Treating On Scene/En Route

[Jersey]

We're conducting a study, and was just curious to get a little bit of an informal discussion going here along these lines:

What treatments/interventions do you perform on scene? Specifically,

Initiate an IV line
Place the patient on a 3 lead ECG
Initiate a 12 lead ECG
Administer medications (ACLS)
Administer non ACLS medications.

This should be a pretty interesting discussion to see how our colleagues around the country do things differently.

All the best

 

[8jimi8]

3 lead, or 12 lead if indicated. Initial impression and ABC's, rapid / focused assessment. Everything else needs to be done in the back of the bus. The organization where I volunteer for 9-11 EMS has a 10 minute scene time standard of care. The fire department where i volly at doesn't transport, so whatever you can get done before the rig shows up is fair game... if it is warranted for the patient's care.

 

[medic417]

On scene time limitations are quickly becoming a thing of the past because a few extra minutes starting treatments in the field such as thrombolytic therapy can save 30 minutes to more than an hour if we were to wait to the hospitals. We need to start practicing medicine rather than being taxi drivers.

 

[reaper]

Exactly. You cannot answer this poll, without knowing what you are treating. The majority of Pt's you see can have most interventions done on scene. There is no rush.

Very few Pt's are ever in need of scope and run tactics. Treat your Pt's, not your protocols!

 

[Epi-do]

Exactly. You cannot answer this poll, without knowing what you are treating. The majority of Pt's you see can have most interventions done on scene. There is no rush.

Very few Pt's are ever in need of scope and run tactics. Treat your Pt's, not your protocols!

+1

Now if only my officer agreed with this statement. Unfortunately he is of the mentality that we need to get everyone to the ambulance and enroute to the ER ASAP. I figure I am about due for another "talking to" about it, because I still try to do as much as I can onscene. Once he starts getting antsy though, I have to move to the truck.

Yes, there are some patients I would prefer to just get moving with and work as much as I can on the way to the hospital, but those patients are few and far between. The majority of them, time isn't really a huge factor for though, and are actually better served by getting a better assessment and history while onscene.

 

[mycrofft]

I answered #2 as a compromise.

SOME cases benefit more from a longer on scene period, SOME need a snatch and run, most fall in between, because of reasons eveyone's tired of hearing me talk about. Rule out or in these "SOME" groups and work from there.

 

[8jimi8]

Well,

I have yet to lead an ALS unit, I've never lead a BLS unit. I've always been 3rd rider and followed my lead's instructions. I am definitely keeping an open mind to your opinions.

 

[FLEMTP]

SOME cases benefit more from a longer on scene period, SOME need a snatch and run, most fall in between, because of reasons eveyone's tired of hearing me talk about. Rule out or in these "SOME" groups and work from there.

Im with you on the "it depends" answer.. i didnt vote in the poll.. because it really depends on what you're looking at. If you get on scene, and someone is shot, or its a trauma alert.. im gone before you realize i was there...literally.. 2 minute scene times...

if I arrive on scene of a chest pain, the FIRST thing im doing is a 12 lead to rule out an acute MI... because that completely changes the destination and treatment course you're going to use.

Altered level of consciousness is another good example.. you grab and go.. get in the truck.. begin transport. then find out the sugar is only 20.. you treat them.. and have an awake alert and conscious patient who either doesn't want transport.. or doesn't need transport.

Respiratory distress ... you need to do a good assessment. If i have a CHF exacerbation, im going to get them on my cot, in the truck, get a 12 lead.. 2 IV lines, initiate a tridal drip, and reassess them from there.. and either transport if they begin to improve.. or perform a Drug assisted intubation and get them on a ventilator with some PEEP if they arent improving.. ALL before i transport... while i still have my partner handy.. and a controlled enviroment (ie: not flying down the road lights and sirens trying to push meds, ventilate and intubate)

So it really depends on the situation... I think another user hit the nail on the head.. we need to start assessing and treating our patient's rather than giving them a fast glorified taxi ride.

