Time spent on scene

[medicsb]

I disagree again. For the stable or questionable patient, spending a little time on scene is understandable, especially if at a SNF where being able to mine the chart for a few minutes can be helpful.

For the acutely unstable patient not in arrest, I don't see why the EMT crew should be doing anything more than getting a report, slapping on a NRB, and moving towards the ambulance. The lack of treatment options limits the utility of any on-scene assessment once the decision is made that the patient is critical.

Ehh, I don't know. The stable patient requires nothing other than a set or 2 of vitals, decent HPI, brief screening physical exam, and transport. More of them are likely to be ambulatory, which can save a lot of time. Minding the chart on scene for a patient from some place that provides a chart is unlikely to be useful and can wait for transport or until at the receiving facility. The sick patient still needs some sort of HPI and physical exam (even it just lung sounds) on scene and brief assessment of vital signs (even if just eyeballing respiratory rate and assessing the pulse). And then there may be an intervention, whether placing on O2, or bagging or assisting with a med (e.g. epi-pen, NTG, or MDI). When bagging is needed or a med that you can give or help give, I think it would be poor form to just slap on a NRB and then move to the ambulance (which can actually be quite time consuming).

Overall, sick or not sick, I imagine the difference of scene time probably doesn't need to vary more than 5 minutes or so (with cardiac arrest being the exception).

 

[RocketMedic]

For my sick people, I actually like to assess, start treatment, set up follow-on care and then roll. I would much rather not have to move around and panic in the back wgen I can simply follow my plan.

 

[JPINFV]

Ehh, I don't know. The stable patient requires nothing other than a set or 2 of vitals, decent HPI, brief screening physical exam, and transport. More of them are likely to be ambulatory, which can save a lot of time. Minding the chart on scene for a patient from some place that provides a chart is unlikely to be useful and can wait for transport or until at the receiving facility. The sick patient still needs some sort of HPI and physical exam (even it just lung sounds) on scene and brief assessment of vital signs (even if just eyeballing respiratory rate and assessing the pulse). And then there may be an intervention, whether placing on O2, or bagging or assisting with a med (e.g. epi-pen, NTG, or MDI). When bagging is needed or a med that you can give or help give, I think it would be poor form to just slap on a NRB and then move to the ambulance (which can actually be quite time consuming).

The problem is that it's very easy to determine based off of chief complaint the number of patients who qualify for EMT level medical interventions outside of oxygen. Sure, that patient with pulmonary edema secondary to CHF could benefit from NTG, but I haven't seen any EMT protocols that allow for NTG to be given by EMTs for that purpose. The vast majority of time, epi-pens, oral glucose, ASA, or NTG aren't going to be indicated at the BLS level for the acutely ill patient with edema, sepsis, non-ACS cardiac conditions, stroke like symptoms/focal deficits, etc. For these patients, I'm at a failure to see how the HPI, outside of the handoff report at health care facilities, changes the treatment plan at the EMT level. It's certainly not going to change the treatments indicated (and, sure, BVM is nice and all, but it's not going to be easily done while wheeling the patient down the hall) or the question of hospital vs medics ETA.


Once the decision is made that the patient is critical and the hospital is closer than the paramedics, why spend time on scene for questions that can be answered during and don't ultimately change the immediate treatment plan?

 

[Btalon]

I don't think there is a steadfast answer, but for the most part we get vitals at the scene, it's good to establish a baseline, often they calm down or get excited in the back of the ambulance, it's nice to have the baseline to compare to.

I'm fresh out of testing for my AEMT and it's stressed for a medical patient that you make a transport decision after the primary survey, you either get going and do your secondary enroute, or you can stay and do it on scene if they aren't a priority patient. There is nothing to say you have to stay and do it on scene, but some prefer to do it enroute. If you have a long transport it's good to do it that way, if you are like me and it's 5-7 minutes most of the time, then you can take more time on scene and get your information to help them and help the ER staff.

The biggest problem is you miss things when you rush, and if you aren't careful and sometimes ask the same question multiple times, they can remember stuff or give the ER staff information that they didn't bother to tell you.

 

[Epi-do]

I prefer to stay on scene and do a good assessment, and get some things started, when it is appropriate. I have found that most people are most comfortable in their own home, and it just makes it easier to get things done if they are a little bit less nervous. There are always exceptions that require moving quickly, but for the most part, I don't think that is the rule. Fortunately, I am lucky to currently be working someplace that isn't overly concerned about scene times.

