Why do urban EMS fear on-site treatment?

[vs-eh?]

Population of 3+ million, 300k+ calls a year, 99.9% of treatment (acute immediately necessary if feasible) done on scene.

I really, really dislike the mentality of the "let's get going to the hospital, I'll do everything enroute" mentality. Obviously factor's perhaps can be city dependent, but generally speaking unless you see an acute life threat that can basically only be managed in hospital, manage it prehospital.

The major points of assessment, inital vitals, and treatment are basically initiated on scene. If the patient is not in a public place and we are going toward the ambulance, they are going to the hospital in my book.

Do all people in such system go to the hospital? Unconscious diabetics? Post-ictal patients that have "3 seizures a day"? Johnny Abdopain? Cardiac Arrest? Are there no treat and release options? Or do people take them in the ambulance, give them say dextrose, wait, then ask them if they want to go? What about cardiac arrests? Do you work them out in the ambulance staying on scene, pronounce and take them back in the house or do you transport to the coroner? What does the family think about this (i.e. why aren't the ambulance drivers going to the hospital with Joe-Bob)?

FYI - I don't consider certain treatments potentially necessary given certain patients and extrication situations.

CP consistant with past MI in the basement of house? I'll assess, vitals, EKG, ASA, O2, but I won't start an IV (our locks suck, basically only use lines) necessarily +/- nitrating them prior to getting into the ambulance. Nitrating is not key (as much as ASA) in your average query ishemic CP pt. Acute CHF'er is generally different given the same circumstance.

SOB asthmatic who "can't walk" because they are SOB? Same assessment, vitals, +/- EKG and say a salbutamol tx on scene. Wait the 10-15 mins. You feeling better? Can you walk? You want to go to the hospital? Ok, we'll help you walk out to the stretcher...

Also FYI, I usually do not start an IV on your average asthma/COPD patient unless I anticipate issues.

[Herbie]

One thing that has not been mentioned here yet is the obvious, first thing you are told in EMT school-scene safety. In many urban areas, the entire neighborhood is not safe, and as a general rule, people travel light into a house, etc- the basics only in case things get out of hand and you need to make a hasty retreat.

Also, how much help is available- fire assist companies, other nearby crews, how many crew members you work with, etc is another critical factor. Having to make 2 trips to remove the patient and then go back to grab your gear- which may decide to sprout legs and disappear when you turn your head- also takes precious time in a critical or hazardous situation.

As was alluded to here, it seems that in these busy areas, the calls are either taxi rides to get a prescription refill or a very sick trauma or medical patient, so going in, it is not easy to gauge what type of call you may have- especially when many folks are "less than honest" about their complaints when they call for help. At the very least, we would bring a bag with first line drugs, intubation/airway equipment, and a stairchair. If warranted, we would also bring in the o2, but the monitor would stay in the rig unless we had extra help. We simply didn't have enough hands to carry everything AND the patient.

Is it burn out? Some of it-absolutely. Is it also knowing your area and the hazards associated with it- absolutely. Bottom line: We get involved in many dangerous and hazardous situations as part of our jobs, so if we can minimize those hazards and still fulfill our responsibilities, it is a good thing. A lot of what we do is common sense and nontechnical. The procedures and knowledge we can study for and learn, but the experience and street smarts- especially in a busy and hazardous urban area-can only come through time. It may seem cold, but at the end of the day and after we do our thing to the best of our ability, we want to come home to our families and friends in one piece. [/font:4466460859]

[Herbie]

Population of 3+ million, 300k+ calls a year, 99.9% of treatment (acute immediately necessary if feasible) done on scene.

I really, really dislike the mentality of the "let's get going to the hospital, I'll do everything enroute" mentality. Obviously factor's perhaps can be city dependent, but generally speaking unless you see an acute life threat that can basically only be managed in hospital, manage it prehospital.

The major points of assessment, inital vitals, and treatment are basically initiated on scene. If the patient is not in a public place and we are going toward the ambulance, they are going to the hospital in my book.

