"Keep on-scene time < 20 minutes for medical"

I was listening to Cliff Reed being interviewed on emcrit today, actually, and I agree with his opinion on this issue. "It depends." Hopefully our education will increase to the point that we don't rely on hard and fast rules and dogma. We should be able to evaluate whether or not a patient needs a hospital immediately.
 
Wheel said:
I was listening to Cliff Reed being interviewed on emcrit today, actually, and I agree with his opinion on this issue. "It depends." Hopefully our education will increase to the point that we don't rely on hard and fast rules and dogma. We should be able to evaluate whether or not a patient needs a hospital immediately.
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Sure, your total scene time does depend on a number of independent factors. But the reason many agencies have adopted the 10 minute scene time for traumas should be apparent: barring extrication or hiking up and embankment with a stokes or (rarely) immediate necessary interventions, there really isn't any reason that you can't be on the road promptly. They adopted this rule to remind EMS personnel that ultimately what the patient needs is a surgeon, not the limited treatments we can provide on scene.

Medical calls are a different beast. Certainly there can be reasons to stay and play, but by and large there still isn't a reason that you can't hit the road within 20 minutes. Breathers are the exception to the rule, as you are sometimes better off providing treatment to stabilize them before heading out.

Even hip fractures can get an IV, a dose of morphine or fentanyl, and then carefully moved out to the ambulance in less than 20 minutes.
 
We try to minimize our on scene times to under 20 minutes. It keeps the system flowing, so we have ambulance to handle the next call.

Personally, I try to keep my on scene time to under 20 minutes for most calls. However, if I have a sick patient that needs to be treated on scene, I will take as much time as I need but the vast majority of the time that isn't the case.

My logic as as follows: on a not sick patient, I can do the majority of my interventions enroute to the hospital, and don't need to be done on scene. On a sick patient, more often than not the patient needs definitive care in the ER (and beyond), and while my prehospital care might help things in the short term, they really need an ER (see studies that say ALS doesn't affect overall mortality). However I will repeat, if I have a sick patient that needs to be treated on scene, I will take as much time as I need but the vast majority of the time that isn't the case.

You want to set up camp on every call? be my guest. but I work in a 911 system, where we have a finite set of resources, and a transport time where we are unavailable until we are back in our primary area, so I'm not a big fan on staying on scene just because we can, because the majority of calls I can do all my interventions on the way to the ER. And before you ask, assessment and life saving interventions are done before we leave the scene.

After 20 minutes, dispatch checks us to make sure we are ok, as well as to see if we need any more resources.
 
I don't think anyone is disputing short scene times for trauma or surgical or other time sensitive emergencies (e.g. CVA in 3 hour window or STEMI). The topic is general medical patients.
 
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Wheel said:
I was listening to Cliff Reed being interviewed on emcrit today, actually, and I agree with his opinion on this issue. "It depends." Hopefully our education will increase to the point that we don't rely on hard and fast rules and dogma. We should be able to evaluate whether or not a patient needs a hospital immediately.
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Really, this is sort of the money shot for this thread, reducing the rest to beer and skittles talk.

The pivotal question is not whether there ought to be a twenty minute benchmark , (although evidence for one might emerge), but whether certain classes of cases require sooner definitive intervention than others, and if so, be able to state why (i.e., prompt intervention by measure X in-house which cannot be done in the field). I would suspect the rough dividing line would be down the old medical/surgical watershed.

For instance, I can do good definitively on-scene and enroute for a patient with asthma by assisting in their inhaler use, maybe applying oxygen, and used other medication as needed or dictated.

On the other hand, I can't do a patient with a GSW to the chest as much good by "stay and play". Chest tube,oxygen and pain meds. ANd of courser pt history, which should not be forgotten ever.

Everything I'd do in the field for a fracture would be aimed at temporary stabilization for transport (first aid) and alleviate pain (medical), whereas the actual aid would be diagnostic (X-ray etc) and surgical (debride prn, re-approximate, and immobilize) .

