Scene times

[Melclin]

I've been thinking about scene times a bit lately. Then tonight I found myself reading a post on another site about scene times. So many people seemed to have what I would consider to be ridiculously short scene times. 10-15minutes. Kinda blows my mind. Many of my scene times are longer than 30. Even when we're moving quicker with someone who has dropped their bundle, its rarely under 20.

I understand its probably a difficult question to answer in text but could anyone and everyone give me some insight, a narrative perhaps, about how you run your jobs, what your scene times are like and what factors contribute to them (clown car crewing, stay and play vs scoop and scoot etc).

Now I know, many pts don't require L/S and all that hoopla, but I'm interested to know in order to improve my own scene times in punters who are proper sick and just as a matter of interest.

I'll give an example:

Uncomplicated typical chest pain with no ECG changes, 56 YOM: Arrive, introductions, get some hx while my partner pops the monitor/ pulse ox on, speaks to the mrs about fetching some meds. Get some obs somewhere around the 5-10 minute mark depending on the pts condition, complexity of hx taking and the results of my initial pulse/extremity warmth check. Somewhere in between the 8-12 min mark, we'll be making some treatment decisions. Aspirin, IV access in the 8-15 min mark. Nitro, morphine another BP while my partner gets the bed + a wheel chair. Bums on seats and egress over 15-25 min mark: Lock up, get the phone, wallet, keys, put the dog out. Move pt to stretcher from chair. Load to ambulance. Reassess, BP, chest auscultation, further morphine/nitro over 20-25mins. Leave scene around the 25 min mark. This is all assuming everything goes to plan. No problems with IV access, difficult historian, deciding on appropriate care pathways, difficult egress, more complex interventions.

I did a STEMI a while back. Everything went perfectly. Great historian, easy IV access, extra set of hands from intensive care back up. Uncomplicated presentation. It felt like we were flying. 19 min scene time.

How do you guys compare?

 

[STXmedic]

I'm on my phone, so I won't be giving as in depth an answer as I'd like.

My scene times vary tremendously. It obviously depends on what's going on with the patient.

For an uncomplicated, say... abdominal pain, my scene time can be 30min or more (rarely passes 40 unless there's some kind of extenuating circumstances). History, assessment, treatments, chat chit; I'm really in no rush.

On an MI or CVA, the goal is to be driving at the 10min mark. I don't always hit it, but I hit my mark more often than not. I rarely surpass 15min.

On severe traumas, the goal is the same, but can be hit less often depending on the circumstances.

Our scene times can be so short because we have more than enough manpower on the majority of these runs. Typically 6 people on these calls, with 3-4 being medics. I realize a lot of places aren't as fortunate to have as much help. (The runs dispatch doesn't pick up as "critical" will only have 2-4 people on scene, though)

 

[Melclin]

I'm on my phone, so I won't be giving as in depth an answer as I'd like.

My scene times vary tremendously. It obviously depends on what's going on with the patient.

For an uncomplicated, say... abdominal pain, my scene time can be 30min or more (rarely passes 40 unless there's some kind of extenuating circumstances). History, assessment, treatments, chat chit; I'm really in no rush.

On an MI or CVA, the goal is to be driving at the 10min mark. I don't always hit it, but I hit my mark more often than not. I rarely surpass 15min.

On severe traumas, the goal is the same, but can be hit less often depending on the circumstances.

Our scene times can be so short because we have more than enough manpower on the majority of these runs. Typically 6 people on these calls, with 3-4 being medics. I realize a lot of places aren't as fortunate to have as much help. (The runs dispatch doesn't pick up as "critical" will only have 2-4 people on scene, though)

I hope you find the time to reply in more detail. I'd love to here how you run your 10 minute jobs. Although having half the service on scene couldn't hurt.

How many people are on each ambulance? Are you having three cars turn out to these jobs? Thats amazing. Do you ever find you get a too many cooks in the kitchen type situation?

 

[Veneficus]

I don't think you are going to get a fair comparison because of system dynamics and goals.

In the US, the goal is to go to the hospital, as fast as possible, and be ready for the next run. (for a variety of reasons but all with the same end)

Things like appropriate care decisions, on scene treatment, etc. Are extremely limited.

