pt groups that I just mentioned.

Australian Study

London's Experience

I suspect this is a more european perspective to the issue at hand. I would be keen to hear what you think.

WM

[Herbie]

Ah- the age old question- "stay and play" or "throw and go".

Our business is still evolving, although it has come a long way. Before the advent of Trauma systems and Level One trauma centers, a seriously injured person was likely to die from what are now seen as very "fixable" injuries. We learned about the golden hour and that a couple large bore IVs were NOT going to fix someone who had 3 or 4 GSW's to their chest- they needed an OR suite ASAP. Needle decompressions enroute, stop the bleeding, assist ventilations, advanced airways if warranted, or anything else you are capable of doing as needed, and fly. Is treatment enroute optimum- of course not, but you would be amazed at what you can do when pressed.

We used to use the MAST on everything from GI bleeds(messy) to routine cardiac arrests(useless), but we all know how long this can take to apply. Clearly, the conventional wisdom in that has also changed over the years.

In our system, we are encouraged to do as much as possible enroute with a trauma patient.

For sick medical/cardiac patients, such as bad CHF'ers who can literally die in front of you, the more you do prehospital, the better chance they have. I have ALWAYS been aggressive with these patients- this is what we are trained for, but you also need to weigh the possibilities. ETA to hospital, how busy the ER may be(how quickly they can mobilize and give the care needed, etc. I've had ER docs tell me that for bad cardiacs, our initial treatment is essentially the same as theirs and can mean all the difference in the world, so stay and play is totally appropriate in most situations. (Yes, sitting in the ER driveway would be an exception to that rule)

Point being, we should all know our limitations, but someone said it above: Unless we use the skills we learned, we are simply ambulance drivers.

[triemal04]

So Herbie, I'm really curious here. You say that for medical patients more prehospital care is good...that you are very aggressive in treating pt's prehospital...and that we need to use all of our knowledge on calls.

And yet you also espouse leaving equipment in the ambulance in another thread. http://www.emtcity.com/phpBB2/viewtopic.ph...03&start=15

Interesting that you would have these two views since they seem to contradict one another; kind of hard to start treatment right away if your gear is still out in your ambulance, isn't it? Kind of hard to say that we need to use all our knowledge (oh sorry, you just said skills) when we don't have the right tools handy, isn't it?

[UnapprovedUses]

Hey just wondering how people deal w/ short trnsport times.. less than 5 minutes. since the rural guys are talking about the long transport times.. anyone got things to say about the other extreme?

Here's how I deal with it. Option 1.

Walk up patient. "I need to go to the hospital. Take me to the hospital."

Me: Why?

Patient: I have a cold.

Me: Great! There's one next door.

Patient: I don't like that one. I just got kicked out of there.

Me: Fine. We'll go to the next closest one. Get in.

Patient: Here in this side door?

Me: Yes. Get in the side, grab a seat on a the bench, put your seat belt on. I'll be back in a second. We have some paperwork to do and some assessment to do.

Patient: Ok. Can I finish my beer?

Me: If there's any beer in the truck by the time it takes me to walk out of my seat here, around the back to get in, I'm tossing it. This is an ambulance, not a bar. Do what you need to do with that beer, but I don't want to see you drink it and I don't want it in the truck. Same with any drugs.

Patient: Ok. I have a crack stem. But I won't smoke. I promise.

Me [to EMT]: Let's go.

There you have it.

Option 2.

Call from a nursing home right across the parking lot from a hospital. I generally will do everything required by protocol as if the hospital wasn't right across the parking lot. If that means O2, IV, Monitor, etc...I'll do all that. If the call doesn't require anything more than BLS care, we'll just drive.

[JPINFV]

You know, sometimes I wonder why nursing homes just don't put their patient in a wheel chair and push them to the ER. Case in point: SNF is literally in the parking lot of the ER. [Royal Court to PIH for you So Cal people). You can SEE the ambulance bay from the parking lot and it would take them about 3 minutes to push the person up the ramp.

[akroeze]

You know, sometimes I wonder why nursing homes just don't put their patient in a wheel chair and push them to the ER. Case in point: SNF is literally in the parking lot of the ER. [Royal Court to PIH for you So Cal people). You can SEE the ambulance bay from the parking lot and it would take them about 3 minutes to push the person up the ramp.

Liability maybe?