Your workup?

[NYBLS]

Whats the general flow of your ALS work up? I know about 25% of people will respond with "it depends" however humans are pattern based individuals so what are your patterns?

12 leads on scene or in truck?
IVs on scene or in truck?
Where do you start your initial medications? (neb treatments, etc)
How much physical assessment do you do on scene?


I'm curious to see the reasoning behind why you do what you do! If it varies based on the patient state which patients get what and why.

 

[chaz90]

12 leads are typically done on scene if the patient presents with chest pain or an anginal equivalent. Basically, if I determine there is a reasonable possibility that these symptoms could be caused by something cardiac or there is significant history, the 12 lead is done early after making patient contact. If it's more of a "nice to know" additional assessment, I'll do it in the truck and acquire it at a stoplight or smooth stretch of road.

IVs are in the truck unless I am A. Using it to treat something immediately life threatening or treatable IE cardiac arrhythmias, hypoglycemia, pain management, allergic reactions, and cardiac or respiratory arrests or B. Waiting a while for an ambulance to respond.

Nebs are almost always started on scene shortly after patient contact. Same goes for CPAP when I use it, unless it's something I progress to after a neb treatment isn't sufficient alone. Most other meds are started in the truck apart from those I mentioned earlier or ODT Zofran, ASA, or SL and transdermal NTG. Oh, and fentanyl. If I'm administering opioids, 9/10 times I try to get some on board before we start moving the patient around and packaging them.

Physical assessment truly does depend, even though that's a bit of a cop out. All patients get a brief, general survey and enough of a symptom based physical exam to determine "sick/not sick" on scene. The closer they get to either extremely "not sick" or "extremely sick" and not treatable by me, the more of the detailed exam ends up getting deferred to being performed en route. Patients on the moderate side of the spectrum may get slightly more of an exam on scene, but I still prefer to get moving somewhat quickly rather than listening to bowel sounds or anything crazy on scene.

 

[Akulahawk]

Seriously, it really just depends upon the situation. Like chaz90 does, I tend to do enough of an assessment to determine not sick/sick/oh crap! and then I go from there. Cardiac stuff and respiratory stuff tend to start being worked up and treated on scene, once things are initiated, I move to the truck. MSK stuff gets a fairly rapid physical exam, and then anything that needs to be done NOW gets addressed on scene. Abdominal stuff gets a quick workup on scene and then it's off to the truck. Anything that has potential to go south quickly gets a line early on.

Truth be told, I don't like being on scene longer than 8 minutes for most 911 calls. I get the ball rolling and do the rest en-route to the hospital. I will, however, "stay and play" if circumstances show that doing so for a particular patient is better than moving the patient toward definitive care. While I'm not a "scoop and run" medic, I don't like to waste time either.

 

[MS Medic]

Most of my assessment and treatment are done on scene. IVs are usually in the truck unless it needed for treatment or the location has good lighting. Exactly what I do in what order is dependent on the nature of the call. Cardiac gets a 15 lead before anything else is done. Respiratory gets ETCO2 and SPO2 first. AMS gets CBG out the gate. Everything else gets the usual run down of obtaining medically pertinent demographics while my partner runs baseline vitals and things get tailored from there.

 

[Akulahawk]

Most of my assessment and treatment are done on scene. IVs are usually in the truck unless it needed for treatment or the location has good lighting. Exactly what I do in what order is dependent on the nature of the call. Cardiac gets a 15 lead before anything else is done. Respiratory gets ETCO2 and SPO2 first. AMS gets CBG out the gate. Everything else gets the usual run down of obtaining medically pertinent demographics while my partner runs baseline vitals and things get tailored from there.

I suspect that a lot of medics do something similar. We do say "it depends" a lot because it just does. We'll do things in a generally logical sequence, but the specific sequence/timing of events just varies from case to case.

 

[TXmed]

Initial assessment, and any airway issues treated on scene. 12-lead in the truck (that way I can transmit it as soon as its done) everything else I try to do during transport. I'm pretty big on short scene times, and if you get into that flow with the non serious calls it'll carry over to the serious ones. But like everyone else it all depends on my initial assessment and whether or not I believe my immediate Intervention will make a difference IE: cardioversion, hypoglycemia, anything airway.

 

[medicaltransient]

It depends on how far from the ER you work and what service you are working for.