On-scene versus in-house: the same or different?

[mycrofft]

What can you do in a hospital you can't do on scene or in an ambulance? When do you NEED to have a pt in-house instead of on the road? Is there an instance where the ambulance isbetter than the hospital?

 

[18G]

One that jumps out in my mind is pain and nausea. I like to get a pain med and/or zofran onboard prior to arrving at the ED. If I don't, then the patient will go even longer without them and that is longer the patient will have to be miserable.

Sometimes depending on how busy the hospital is, a patient could go a good 20mins or longer without an analgesic or antiemetic. So I think in this case field delivery is much better than waiting for the hospital.

 

[usalsfyre]

Severe pain, nausea, asthma and COPD, anaphylaxis or severe allergy, CHF exacterbation, hypoglycemia, initiation of pressors, initial resuscitation and control of the unstable airway are all stuff I do at bedside, in the house, rather than running to the truck and/or hospital.

Stroke, STEMI, the need for mechanical ventilation beyond what I can provide (invasive or non-invasive), uncontolled or intenal hemorrhage and suspected metabolic disturbances (outside hypoglycemia) are all reasons to transport as soon as practical.

 

[MrBrown]

It seems we stay on scene a lot longer than in the US; 20 minutes is not uncommon here and fairly standard; if the patient is really crook or time sensitive that comes down or it might go up if we need to properly control pain and package.

If the patient has a problem that Brown knows needs a cath lab, or an operating theatre or something more than what is in the box of Brown tricks then we will extricate and load and treat en route. For example a sick STEMI we will get a history, set of vitals, a 12 lead, aspirin and GTN (which takes about 10 minutes), on the stair chair and out to the ambulance and off to hospital.

Nana who fell over on the kitchen floor and is in screaming agony will take a lot longer to manage. Brown has spent almost an hour on scene getting lots of morphine and ketamine onboard in order to move, split, package and extricate Nana to the ambulance.

We need time to appropriately do an assessment, get a bit of history, formulate a differential and work with the patient and family rather than ripping everybody up, implanting them on a spine board and racing to the hospital. A sick patient obviously we treat a bit more urgently but there is no point in rushing in and running round like a headless chicken.

 

[Veneficus]

What can you do in a hospital you can't do on scene or in an ambulance?

If you have the equipment with you, nothing. But most places don't have labs and xrays on their rigs.

Several of the surgeons I have met all over the world could operate on somebody's kitchen table. One even worked in a hospital that was nothing more than a tent in Nigeria for 10 years, and has regailed me with stories on how to clean IV/IO needles for reuse because there were only so many new ones coming in a year.

In school were have been and continue to be specifically taught how to fnction without all those fancy hospital gadgets. From hand spinning and calculating hematocrit to making our own slides for organism or atypical cell presentations, a properly trained clinician can function anywhere. Proficently.

When do you NEED to have a pt in-house instead of on the road? Is there an instance where the ambulance isbetter than the hospital?

Depends on the quality of the people in the hospital, not the facilities.

 

[mycrofft]

Good replies, but so few...

Someone, I forget who, recently said there's nothing to be done in the ER that can't be done in the ambulance and I was curious. IN some senses and cases, I agree, and not just the ones when the ambulance wasn't needed.
The seemingly superior care I keep hearing tales of from other countries is depressing. Maybe I'll get myself downunder or north of the Canadian border when I undergo my ablation one of these days.

 

[canisdoo]

Safety in mind. I work the patients where I find them. Unless its trauma then I typically scuttle to the appropriate trauma facility

 

[Medic2409]

It's case dependent, obviously, but I was taught to do something I found interesting when told what I'm about to relate.

The fact of the matter is, that a lot of the public has no idea what it is we do or are capable of doing.

One way to educate the public, is to actually do what we do in the house, rather than doing it all in the truck, in the driveway.

First off, why not spend a little bit of time actually treating the patient where we find them?

When the family arrives at the hospital the pt. is, hopefully, much improved, with IV's etc. in place. Although it is most likely our interventions that are responsible, EMS won't get the credit, the ED staff will. All the family sees is the pt. sitting in the bed, all this wonderful stuff having been done, and the pt. feeling better. They will credit this to the ED staff, since that is where they see the result of the interventions, and not who actually did those interventions. All EMS did, in their eyes, was drive the pt. to the ED.

And we are surprised that people refer to us as "Ambulance Drivers?" Why should they call us anything else, when that is all they see us doing? Doing everything in the truck on the way to the hospital shows noone anything.

 

[MrBrown]

Well good sir Brown's take on your question is that it seems very common in the US to charge in cavalry and all (read: an ambulance, a fire truck and maybe two cops, oops and the medical director coz he was bored) and drag the patient out on a spine board, cram 15 litres of O2 down their gob, stick in a drip and race to the hospital.