Do all people in such system go to the hospital? Unconscious diabetics? Post-ictal patients that have "3 seizures a day"? Johnny Abdopain? Cardiac Arrest? Are there no treat and release options? Or do people take them in the ambulance, give them say dextrose, wait, then ask them if they want to go? What about cardiac arrests? Do you work them out in the ambulance staying on scene, pronounce and take them back in the house or do you transport to the coroner? What does the family think about this (i.e. why aren't the ambulance drivers going to the hospital with Joe-Bob)?

FYI - I don't consider certain treatments potentially necessary given certain patients and extrication situations.

CP consistant with past MI in the basement of house? I'll assess, vitals, EKG, ASA, O2, but I won't start an IV (our locks suck, basically only use lines) necessarily +/- nitrating them prior to getting into the ambulance. Nitrating is not key (as much as ASA) in your average query ishemic CP pt. Acute CHF'er is generally different given the same circumstance.

SOB asthmatic who "can't walk" because they are SOB? Same assessment, vitals, +/- EKG and say a salbutamol tx on scene. Wait the 10-15 mins. You feeling better? Can you walk? You want to go to the hospital? Ok, we'll help you walk out to the stretcher...

Also FYI, I usually do not start an IV on your average asthma/COPD patient unless I anticipate issues.

Clearly you work in a busy system, as have I for my entire career of 25+ years. I was also on a rig that averaged 25+ calls a day, 7,000 runs /year- one of the busiest in the country. I've done volunteer work, privates, Red Cross Disaster team, preceptor, instructor, and trainer, so I have a pretty good perspective of the business. Local protocols differ widely in what the crews are allowed to do, what they are required to do, and how long their response and transport times are. Do they have assist companies on scene to stabilize the patient, initiate basic care and help carry equipment? Is the scene safe? How familiar are they with their patients and areas, the types of calls, the hazards associated with these areas? Is this a regular patient? What is the pressure by the company/department/system to get back in service for the next call? What are the protocols for treat/no transport? How are DOA's handled? Can you terminate resuscitation in the field?

Point being- too many variables to make blanket statements.

About the only type of call in our system we would routinely NOT transport is the long time diabetic whose glucose was low and we "fixed" them with a bump of D50. Anyone else requires a great deal of documentation and legally covering your arse if they don't want to go. Anything else- let the hospitals sort it out- the liability is simply too great.

[p3medic]

You leave the monitor in the truck, but take first line drugs with you? What happens when you're in a high rise housing project without your monitor and end up with an arrest?

[Herbie]

You leave the monitor in the truck, but take first line drugs with you? What happens when you're in a high rise housing project without your monitor and end up with an arrest?

The bag comes in with every call- a finger lac or a cardiac arrest. First line in this case(without the monitor, non cardiac) would mean things like Epi for a status asthma, Valium for a status seizure, Narcan for an OD, Albuterol, the Ambu bag, and usually O2, etc. We also have enough for a couple rounds of epi/atropine, lido, adenosine, etc but obviously we need to monitor too.

Sorry, but traveling light in this case(high rises) is a must. Truth be told, in most project calls, the elevators are unreliable at best and usually dangerous, so humping 17+ floors is pretty much the standard. In a high rise housing project(or any high rise call), everything depends on the type of call and if it's a suspected/potential cardiac, everything comes in.

Thankfully though, most of the high rise projects here have been torn down.

[Asysin2leads]

I'm not going to comment on the choices the paramedics you rode with made because I am not fully aware of the situation.

Your post to me seemed to be two seperate questions. The first is, should medics (and EMTs for that matter) always bring their equipment in on every call, and the second is, is it okay to initiate ALS treatment in the ambulance?

The first question is, yes, absolutely, medics should bring all equipment, O2, monitor, med/tech bag, and carrying device in on every call. Every one. No matter how tired, overworked, or underpaid a crew is, there is no excuse to not bring in all the necessary equipment, every time. If you can't lug 30-40 lbs. of equipment around for the duration of your shift, up and down stairs, in and out of narrow corridors, its time to find another job.

Now, the second part of your post I think gets at a different point, and the answer is, yes, it is perfectly acceptable to safely remove a patient to the ambulance or to a better area depending on necessity. Unless the patient is critical, there is no reason I have to start an IV while in someone's dimly lit apartment, with loud music, and barking dogs going on. I am fully capable of doing so, if necessary, but unless the situation warrants, it is better in terms of patient care and provider safety to initiate ALS procedures in the ambulance. Now, if the person is in cardiac arrest, of course, we pretty much work 'em where they are.