Just because it isn't a big deal to us to be in the back of the truck, that doesn't mean everyone feels comfortable there. I know that is something we all know, but I think we sometimes loose sight of that fact, and it is good to be reminded of it from time to time. We've all had that patient that was fairly relaxed in their house, but the second you put them on the cot they tense up, are convinced the cot is going to collapse, you are going to drop them, and they are going to go flying across the back of the ambulance the first time your partner slows to stop at a light, stop sign, or make a turn.

I've also had to work with "that guy." You know the one - he's been doing this since the dawn of time, and is convinced that the way things have always been done is the only way to continue to do them. Therefore, if you spend more than ten minutes on scene, he starts getting antsy, and begins to fidget and make comments that imply you should already be in the ambulance and on the way to the hospital no matter what is going on because that is the only place that can do anything at all for the patient.

 

[DrParasite]

I don't do crap on scene, with very few exceptions (e.g. 12-lead if warranted, cardiac arrest). And honestly that is double so for sick patients. Generally first question out of my mouth is "do you want to go to the hospital?" If the answer is yes I get them on the cot heading to the medic while I ask my questions. And any interventions are done in route.

me thinks I would really really really enjoy working on an ambulance with you..... and I'm guessing you work in the inner cities too, correct?

I'm the exact same way. If I am on scene for more than 20 minutes, the patient is either really sick, or really heavy.

If they are ambulatory and not sick, I get name, DOB, and a quick history, and lets go to the truck. maybe vitals depending on the complaint. usually less than 10 minutes on scene.

if they are not ambulatory, I get name, DOB, vitals and a better history, move them to the cot, and start making my way outside. usually less than 10 minutes on scene.

If they are sick, and I have no ALS available, than it's name, DOB, NRB or BVM, and start going to the cot because we are leaving for the ER as soon as I can. I can do my assessment and the rest of my interventions enroute once I stablize any life threats. usually less than 10 minutes on scene.

If they are really sick, and I have more help coming, i'm taking my time, and letting ALS do their thing (depending on the complaint, if they can do something). 20+ is not unheard of, but I still want to get the patient to definative care.

I don't set up camp on scenes if I can avoid it, and after 10+ years on a truck, I got really good at doing my job in a moving ambulance. The exception to this is cardiac arrests.... still would rather work them on scene, but that decision is made by more educated people than me....

 

[JPINFV]

If they are sick, and I have no ALS available, than it's name, DOB, NRB or BVM, and start going to the cot because we are leaving for the ER as soon as I can. I can do my assessment and the rest of my interventions enroute once I stablize any life threats. usually less than 10 minutes on scene.

We agree on something?

 

[the_negro_puppy]

We tend to stay and play here a little bit more. Given our metro area, the choice of hospital will vary depending on the pt's illness or injury - need to spend longer working out what the problem is before just rushing off and heading for the nearest hospital.

We use small sprinter ambulances that makes it difficult to access the pt's left arm to start on IV. It's more awkward leaning over the pt to put things like 12 lead ECG electrodes on as well.

I usually do a set of vitals / assessment. Start any treatment required then work on extrication. We are told to do 12 leads as soon as possible on scene to get the ball rolling for ICP intercept (with triage to PCI, plavix, heparin and thrombolyse if not near a cath lab) and cath lab activation. If my patient calls with significant pain (stable) I will work to provide analgesia ASAP rather than gather their things, work out extrication, start IV draw up drugs then give analgesia 10 minutes later.

To each there own. We also leave many people at home so a better assessment is required first rather than just pulling up to the house and loading them on the stretcher

 

[kjacksonemti]

I was wondering, if you are on the scene with a patient that you know is going to the hospital and the hospital is a good ways away (20-25min), are you going to take the time to get vitals and all that on the scene or just get them in the ambulance and transport as soon as possible? Lets say its a non-emergency transport though.

Provided there's no packaging or anything else that absolutely has to be done on scene, I get one set of vitals and I'm out. IVs I try to do en route if it looks like an easy stick.

Our minimum transport time here is half an hour and I don't like blowing any unnecessary time on scene playing around. Once I move up to medic this will probably change, though.