In fact, here is the perfect example.. you get a call for a pediatric unknown.. walk in the house, and mom is freaking out and the kid is in cardiac arrest... how many of you are going to grab the kid and run like hell for the ER? (im talking ALS... BLS is a completely different story)
How many of you are going to work the child right where you're at.. and give them your best 20 minutes.. with good quality CPR and a good quality airway? (BLS airway typically, especially with children)

We just had this chat in our latest dept inservice and PALS renewal... our medical director and our Captain in charge of education and training made it a point to tell us to work the child on scene, and give it your best. The time you waste running for the truck and doing haphazard CPR all the way to the ER is going to ruin that child's chances for survival if there are any... not to mention, if the child does not recover ROSC on scene, you can pronounce and call the ME (at least in my agency, yours may be different) rather than transporting a dead child to the ER, which puts you, your crew, and the general public at risk...not to mention taking a dead child out of a house like that may be destroying and removing valuable evidence should this become a criminal case with law enforcement.

Just some examples.. YMMV

 

[MrBrown]

If you restrict your study to those treatments, your study is flawed.

It all depends what you are treating. We have a principle called LATER, load and treat enroute but that is not always done, it depends what we are treating!

 

[TransportJockey]

Im with you on the "it depends" answer.. i didnt vote in the poll.. because it really depends on what you're looking at. If you get on scene, and someone is shot, or its a trauma alert.. im gone before you realize i was there...literally.. 2 minute scene times...

if I arrive on scene of a chest pain, the FIRST thing im doing is a 12 lead to rule out an acute MI... because that completely changes the destination and treatment course you're going to use.

Altered level of consciousness is another good example.. you grab and go.. get in the truck.. begin transport. then find out the sugar is only 20.. you treat them.. and have an awake alert and conscious patient who either doesn't want transport.. or doesn't need transport.

Respiratory distress ... you need to do a good assessment. If i have a CHF exacerbation, im going to get them on my cot, in the truck, get a 12 lead.. 2 IV lines, initiate a tridal drip, and reassess them from there.. and either transport if they begin to improve.. or perform a Drug assisted intubation and get them on a ventilator with some PEEP if they arent improving.. ALL before i transport... while i still have my partner handy.. and a controlled enviroment (ie: not flying down the road lights and sirens trying to push meds, ventilate and intubate)

So it really depends on the situation... I think another user hit the nail on the head.. we need to start assessing and treating our patient's rather than giving them a fast glorified taxi ride.

In fact, here is the perfect example.. you get a call for a pediatric unknown.. walk in the house, and mom is freaking out and the kid is in cardiac arrest... how many of you are going to grab the kid and run like hell for the ER? (im talking ALS... BLS is a completely different story)
How many of you are going to work the child right where you're at.. and give them your best 20 minutes.. with good quality CPR and a good quality airway? (BLS airway typically, especially with children)

We just had this chat in our latest dept inservice and PALS renewal... our medical director and our Captain in charge of education and training made it a point to tell us to work the child on scene, and give it your best. The time you waste running for the truck and doing haphazard CPR all the way to the ER is going to ruin that child's chances for survival if there are any... not to mention, if the child does not recover ROSC on scene, you can pronounce and call the ME (at least in my agency, yours may be different) rather than transporting a dead child to the ER, which puts you, your crew, and the general public at risk...not to mention taking a dead child out of a house like that may be destroying and removing valuable evidence should this become a criminal case with law enforcement.

Just some examples.. YMMV

Probably one of the best responses I've read on this topic. I agree fully.

 

[Shishkabob]

Obviously it depends.

For the sake of argument, on scene can be in the back of the ambulance infront of the scene.


Cardiac in origin can stay on scene. If it's an MI, the 15 minutes we spend doing a 12lead, IVs, and initial round of drugs saves what, an hour in the ER? Plus we can get them to the proper hospital once we know what's going on.

Stroke gets moving once I get an IV started, as they need to get to a CT scanner.

Shortness of breath depends, as well. If it's asthma and they are reacting to my treatments, we'll probably stay as they might refuse transport. Refractive asthma starts to get moved. CHF? Try to get moving once I get the earliest interventions done.

