Scene Times

[downunderwunda]

Is there an optimum time to use as a target to attempt to have a patient in hospital????? I refer to trauma.

For many years we have been taught that the Golden Hour is the standard, but is this the case.

Considering the fact this was a marketing ploy used to get people to go to a Trauma Centre, can it be used as a tool in todays EMS?

I say no.

Reality is, a person who would probably benefit from this efficeint transport is probably in a position to be delayed on scene through initial patient managment & stabilisation. This includes spinal care, wound managment etc. It is also reality that we see too many ambulance rushing to get a patient into an ER to have them assessed & lying on a hospital bed for hours because they are determined 'not to be an urgent case'.

With the advances in pre hospital medicine, should we not, as professional pre hospital clinicians be give the ability to make the assessment on scene as to what is best for the patient, rather than be driven by some blind catchphrase that has no real basis for fact (the data used was on soldiers from the vietnam war, not a true comparison for civilian casualties)

Be safe

 

[piggy16]

I think the "golden hour" is still used, although some might find it controversial. Also, the golden hour is the time of injury to time of surgery, so really EMS has a much shorter time frame of pt care. Hopefully protocols are based off of the pts injuries and how critical they are (class system) rather then treating all patients as a trauma. But yea I agree that medics should have some say in the process because obviously some things can be treated in the field, others can't be.

 

[BossyCow]

I think the "golden hour" is still used, although some might find it controversial. Also, the golden hour is the time of injury to time of surgery, so really EMS has a much shorter time frame of pt care. Hopefully protocols are based off of the pts injuries and how critical they are (class system) rather then treating all patients as a trauma. But yea I agree that medics should have some say in the process because obviously some things can be treated in the field, others can't be.

In wilderness med and SAR its the golden day.. not the golden hour.. and some pts have a golden 10 seconds after the event.

 

[EMTWintz]

Its going to vary alot from place to place. Here our Para's go with this Trauma 10min max on scene (assuming not extracation), do everything else enroute. Med 20min max. That doesn't always happen of course, but that is what they strive for.

 

[Grady_emt]

Its going to vary alot from place to place. Here our Para's go with this Trauma 10min max on scene (assuming not extracation), do everything else enroute. Med 20min max. That doesn't always happen of course, but that is what they strive for.

Same here, 10 min also applied to CVA and STEMI pts. If greater than 10min on a trauma/CVA/STEMI, delay reason (multi-story extrication, entrapped, fire, etc...) must be coded on the PCR.

 

[Veneficus]

Same here, 10 min also applied to CVA and STEMI pts. If greater than 10min on a trauma/CVA/STEMI, delay reason (multi-story extrication, entrapped, fire, etc...) must be coded on the PCR.

I have heard both sides of the golden hour idea. But I think there is little evidence to support it.

First, it stipulates from time of injury to surgery. This stipulates your patient actually needs surgery. Not all patients will survive to surgery with grevious wounds. With modern advances nonsurgical treatment may also be the case. (there was a time all liver or splenic lacs meant an open abd. This is not true anymore. Not to mention surgical trauma is a pretty small % of all trauma in the civillian world.

Now the best time in my mind to get a surgical trauma candidate to surgery is: As soon as safely possible.

Proficiency builds speed, speed does not build proficiency. All these time limits for things cause mistakes, or render less care to the patient. It also sets up a mindset that can lead to dangerous practices like poor driving or unnecessary air evac. There is no substitute for a good assessment.

As for STEMI, time is tissue, I am not so crazy to dispute that, but are you deciding to pack the patient instead of giving treatment? Not a good idea. Especially since the earlier treatment is rendered the more effective it is. What is the purpose of being an ALS unit that shows up, packs a STEMI patient and is on the road in 10 minutes? That is 10 minutes of little to no treatment where increasing perfusion even minimally might have profound effects. That sounds to me like a lack of faith in EMS providers than it does a medical goal. (unless you are BLS only, then there is not much else to be done)

EMS should not be judged on scene time, response time, or any other arbitrary time to judge performance. “We are off scene in 10 minutes 90% of the time with poorer medical outcomes than a comparable service, or 6 traffic accidents a year” is of no help to anyone. Neither is spending millions of dollars a year to put an ALS squad on every corner “just in case.”

Why does it sound like EMS in the US is regressing to me?

 

[Grady_emt]

I have heard both sides of the golden hour idea. But I think there is little evidence to support it.