Management putting artificial/arbitrary limits on scene times doesn't help either.

Consider also, in US EMS, there are relatively few decisions to be made. The protocol are driven by common presentations, so often providers know what they are going to do no matter what they find. (Not accusing, just calling it out, I did it too)

Things that help reduce scene time.

Setting up diagnostics while questioning your patient. Speeds physical exam and allows your partner to start worrying about the logistics of getting people out, fishing out boxes of meds, etc.

Early decision, are we going or not?

Then decide on where.

Run vitals in the house, then rerun in the truck? Only if the truck is moving towards the destination, certainly not waiting on scene to do it.

Physical exam while taking history and hooking up diagnostics.

Using diagnostic data as it presents, not waiting for it.

ie: crushing substernal chest pain raidiating to arm and jaw is most likely going to get ASA and Nitro as soon as allergies, and BP is done. ASA most likely before.

Anticipate the next step. Be ready.

20-25 minutes on a non-critical scene seems reasonable.

remember, the purpose of US EMS is based on the philosophy of treating while going to the hospital, that philosophy persists. (good or bad depending on point of veiw.)

 

[Engine3/emt]

I also think it depends on where you live. If you live in an urban area, times may vary due to traffic and whatnot.

 

[Melclin]

I don't think you are going to get a fair comparison because of system dynamics and goals.

In the US, the goal is to go to the hospital, as fast as possible, and be ready for the next run. (for a variety of reasons but all with the same end)

Things like appropriate care decisions, on scene treatment, etc. Are extremely limited.

Management putting artificial/arbitrary limits on scene times doesn't help either.

Consider also, in US EMS, there are relatively few decisions to be made. The protocol are driven by common presentations, so often providers know what they are going to do no matter what they find. (Not accusing, just calling it out, I did it too)

Yeah I understand there are some considerable differences. I'm still curious. Its not just me. <20min scene times are pretty unheard of here. With a few obvious exceptions. I'd be interested to know if there are a few tricks to running jobs that we might learn from our antipodean cousins.

Things that help reduce scene time.

Setting up diagnostics while questioning your patient. Speeds physical exam and allows your partner to start worrying about the logistics of getting people out, fishing out boxes of meds, etc.

Early decision, are we going or not?

Then decide on where.

Run vitals in the house, then rerun in the truck? Only if the truck is moving towards the destination, certainly not waiting on scene to do it.

Physical exam while taking history and hooking up diagnostics.

Using diagnostic data as it presents, not waiting for it.

ie: crushing substernal chest pain raidiating to arm and jaw is most likely going to get ASA and Nitro as soon as allergies, and BP is done. ASA most likely before.

Anticipate the next step. Be ready.

20-25 minutes on a non-critical scene seems reasonable.

remember, the purpose of US EMS is based on the philosophy of treating while going to the hospital, that philosophy persists. (good or bad depending on point of veiw.)

Well I used to be of the opinion that I should just start treating as soon as I collected enough information to inform that choice. But I kept buggering things up, usually because of communication issues/poor historian type things. The crushing central chest pain at 2 mins post arrival was actually cramping abdominal pain with GI symptoms for 5 days at 8 mins. The second I started taking more time to do things, I started getting far more accurate pictures of pt's conditions. Now that I'm more comfortable with all that, I'm interested in streamlining things a bit more. Mostly because I enjoy being efficient but also because it'd be nice to apply a quicker process in the 1 pt a month who might actually benefit from it.

 

[Melclin]

I also think it depends on where you live. If you live in an urban area, times may vary due to traffic and whatnot.

I think there may have been a misunderstanding. Why would traffic affect scene time?

 

[STXmedic]

Our ambulances ride two medics unless we have a student or rider (which is fairly common). On low priority runs, they'll be the only responder unless they have are going to have an extended response time >5min. Extended response times get a "squad" which has full ALS gear and two firefighters who are either basics or medics.

High priority calls get an ambulance and fire unit staffed with four guys, typically at least one of whom is a medic.

Full arrests get 2 ambulances, a fire unit, and an EMS officer.