The paradigm is "The mark of pre-EMT era care was grab and run, so it should be avoided at all costs", when we ought to be asking "Which types of cases and which discrete patients will benefit from getting in ftaser than others?", based upon rate of the exacerbation of morbidity or mortality versus our need to do something that makes us feel good and look professional.

Going back to the quote, and using the "How would I sound defending this on court?" yardstick, if I found out some tech had delayed my getting definitive care to stay and play, I'd be tempted to sue her or him.
 
Just a common rule of thumb, I think. A little light flips (literally) and dispatch starts checking to make sure we're alive if we go much past 20, but it's no problem if we do.
 
Brandon O said:
Just a common rule of thumb, I think. A little light flips (literally) and dispatch starts checking to make sure we're alive if we go much past 20, but it's no problem if we do.
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Sounds great to me! Put me in the Wayback machine and I'll sign up.
 
We get "code 4'd" at every 30 minutes. Both an automated page and an alert in the CAD that prompts the dispatcher to hail us on the radio. We don't come back we start getting people dispatched our way.

My average scene time is probably 20-30 minutes. There's no reason we need to be rushing around unless it truly is a time sensitive issue like have been pointed out.

We have a line in our protocols about 10 minute scene times for trauma and you'll get dinged by QA if you're not close.
 
We have at the LEAST a 45 minute transport 90 to Level I hospitals. So shortest time on scene is the best. I have had 2 medical patients with 4 minute scene time get them in the truck strap them in and transport
 
johnrsemt said:
We have at the LEAST a 45 minute transport 90 to Level I hospitals. So shortest time on scene is the best. I have had 2 medical patients with 4 minute scene time get them in the truck strap them in and transport
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I work in a similar area. We work efficiently but there isn't usually much sense of urgency. For most run of the mill calls we probably spend 15 minutes on scene. What's an extra 10 minutes when the whole call is going to take three hours?
 
Most of us remember Trauma is a Surgical Disease.. with that being said, true trauma... minor injuries, etc of course need to be transported in a safe and moderate mode.

What I question is the majority of calls that most systems have such as falls, n/v/d, sick calls etc... I have seen so many patients transported from various levels and agencies with little to no H & P and very little treatment.

What I do find many times is the poor attitudes of EMS responders. So many having that they are far and above such trivial calls.

What many do not understand is:

It is really a part of the job/profession ... as much as those hero calls.

Do you think the receiving facility is to focus on your report? If you can't give me information on the DKA or Granny that fell ... do you think we will all of sudden respect you when you bring a train wreck type patient in? Physicians can be fickle.. listen to how they give report to each other, even in residency and fellowships. Consistent methodology .. detailed ... each and every time. No matter if it is a snotty nose to placenta previa case.

Working back on the other side again is an eye opener. I hear and see what physicians think of EMS personnel. I notice who they listen to, acknowledge and respect as peers. From what I have seen it is those that give that extra detail on mundane calls. Ensuring that the IV is actually a functioning one, the 12 lead is readable, a pertinent history and medication list.

Now, this does not mean it has to be a war and peace report, but hopefully one learns content not context is important.

There are many that have gained my respect by taking a few seconds to extra minutes to ensure patient safety, comfort and performing quality assessment and care. It is noticed and appreciated.

R/r 911
 
I think that all the texts I have worked with from a student standard, have all stated a 20 minute scene time for a maximum for medical, and a 10 minute maximum for trauma patients.

the 10 minute thing I believe is derived from the infamous "Golden Hour Rule" and the Platinum 10 minutes. of course there is always exception to those rules.

Usually I try to minimize my scene times just to get what I need to get done there and move on, if we have a 20 minute transport time I got 20 minutes to get things done.