First, it stipulates from time of injury to surgery. This stipulates your patient actually needs surgery. Not all patients will survive to surgery with grevious wounds. With modern advances nonsurgical treatment may also be the case. (there was a time all liver or splenic lacs meant an open abd. This is not true anymore. Not to mention surgical trauma is a pretty small % of all trauma in the civillian world.

Now the best time in my mind to get a surgical trauma candidate to surgery is: As soon as safely possible.

Proficiency builds speed, speed does not build proficiency. All these time limits for things cause mistakes, or render less care to the patient. It also sets up a mindset that can lead to dangerous practices like poor driving or unnecessary air evac. There is no substitute for a good assessment.

As for STEMI, time is tissue, I am not so crazy to dispute that, but are you deciding to pack the patient instead of giving treatment? Not a good idea. Especially since the earlier treatment is rendered the more effective it is. What is the purpose of being an ALS unit that shows up, packs a STEMI patient and is on the road in 10 minutes? That is 10 minutes of little to no treatment where increasing perfusion even minimally might have profound effects. That sounds to me like a lack of faith in EMS providers than it does a medical goal. (unless you are BLS only, then there is not much else to be done)

EMS should not be judged on scene time, response time, or any other arbitrary time to judge performance. “We are off scene in 10 minutes 90% of the time with poorer medical outcomes than a comparable service, or 6 traffic accidents a year” is of no help to anyone. Neither is spending millions of dollars a year to put an ALS squad on every corner “just in case.”

Why does it sound like EMS in the US is regressing to me?

Sorry, I should have elaborated on the STEMI time. The 10 minutes is from the time the 12 lead is done, which according to protocol should be within 5 minutes of pt contact on a chest pain pt.

10 minutes is plenty of time do preform many interventions. Divide and conquer is the way to get alot done in a short period of time. Usually my partner takes airway/monitor, I take access/medications/bleeding control/immob. It's possible to immobilize, intubate, have 2 large IV's, and load the pt up well within 10 minutes.

 

[Veneficus]

10 minutes is plenty of time do preform many interventions. Divide and conquer is the way to get alot done in a short period of time. Usually my partner takes airway/monitor, I take access/medications/bleeding control/immob. It's possible to immobilize, intubate, have 2 large IV's, and load the pt up well within 10 minutes.

That sounds very skill based.

 

[medicdan]

Personally, in urban BLS emergencies, I try to get on the road as soon as possible. The biggest and best tool I have for my patients is rapid (but safe) transport to an appropriate medical center for assessment by an ER doc. I may be an EMT, but for many illnesses and injuries there isnt much treatment I can do, so the best bet for my patient is to get to an MD ASAP.

On scene, I like to get one set of vitals, any pertinent information from family, etc (med list, recent hosp documents, etc), then get going. I usually get another set of vitals before turning a wheel, go en route, finish my assessment, get another set of vitals, prepare my triage report (I am always scared of how it will come out, so if I have a chance, I write it out), put in an entry note, and start paperwork, depending on transport time.

I never really thought about it, but without extenuating circumstances (extrication, many flights of stairs, CPR, etc.) I usually am on scene fewer than 10 minutes.

I guess I just like working in my own element, where I control the variables. I concede that for many of my patients, there is little I can do aside from O2, monitoring and a little PFA.

 

[daedalus]

That sounds very skill based.

I hope that the word "monitor" is not the sum of Grady's assessment. There are some providers where the monitor is the only assessment tool or technique used on the patient.

 

[Veneficus]

I hope that the word "monitor" is not the sum of Grady's assessment. There are some providers where the monitor is the only assessment tool or technique used on the patient.

I am not trying to sling insults at anyone, I just worry about providers who are more involved with skills than knowledge.

As I keep trying to remind people, arbitrary time limits are not the measure of a good provider or system. Drug addicts can start IVs and an AED can analyze and defib heart rythems. CPR machines have been around for ages now. It is not the psychomotor skill that makes a good provider.

The worst diagnostic tools I worry about is the preconceived notions and the x-ray eyes.