We're definitely never short of hands It starts getting crowded once a lot of medics start showing up on scene, but typically only at full arrests.

For a typical CP call:
Arrive at patient
Find out chief complaint
Immediately start hooking up to monitor for vitals and 12-lead while partner gets demographics and medications
Assessment all throughout this
ASA and NTG given if appropriate (if hypotensive and suspect RVI, move IV to here)
If STEMI found, immediately start heart alert at ED via radio
Load on stretcher and into unit
Start driving, get IV en route

Quickest I've gotten all this done was 6 minutes, but typically it's 9-10.

Strokes run the same way, but stroke screen added and NTG and ASA held of course Lol

*On calls that aren't "alert" based, the patient is sick, and there's treatments we can provide to give the patients relief sooner, those tend to have longer scene times than that. 20-30 minutes isn't at all uncommon.

 

[medicsb]

When I was working 911, scene times would depend on the patient's condition and how quickly the EMTs loaded the patient. I found that with the sick patients, we tended to stay on scene a little longer, which for us would be >20 minutes, overall we probably averaged 10-15 minutes. Generally, the more stable, the shorter the scene time as there wasn't any interventions that needed to be initiated immediately. Sometimes the EMT might be loading the patient as we would be arriving, which would decrease scene time.

If it was a "typical" CP patient, one medic would get a brief report from the EMTs (usually not that in depth, takes a minute) then that medic would proceed to get a more detailed history from the patient or a family member while the other medic would do a physical exam (radial pulse, lung sounds, checking ankles for edema, neck for JVD, brief abd exam) and attach the patient to the monitor and perform a 12 lead. If the patient was stable and the 12 lead negative for STEMI and already in the ambulance, then we'd transport and initiate an IV enroute along with ASA and NTG. If the patient wasn't loaded, then usually the IV would be initiated and ASA given along with one NTG. The patient would be transferred to the stretcher or stairchair afterwards. Once placed in the ambulance, the patient would be reassessed and then transport would be initiated with additional treatments performed enroute. For the stable patients only one medic would ride with the patient, the other would follow behind in the "chase car".

For sick patients, such as a CHF patient, the treating medic would get the H&P while the other placed the patient on the monitor, O2, and initiate an IV. If it was apparent enough, the medic getting the H&P would admin NTG while the IV was being initiated then move to 12 lead or CPAP depending on severity (CPAP sooner than later, 12 lead can wait a couple minutes). While CPAP being applied, the other medic would draw up the furosemide. By that point the EMTs would have the stretcher nearby and the patient would be moved to the ambulance and then transported. If the patient was still felt to be critical, I might have my partner ride along in case they needed to be intubated. In that case, one of the EMTs would drive our vehicle. In cases like this, scene time would be around 20 minutes altogether.

Because of the system set-up, ALS patients had a minimum of 2 medics on scene and 2 EMTs. We'd have more EMTs if an engine responded or if the ambulance had additional EMTs (often with volunteer ambulance services). A lot of things were done simultaneously.

Sometimes we'd spend less than 5 minutes on scene as the patient was already loaded. We'd get in, get a brief history, determine that the patient was low acuity, but not low enough to be turfed to BLS, and just get moving and do everything enroute. There were times I'd get in an wave away my partner and begin transport in less than a minute. IF the patient could be turfed to BLS, I would make sure the EMTs were okay with it and double check that I had all the info I needed and then have the ambulance pull over to let me out. Then they'd continue to the hospital

I personally think short scene times are over emphasized, but I also don't see the need to play around on scene when you can do stuff enroute. The problem with emphasis on short scene times is that some paramedics and EMTs feel compelled to rush and inadvertently omit certain treatments or exams in order to not stay on scene "too long".

 

[STXmedic]

I also think it depends on where you live. If you live in an urban area, times may vary due to traffic and whatnot.

Scene time, not time to the hospital

 

[DesertMedic66]

Most of our on scene times are done in under 30 minutes. We have to check in with dispatch every 30 minutes (I believe it's 30 minutes). If we don't check in then law enforcement will be dispatched to check up on us.