Of course the management of most associations want rapid transport and rapid return to services.. for system management. as its good for business
 
unleashedfury said:
I think that all the texts I have worked with from a student standard, have all stated a 20 minute scene time for a maximum for medical, and a 10 minute maximum for trauma patients.

the 10 minute thing I believe is derived from the infamous "Golden Hour Rule" and the Platinum 10 minutes. of course there is always exception to those rules.

Usually I try to minimize my scene times just to get what I need to get done there and move on, if we have a 20 minute transport time I got 20 minutes to get things done.

Of course the management of most associations want rapid transport and rapid return to services.. for system management. as its good for business
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Golden Hour, Platinum Ten Minutes, Tungsten Twelve Seconds… they all meant something to someone once and attained infamy by being seized upon by instructors who are always looking for another hook to make students remember and act accordingly.
 
Thanks for the feedback.

Funny, no one has a definite reference. For example, I looked in the latest Caroline's, and didn't find a "20-minute goal" mentioned for medical calls. It's possible I just didn't see it (big books!), but I wonder if this is really set down in print in any textbooks...
 
KellyBracket said:
Thanks for the feedback.

Funny, no one has a definite reference. For example, I looked in the latest Caroline's, and didn't find a "20-minute goal" mentioned for medical calls. It's possible I just didn't see it (big books!), but I wonder if this is really set down in print in any textbooks...
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Yes. Right next to "Mycrofft's Minute". :rofl:

I found some citations of interest but not scientific. They suggest that 20 is a magic number for prehospital EMS. Watch your email
 
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Actually, that reference wasn't far off from my follow-up question. I wanted to first see if anyone had heard of the "20-minute limit" for medical calls, and if this was promulgated by textbooks or culture. Apparently, the un-written culture seems to play a larger role.

I think I can anticipate the responses to my follow-up question:

Is there a perception that cardiac arrests should have a 20-minute on-scene time?
 
We are about 40 minutes from the closest hospital. We are strictly BLS ambulance and have to do ALS intercepts, if necessary. They want us to load and go under 10 minutes, and continue care on the ambulance, since hospitals are at least that far away.

STXmedic said:
Do your instructors give you a rationale behind this?
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RebelAngel said:
We are about 40 minutes from the closest hospital. We are strictly BLS ambulance and have to do ALS intercepts, if necessary. They want us to load and go under 10 minutes, and continue care on the ambulance, since hospitals are at least that far away.
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This does make a huge difference. At the BLS level, there's really not a huge number of treatments to provide anyway even if you are trying to "set up camp." I'm picturing a pretty sparse campsite consisting of a BVM, AED, backboard, and various gauzes. Really, I'll make the bold statement that everything except cardiac arrests and difficult extrications can be transported in <10 minute BLS scene time (I'm very prepared to redact this statement if/when someone comes up with another good exception).

For ALS, I think there are certainly scenarios to spend more time on scene with a sick patient. Far out from the hospital, certain conditions need to be stabilized-ish prior to making things worse/more cramped during transport. Even close to the hospital, there are a few patients that would be harmed by quickly loading and transporting 5 minutes just to have the ED have to mobilize and begin treatment maybe 10 minutes from EMS contact.
 
chaz90 said:
This does make a huge difference. At the BLS level, there's really not a huge number of treatments to provide anyway even if you are trying to "set up camp." I'm picturing a pretty sparse campsite consisting of a BVM, AED, backboard, and various gauzes. Really, I'll make the bold statement that everything except cardiac arrests and difficult extrications can be transported in <10 minute BLS scene time (I'm very prepared to redact this statement if/when someone comes up with another good exception).
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Are you talking about 10 minutes at the patient side? That is a little more reasonable... but if you mean total scene time, there are countless calls (depending on your area, maybe most of them) where you can eat up most of that just getting in and getting the patient out, leaving no time for anything but a scoop and screw. (That includes no time for assessing the patient and figuring out what care they need and how they're going to get it, which is kinda our job.) Good way to freak them out too.
 
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