 

[vquintessence]

EMTs own

I know how most of you all feel about studies and their limitations, but numerous ones have been done regarding pt outcome with ALS vs BLS. The following is one of them:

http://www.ctv.ca/servlet/ArticleNe...21/paramedic_study_080421/20080421?hub=Health

The study basically states that ALS and BLS were close to being equal (low 80 percentile), however when you broke it down into catagories, BLS would win hands down. Bear through these excerpts:

QUOTE

"""For most of the a priori subgroups examined, there was also no difference in survival to hospital discharge by study phase (Table 4). The exception were the 598 cases with an initial Glasgow Coma Scale score of less than 9, for whom survival was lower in the advanced life-support phase than in the basic life-support phase (60.1% v. 51.2%; p = 0.03). Within the advanced life-support phase, survival was lower for cases in which an advanced life-support crew attended the trauma scene than for those attended by basic life-support crews only (86.4% for basic life-support v. 79.1% for advanced life-support; p < 0.001). The trauma cases in both phases of this study were more severe than norms from the Major Trauma Outcome Study (M = 0.67 and 0.70 for basic and advanced life-support phases, respectively). The number of survivors in each phase of the OPALS Study was not substantially different from that predicted by Major Trauma Outcome Study norms"""

"""Controlled clinical trials of critically injured patients are difficult to conduct, particularly in the out-of-hospital setting, and observers have called for better evidence from more rigorous studies.3–5 Previous evaluations of advanced life-support programs have generally had small numbers or have used observational methods.20–26 These studies generally found no support for prehospital advanced life-support measures in major trauma. Although our study evaluated the package of interventions that is considered part of advanced life-support protocols, endotracheal intubation and intravenous fluid administration were the dominant elements of the protocols of care. We documented higher mortality among patients undergoing prehospital endotracheal intubation even after controlling for age, injury severity and physiologic measures. It seems intuitive that intubation would help some trauma patients in the field, but there is surprisingly little evidence to support aggressive airway management by paramedics. Multiple studies have found no benefit from paramedic intubation of patients with head injury.23,27–30 Other observational studies have suggested worse outcomes for patients with head injury who are intubated in the field.31,32 Rapid-sequence intubation techniques that employ neuromuscular blockade are particularly controversial, and expectations of benefit have not been confirmed by controlled studies.6,7,33–38"""

END QUOTE

Although this one ostensibly is a tie, many of the reports I've seen, BLS wins or ties hands down.

 

[karaya]

As you can see from the link below, PHTLS works toward the "Golden Period" as opposed to the "Golden Hour". This topic reared its head as a critical point of discussion in the shadow of the rapid increase in EMS helicopter crashes. Mr. Chapleau brings out some good points.

http://www.jems.com/news_and_articles/columns/Chapleau/prehospital_time.html

 

[Grady_emt]

I hope that the word "monitor" is not the sum of Grady's assessment. There are some providers where the monitor is the only assessment tool or technique used on the patient.

No, not by anymeans is it the only factor in an assessment. It's just to confirm what you already suspect at that point. If they look like crap, they probably are sick. The pt's appearance, hx, co-morbid factors, etc all go into your assessment of that pt.

 

[JPINFV]

<trauma study>

You should clarify that that is a trauma study since there are plenty of medical diseases where paramedics makes a large difference in patient outcome. As a contrast to your study, may I present the "EMS v Home Boy [private auto] Ambulance Service" study that indicated that patients transported by private auto may be better served than transport by private auto. The simple problem with multisystem trauma is that EMS can do nothing for most trauma patients besides provide transport.

Paramedic vs private transportation of trauma patients. Effect on outcome.
http://www.ncbi.nlm.nih.gov/pubmed/8611068

 

[vquintessence]

You should clarify that that is a trauma study since there are plenty of medical diseases where paramedics makes a large difference in patient outcome. As a contrast to your study, may I present the "EMS v Home Boy [private auto] Ambulance Service" study that indicated that patients transported by private auto may be better served than transport by private auto. The simple problem with multisystem trauma is that EMS can do nothing for most trauma patients besides provide transport.

Paramedic vs private transportation of trauma patients. Effect on outcome.
http://www.ncbi.nlm.nih.gov/pubmed/8611068

You're right my bad. When I see golden hour I assume trauma/CVA. I'm not trying to dismiss ALS in one broad sweep. However, when going to that multi system trauma, the only difference between treatments that you or I would typically give, is that I may tube them (if feasible) or other airway support and perhaps the traumatic code. Other than that it should be a reasonable scoop and screw. Like you said, we're not an OR or even an ED.


As far as EMS vs Auto, that case seems pretty cut and dry. Aside from camping mentioned above, the difference between EMS and "oh **** Mikey got hurt real bad" can be broken down into:
*No dispatch and response time
*No searching and no methodical extrication
*Lights and sirens don't make a remarkably significant difference in transport times

figure that time with compensated shock.