[Herbie]

I'm not going to comment on the choices the paramedics you rode with made because I am not fully aware of the situation.

Your post to me seemed to be two seperate questions. The first is, should medics (and EMTs for that matter) always bring their equipment in on every call, and the second is, is it okay to initiate ALS treatment in the ambulance?

The first question is, yes, absolutely, medics should bring all equipment, O2, monitor, med/tech bag, and carrying device in on every call. Every one. No matter how tired, overworked, or underpaid a crew is, there is no excuse to not bring in all the necessary equipment, every time. If you can't lug 30-40 lbs. of equipment around for the duration of your shift, up and down stairs, in and out of narrow corridors, its time to find another job.

Now, the second part of your post I think gets at a different point, and the answer is, yes, it is perfectly acceptable to safely remove a patient to the ambulance or to a better area depending on necessity. Unless the patient is critical, there is no reason I have to start an IV while in someone's dimly lit apartment, with loud music, and barking dogs going on. I am fully capable of doing so, if necessary, but unless the situation warrants, it is better in terms of patient care and provider safety to initiate ALS procedures in the ambulance. Now, if the person is in cardiac arrest, of course, we pretty much work 'em where they are.

LMAO

You must be a better provider than I. Apparently I've been doing it wrong for the past 25 years.

Textbook vs reality, sir.

[WANTYNU]

LMAO

You must be a better provider than I. Apparently I've been doing it wrong for the past 25 years.

Textbook vs reality, sir.

I’ve been following this thread, and know that protocols vary wildly, BUT 25 years or not, I wouldn’t be laughing if I were you.

In either textbooks or reality, I find it hard to believe you would / could give drugs without a monitor.

This why we have such problems as being viewed as professionals within the medical community.

I will stay away from the GREAT temptation of being insulting here as I find it nonproductive, but if you were caught doing that in NYC, at best you’d have a few days (more likely weeks) off without pay but more likely you’d just be out of a job.

With that said working in a heavy call volume system, how many times have you found the SOB actually turn out to be an ARREST, now you’d not only look kind of silly without a defib, but you’d actually be in dereliction of duty, just the same as pt abandonment… Hell even BLS and dare I say FF’s must take an AED one EVERY (medical) call.

I ask again, out of sheer disbelief, how could you even think of pushing drugs without a Monitor???

I won’t even start on leaving the O2 behind.

Suffice to say I am unpleasantly surprised at such statements made from a supposedly practicing medic anywhere period.

I truly hope you were just putting that statement “out there” to ruffle a few feathers and get a response.

Like 2leads says, if you’re not taking your O2, Monitor, Drugs, and something to carry your patient in on EVERY job, ESPECIALLY on the sort of verticals you describe, you should be looking for different work.

Sorry if you find that harsh, but if I found you working on one of my family members in such a slipshod way, you’d have more to worry about then your supervisor.

If this is truly the way you work, then YES Asysin2Leads is a better provider then you.

As always IMHO.

Be Safe,

WANTYNU

[Asysin2leads]

LMAO

You must be a better provider than I. Apparently I've been doing it wrong for the past 25 years.

Textbook vs reality, sir.

I assume you're talking about the first part of my post, and not the second. Let me tell you this, because I mean it. My system probably has the record for the next 500 years for sheer amount of bullshit we do on a given day. A good bulk of my time is spent treating...er... not really treating.... dealing with people who not only don't have a life threatening emergency but really don't even need to see a physician in the first place, or even a nurse, or hell, even a paramedic. Also, I will go out on a limb and say I do some of the most walking of any paramedic in any system. Five flights up, down, and through the not-quite-up-to-date-in-the-fire-code-narrow-hallway is really pretty much routine for me, everyday. But guess what? Every single call, no matter what, oxygen, med/tech bag, monitor, and stair chair, or stretcher if we are really lucky. I don't drag 40 lbs. of equipment down to the lowest level of Grand Central Station to wake up a drunk for my health, and few will ever accuse me of being textbook, and I have the command disciplines to prove it.

[p3medic]

What they said^^^^^^^^^^^^^