Major trauma? Just like is taught- cspine and airway are one scene, everything else is done in motion.



But each call is depending on how they present. If it doesn't seem major or time sensitive, no reason we cant start treatment on scene for a bit.




PS-- 3000 posts!

 

[DrParasite]

Obviously it depends.

For the sake of argument, on scene can be in the back of the ambulance infront of the scene.

Cardiac in origin can stay on scene. If it's an MI, the 15 minutes we spend doing a 12lead, IVs, and initial round of drugs saves what, an hour in the ER? Plus we can get them to the proper hospital once we know what's going on.

Stroke gets moving once I get an IV started, as they need to get to a CT scanner.

Shortness of breath depends, as well. If it's asthma and they are reacting to my treatments, we'll probably stay as they might refuse transport. Refractive asthma starts to get moved. CHF? Try to get moving once I get the earliest interventions done.

Major trauma? Just like is taught- cspine and airway are one scene, everything else is done in motion.

But each call is depending on how they present. If it doesn't seem major or time sensitive, no reason we cant start treatment on scene for a bit.

+1

there is no definitive answer, however, I will say this: how many ALS procedures will provide definitive care? more over, how many NEED to be done on scene, vs enroute?

as a general rule (very general), I try to load and go almost every patient that is going to be transported to the hospital. there are generally jobs holding in my city, and the less time is spent on scene the sooner we are available for the next job.

however, if a patients condition requires treatment on scene (12 lead, unconc diabetic, airway complications), then we do what is in the patients nest interest.

 

[abckidsmom]

+1

there is no definitive answer, however, I will say this: how many ALS procedures will provide definitive care? more over, how many NEED to be done on scene, vs enroute?

as a general rule (very general), I try to load and go almost every patient that is going to be transported to the hospital. there are generally jobs holding in my city, and the less time is spent on scene the sooner we are available for the next job.

however, if a patients condition requires treatment on scene (12 lead, unconc diabetic, airway complications), then we do what is in the patients nest interest.

This.

We certainly could spend 15-20 minutes on scene with every patient, getting the most complete history in the history of patient care, treating and checking boxes all the way down the protocol, or we could do the best, most efficient, expiditious job possible, clear up and serve the next customer.

In our system, HOURS are wasted each and every day with people lollygagging and not having a goal to GET OFF THE SCENE already! Yes, it's important to provide the best care possible to the patient. It's also possible to do this very quickly, and en route to the hospital.

The complex situations described by FLEMTP are few and far between, and there's really not good reason why you can't get a 12 lead or check blood glucose in under 5 minutes on the scene. Treating a CHFer and evaluating whether your interventions are working is sitting, wasting time on the scene. Get the treatments going, get moving. If you need to stop to reassess or to intubate, at least you haven't spent 15 minutes sitting on the scene.

 

[8jimi8]

i'm glad i stayed open-minded
seems like prioritization and common sense must rule the call.

 

[Akulahawk]

The systems I've worked in have generally short transport times. I try to make my transport decision early and as part of my Tx plan. For patients that get transported, it's matter of when it's appropriate to do so. Once a transport decision has been made, I'm going to be working towards getting that patient transported. I'll have started what I need started so that I can be further along the Tx plan. My Tx doesn't stop because I've started moving the patient...

 

[LondonMedic]

Exactly. You cannot answer this poll, without knowing what you are treating. The majority of Pt's you see can have most interventions done on scene. There is no rush.

Very few Pt's are ever in need of scope and run tactics. Treat your Pt's, not your protocols!

You could argue the opposite and say that few patients need full, time consuming, assessment and treatment on scene. Walk them on, transport, walk them off, get another job and increase productivity.

 

[redcrossemt]

I tend to stay on-scene for a few minutes to initiate treatment that will benefit the patient immediately. Obviously our assessment including BGL/12-lead, airway control/oxygen/CPAP, and usually nebulizer, D50, narcan, fentanyl/morphine... Again, depends on the patient's condition and what they need vs. what I can do. IV if needed to immediately treat the patient.