 

[Veneficus]

I know how most of you all feel about studies and their limitations, but numerous ones have been done regarding pt outcome with ALS vs BLS. The following is one of them:

Cut for brevity

Although this one ostensibly is a tie, many of the reports I've seen, BLS wins or ties hands down.

The points I was referring to was for STEMI.

I have no doubt that the current way ALS is provided for multisystem trauma in the US makes no more difference than BLS. In fact I think the whole approach to prehospital ALS is fundamentally flawed. But that is another thread.

As for trauma, the more I learn about it, the more classes like PHTLS, ITLS, and others directed towards EMS providers look basically like a class to make the providers feel like they are doing something, because most of what is done for seriously injured trauma patients prehospital makes no difference or could possibly be iatrogenic.

With mandated equipment like spine boards and MAST, it is no wonder to me that many trauma professionals (aka surgeons) have little respect for the use of prehospital providers. I would support the case that ALS in trauma only has effects on traumatic conditions(aka minor) not warranting a surgeon anyway.

 

[marineman]

Karaya, I read that article a while ago and that's what I try to go by on severe trauma calls. I don't believe the golden hour is true at all but what it's trying to convey I definitely believe in, on a severe multisystem trauma we do our major "lifesaving interventions" on scene and bug. For example we had one today, this is not a scenario so I'm not giving all details just a brief overview of how it was handled.

Vehicle T-boned and thrown into a ditch by a dump truck at highway speeds. Due to incline, snow etc. holding C-spine was as good as it got while we waited for fire to extricate. Once pt was free we removed patient on long board and "immobilized" then we got pt in the back of the rig and started 2 14g's with LR running wide open and checked for pulse. Patient had GCS of 9 responding to verbal with eye opening. We hooked up a 4 lead (we don't have 3's), V-tach on monitor and got the heck out of there. Essential treatments were done on scene and we were gone. The fractured wrist never got splinted all the way to the hospital. The fractured tib didn't get splinted all the way in.

All in all I think some people go one of two ways, either they're so worried about bugging out of there that they skip identifying immediate threats to life which are a part of ABC's. Please tell me nobody will run on a trauma without checking ABC's so why are you skipping other steps? Other people get too caught up in treating all of the injuries and do waste precious time playing with things that aren't an immediate need.

Remember the trauma assessment we're taught the first day of EMT-B. The only things you treat on scene are immediate life threats such as massive bleeding, pneumo etc. Other things are done en route to the hospital if time allows.

P.S. for anyone keeping score on that call I got to see my first flail segment and hear (or not hear) my first pneumo. We didn't decompress because it just started building when we were pulling into the garage at the hospital. Last update I had pt went through 9 units of blood but made it to and through the first round of surgery. Pretty much destroyed his pelvis and they stopped the hemorrhage but I don't think they've done anything to start putting him back together yet, just trying to stabilize him.

 

[KEVD18]

Heres the formula that I use. There are few things of my own creation that I ever say this about, but this is perfect. Any provider or service not using this formula is doing something wrong.

I spend as much time on scene as I need to asses, treat, and package my patient to the appropriate level prior to departing. I don’t worry about what some inane protocol that assumes every scene is the same and thus one time frame will work for all calls. I don’t look at my watch. I quickly, efficiently, safely and properly go through everything that needs to be done prior to transport. I don’t rush through it to get on the road(thus producing sloppy work) and I don’t dwindle away on scene either trying to get out of another call or trying to cram in unnecessary skills “just because I can”. I do what needs to be done in an efficient manner and carry on with the call.

That's it. Its logical and balanced. It works for every call. Some calls, there's very little to be done on scene and you’re on the road in 3 minutes. Others, you’re on scene for 45+ minutes dealing with access/egress, family issues, lift assists etc etc. but on every type of call, if you only take the time you need to do what needs to be done prior to transporting in a safe, efficient and proper manner you’ll never be wrong.

 

[JPINFV]

^
I agree. As an EMT-B I reconize that my treatment options are extremely limited. Once I determin that the patient is critical any move after that involves getting the patient to the hospital or paramedics to my patient (Yes, that means that I've walked into a hospital once without V/S. Cyanosis is kinda of a serious thing and there was an entire 7 minutes between going on scene (not patient contact) and arrivial at the hospital. Said patient died later that day). Otherwise my on scene time is as long as it takes.