If its a BS call then it's "hop on the gurney and we will do everything enroute". That on scene time will normally be 5-10 minutes (most of our calls are BS).

If its an MI, CVA, another serious call our on scene times will once again be short. Anywhere from 5-20 minutes.

Car accidents can be anywhere from 10 minutes - 1 hour depending on if they have to get cut out.

We normally have at least 5 people on scene. All 5 are at least trained to the EMT level. Normally we will have at least 2 medics on scene. So there is alot of multitasking going on. Joe(Medic) is starting an IV while Bob(EMT) is hooking up the monitor while John(EMT) is asking history and allergies while jennifer(EMT) is getting a blood pressure while Anthony(EMT) is moving stuff out of the way and getting they gurney to where we need it while Jane(Medic) is getting the medications out of the response bag.

It largely depends on the medic who will decide how long they will stay on scene. Some medics like to do treatments and interventions on scene. Some like to due them in the back of the ambulance while not moving and some like to due them enroute to the hospital.

 

[abckidsmom]

I love talking about this topic. I will say, that in your system, the goal is often to deal with the problems on the scene and send the people to the right place, or nowhere, and our systems are not like that.

I have found that when I try to get the patient/family to decide to go to the PCP, or the urgent care, or whereever it always backfires, and they end up calling back and wanting to go to the hospital. In our system, it will be the same ambulance that comes back on the boomerang runs, and that is painful, painful, painful.

Here's how it goes for me: when I step off the ambulance, a little timer is going in my head, and I feel it when we are reaching the end of 10 minutes. On most of our calls it's just me and my partner, so don't go thinking we are doing everything with the whole gang every time.

When I get off the truck, I throw the bag and sometimes the monitor on the stretcher with the laptop and bring it to the door. At the door, we lower the stretcher to knee height, grab the bag and head inside. On patient contact, I introduce myself and ask them what's going on. I try really hard to give them my undivided attention for 90 seconds, during which time I use my bare hand to palpate their radial pulse.

At that point we're 3 minutes in. Usually I need to know meds and history after that, which can take a couple of more minutes, but not usually terribly long. By this point we've established that whether the patient is going to be able to give his own demographics and history, and I plan to get it in the truck or get it then. That can be a couple of more minutes.

When we make a transport decision, we start moving toward the ambulance. Most times, patients walk to the waiting stretcher, or we carry them, I hate going out to the truck for the stair chair or the reeves, but I do it when we have to. All of my routine is thought out with the purpose of saving my partner a trip back to the truck. We don't need all that stuff on every call, but if I needed the monitor inside, I need my partner too, so it's good when it's at the door.

We don't make a lot of responses to commercial places where we are far from the truck. We don't have high rises, and our biggest nursing home has just 50 beds. That said, on commercial responses, you should be even more aware of carrying stuff in with you. While it's more work on the front end IT SAVES YOU TIME IN THE END.

All of this looks like I have this huge sense of urgency, and all my patients are fixing to die. Nothing could be further from the truth. Very few of my patients are sick, almost none of them are going to die without whatever intervention I bring to them. The thing is, though, that we are coming to people who have the expectation that we are going to take them to the hospital. So, why not approach the thing with the expectation that we are going to take them to the hospital?

Even refusals only take this long. You get a read on the situation in that first 3 minutes and you'll know what the patient wants without asking them, and then you just present their desire as the next thing you'll do. It makes you look nicer, and you are getting them closer to the resolution of their thing.

In our system we are at minimum 45 minutes from the hospital, so while the time we save by moving with a purpose on the scene may not make a huge difference in the long run, the patient we deliver to the hospital often looks quite different than the patient we saw when we walked in their door. Mostly for the better, but sometimes not.

This priority on urgency is necessary is systems like ours, where the primary goal is transport. We need to make an acceptable transport decision inside of 5 minutes, and spend the other 5 minutes moving to the truck. All ALS care is done in the ambulance on the way to the hospital, except for the initial 12 lead on scene.

 

[Simusid]

I just ran a quick database query of our runs for the last year. So this is the average for about 2200 calls:

Time spent on scene

Priority Minutes
1 14.05
2 16.64
3 14.59
4 17.89

Good? Bad? It is what it is. Priority 4 in our system is refusal, Priority 1 is immediately life threatening.