I tend to get going on things that need hospital intervention now... trauma alerts, AMI, CVA, anything that needs surgery now, etc.

 

[FLEMTP]

The complex situations described by FLEMTP are few and far between, and there's really not good reason why you can't get a 12 lead or check blood glucose in under 5 minutes on the scene. Treating a CHFer and evaluating whether your interventions are working is sitting, wasting time on the scene. Get the treatments going, get moving. If you need to stop to reassess or to intubate, at least you haven't spent 15 minutes sitting on the scene.

Just to put this out there.. but I tend to get a lot of complex calls with sick patients... I generally follow the same plans for the various different types of calls on most patients, as appropriate.. and my average scene time for the past year and a half is approx 23 minutes... which is below the agency average of 28 minutes.

We have a very diverse area we cover.. from more urban areas with a fairly short transport time of 5-10 minutes, rural farm areas with 30-60 minute transports depending on the destination... all the way to 60 minute plus transports to get off of some of our barrier islands and to the closest trauma center or STEMI facility. We do have our own HEMS... however with only one aircraft, its never a guarantee that it will be up and running or available.

We also have the ability to do any intervention the ER will for about the first hour or so of treatment, with the exception of surgery..

 

[LondonMedic]

We also have the ability to do any intervention the ER will for about the first hour or so of treatment, with the exception of surgery..

Without knowing precisely what you can and can't do I can think of several.

While a paramedic may be licensed and able to do these interventions, give these drugs and perform these investigations, are they always the right person to do it? Do they have enough immediate help and supervision? Do they have enough experience? Are they ultimately delaying definitive management because there are some other things that the hossie can do in that first hour?

 

[FLEMTP]

Without knowing precisely what you can and can't do I can think of several.

While a paramedic may be licensed and able to do these interventions, give these drugs and perform these investigations, are they always the right person to do it? Do they have enough immediate help and supervision? Do they have enough experience? Are they ultimately delaying definitive management because there are some other things that the hossie can do in that first hour?

You do bring up some good points. That's where good decision making comes into play.. something our agency stresses very much so. Granted, no two paramedics will run a call the same way, I'd like to think that most of us here with my agency would make the right call on the right treatment, and think of things in the best interest for the patient.

We have a VERY competitive hiring process, and we get approx 400 applications per open paramedic position ... so we can be very picky about the type of education and experience our new hires have..and we have a very rigorous field training program. In fact, very few people come into our organization as a paramedic from the start, even if they are a licensed paramedic. Most paramedics will chose to hire in and work as an EMT until they get a firm grasp on the level of care and decision making that our agency demands... and then they promote up to paramedic. I chose to come in as a paramedic, and I think I made the right decision... but no two people are the same in that aspect.

The point to all of that, is that we have to use our education, and experience to make the appropriate decision as to what would benefit the patient the best, and follow through on that decision. Do we make the absolute right decision 100% of the time? No, of course not, but we do learn from our mistakes and learn from our decisions. We have a great QA/QI program here and our command staff assigned to that program does a great job on follow up with the ER's to help us decide if we did make the right decision, and if not, how to improve our decision making process so that we can make the right call down the road.

As far as the help goes, we have typically two man crews on the ambulance.. some times a third person if staffing allows it. We dual respond with the fire dept in all areas of the county, and all of them are trained to the BLS level, with about half of the county being ALS... so we have plenty of hands, and plenty of resources. We have the ability to call additional EMS units if we need a hand while transporting, and our supervisors are available as additional hands or for consultation. Our medical director also encourages us to use the ER docs as a resource should we encounter something we are not familiar with for a consultation. We don't really need to seek orders from them, as we are not required to seek orders for anything we do... but its great to know I have that available to me.

I would like to see our agency expand our care even more to allow some additional diagnostic tools to be used, such as checking electrolyte levels, checking for presence of cardiac markers and enzymes, and ultrasound capabilities. Right now we are in a budget crunch, so for right now that type of improvement is on the back burner.