 

[marcus2011]

For critical patients its around 10 to 15 minutes in our system for non critical time ranges from 15 to 30. If we have a long ride to the hospital our scene times are shortened due to the fact we can do so much more in the truck than in the house.

 

[mycrofft]

For some contrast:
Some HMOs etc figure an average MD visit period is 15 min. They divide their scheduling on that basis. They will offer them to you on a thirty minute basis though to avoid looking as though they have them so closely divided.

I did sick call for many years for inmates, and such visits could take as short as one minute (no c/o, normal VS and just wanted something like foot cream or renewal of meds), or as long as fifteen.

Normally, using multitasking (VS during visual survey and beginning history), I could do a basic level sick call slot in about eight minutes. These were frequently described by the pts as emergent because they learned during their years of using ER's as primary care that this would get them seen (actually, we were closely monitored and expected to see everyone every day). THis was possible because I closely knew and followed my standardized procedures and knew at what point I was just delaying getting this person to the MD, or at what point they were wasting my time.

Knowing the exact step off from my scope of care to others', my "onscene" for "man-downs" was, of course, until next care arrived, but my time from arrival to calling for civilian EMS could be as short as ten seconds and as long as one minute, then I continued as best as I could until they arrived (ten to fifteen minutes when FD, forty five to an hour with AMR).

 

[Melclin]

So a couple of themes are common here:

-lots of players on scene.
-treating a lot more on the way to hospital rather than at scene.
-simultaneous hx and physical is something I'll do with sicker pts but I find taking BPs and poking and prodding really distracts the patient from your questioning.

With the issue of IVs on the way in critical pts, surely you want early IV access on scene so you can start treating them and so that you have access if they drop their bundle from say..getting up onto the stretcher or what have you. IV access before we move the pt in anyone sick is generally considered pretty important. Why the difference do you suppose?

The biggest difference to my mind seems to be this assumption of transport. It seems like a lot things happen on the way because you're going anyway. I'd love to do some ride alongs and see how this works. Many of our patients ring to get "checked out", have some vague non-emergent problem or can have their problem fixed on scene. I get to the end of my assessment on scene, I explain to the patient what I think is going on, what tests or treatments will be needed and what I think we need to do about that. Then depending on if they agree once they've been informed, we come up with a pathway thats right for them. Many of them are shocked they have to go to hospital. It seems like perhaps people here don't assume a trip to hospital as much.

Surely if you're just transporting everyone from the 5 min mark, you must often get about 15 mins into a transport and think, why on earth did I bother transporting this person. Followed by a, "Why on earth did you bring this pt here" from triage or doc.

@ABC: A couple of things I don't get about taking the stretcher in first is that, not knowing the house, you have no idea where the best egress is and it must be a bit of struggle with dodgy lawns, steps etc. Why so adverse to you partner getting the bed while you do a few things on scene that you'd be doing anyway?

CARRYING THE PT?? On what? Like over your shoulder? How do you have a back left?

 

[Handsome Robb]

We average 10-15 minutes but I've spent upwards of an hour with a few patients. Diabetic refusals tend to take 30-45 minutes to get everything assessed, setup, treated and reassessed then counseled. Fastest scene time I've ever been involved in was a pediatric traumatic arrest and it was <2 minutes. Dad met us at the driveway with the babe and climbed in the ambulance, fire arrived at the same time we did, we confirmed it was in fact an arrest and by protocol we are bound to transport to the TC due to our proximity on this specific call and the presenting rhythm. Fire started CPR, I dropped an OPA and passed bagging off to fire, started an IO while my partner was getting the monitor set up then he told me to drive. Dispatched to arrival at the trauma center was 13.5 minutes. Fastest call I've ever been involved in.

Everyone pretty much already gave a pretty good description but I'll generally show up on scene, get a report from the fire crew, some I listen to and trust others not one bit. I'll ask a few more questions to solidify what's going on and what actions I need to take right this second, if any, decide on a transport decision and destination then work on egress to the truck. Generally I like to get the patient into the truck before I start IVs or anything like that except for the initial 12-lead on scene because it prevents the "gear explosion" and fire digging through your bags making a mess. Now if there's something I need to immediately correct I will do it on the spot but that's rarely the case.

The quick scene times come from having 6-7 people on scene. 2 man ambulance crew, sometimes with a student or new employee and a 3-4 person engine/truck crew. While I'm doing an assessment fire will be working on how we are going to get this person out of the house and to the ambulance, my partner is talking to family and grabbing meds.

Another factor I have to worry about is Casinos, hotels and clubs/bars. If we are on the casino floor I'm not going to do much of anything there unless it's an arrest. Quick run down, on the gurney out to the ambulance so I and my patient can actually talk without having to scream at eachother. If we are up in the hotel rooms I'll get my initial assessment, a 12-lead if pertinent then start moving. While we are waiting for the elevator my partner or I can grab a quick line. Inside a bar/club, we are leaving ASAP because they will not stop the party on account of us unless there is a sever incident such as a stabbing or GSW and at that point I'm not playing much on scene anyways.

Once we are in the back of the truck my partner or I will grab a line if one isn't already in place while the other reassesses vitals and gets a more thorough assessment. Once the driver is done doing whatever I've tasked them with they will hop up front and drive. If we are close to the hospital I might sit for a bit longer to get the information I need, far away and I'll do most if not all of it en route.

Like someone pointed out US EMS is transport-oriented.

Please excuse my grammar and run-on sentences, its 0230 and I just finished a 16 hour shift.

 

[Bullets]

In my service, we run 2 EMTs on an ambulance, maybe 3.

In the month of may, our AVERAGE on scene time, from moment of contact to depart referring, is 13 minutes. If you exclude on scene times over 15 minutes, then it drops to 8 minutes. We had a few long scene for fires and such that skew the times, but we probably average around 10 minutes before we are transporting.

Here is a summary of one of my calls.

On-scene @0631hrs
First Vitals @0635
Pt on cot at @0639
Leave scene @640

The person who is driving brings in the jump bag and does the primary assessment, vitals, ect. The passenger who is doing the chart fills the info into the ePCR while this is happening. Once a baseline vitals are obtained, the driver goes and gets whatever moving material we might need to get the patient out of the scene while the tech completes the SAMPLE/OPQRST. Driver comes back, patient on the chair/reeves/board, out to the cot and away we go.


Here is a "trauma"

Patient fell and struck head on radiator, positive LOC, 2in laceration and 4 inch contusion on occipital region of skull, bleeding, AMS, 3 EMTs on the truck

Patient contact @2043hrs
Vitals, immobilization on LBB @2048
Wound care for head injury @2049
LBB placed in reeves, carried down from 2nd floor @2107
On cot, Leave @2110


I hate being on scene for too long. The only thing i cant do in the ambulance is package, so lets package quickly while i chart, then scoot

 

[NYMedic828]

We spend 15-30 minutes onscene for medical calls.

Usually try to aim for 10 for traumas.

RMAs can easily take 45-60 minutes if it is post treatment or AMA. (calling doctor takes a while sometimes)

 

[STXmedic]

Oh yes. We get called for what amount to "check-ups" all the time. If its some vague complaint or something that's not an obvious need for the hospital, there's absolutely no rush. However, if it's potential cardiac or potential neuro, they're more than likely going.

I don't find that me multitasking with my patient significantly hinders my ability for an assessment. I'm not going to say I don't have room for improvement, but I tend to be pretty good at extracting information from my patient and finding out what's going on. I don't need to sit there and contemplate every answer I get before I can move on to my next question. It's all pretty fluid.

That also translates into not frequently regretting transporting patients that may be an "expedited" depart from scene. If it's obviously not cardiac, then we change gears. But if I determine it's cardiac or can't rule out cardiac, they're going. Same with neuro. It doesn't take very long to establish that. As abc said, in 5 minutes you can typically tell whether or not you need to go right away. If they don't need to go right away, they may not need to go at all. That can be determined after you've sat around and talked and assessed further. But for the initial decision, 5 minutes is a long time.