Transport Times and Protocol Decisions

[scubanurse]

So it came up on another thread, and I guess the point I was trying to make was that protocols can vary from jurisdiction and one of the factors is distance from a hospital.

It was stated that it should not matter if you are 5 minutes from the hospital or 30 but I disagree. If you are really close to the hospital are you really going to take time to sit there and set up say a dopamine drip? Or will you start a line and do a 12-lead and get them to the hospital quickly. I realize I have been out of the field for a little bit, but is the idea of load and go no longer around? I have seen areas who are 30 min + from a hospital have protocols that are far more extensive than urban protocols for the simple fact you have longer with the patient and can/should perform more interventions. If I'm 5 minutes from a hospital, starting antibiotics isn't realistic, but if I have a significant transport time with an open fracture or septic patient then I could see starting antibiotics.

Maybe my thinking is way off and I should just stick with nursing and bow out of the forum though.

[island emt]

You raise a valid point Kate. I have worked urban, suburban and Rural. Seems like in the city with a hospital ER under 5 minute transport time, that a lot more things are done on scene before loading pt and lengthening time from contact to Transport . Here in Semi rural Maine our scene times rarely exceed 10 minutes , unless the Pt is in extremis and needs intervention right now. We have a 30+ minute transport time to nearest ER's and hour + to a cardiac cath lab or trauma center so there is plenty of time to do the majority of interventions while in the office enroute to ER. A quick assessment ,vitals and maybe O2 then onto the stairchair or stretcher and lets go to the truck. In a chest pain Pt , do you take the 3 minutes to do the 12 lead in the house or move to truck and do it while enroute? I don't usually need the 12 lead to tell me a Pt is having cardiac related compromise and use the 12 lead as a diagnostic tool after basic interventions. The old mark 1 eyeball can tell me what is going on along with decades of seeing Pt's having chest pain & MI's. If it shows a STEMI , then we have plenty of time to call in to the cardiac specialty center and put the cath lab team on alert You can give them a good assessment and package in less than 5 minutes along with ASA O@ and then move on down the road. In the city it's hard to get more than basic interventions done during a short transport so more tends to be done on scene. I'd much rather do my work while heading towards more definitive care than stay and play for 25 minutes on scene and then have a 30 minute ride to the ER. All depends on whats best for the PT.

Edited March 10, 2013 by island emt

[1EMT-P]

I agree with Kate protocols are usually region specific. For example the closer you are in a urban area you might have less interventions & procedures that you can perform, but if your in a remote area you might have more interventions & procedures that you can perform based on your protocols.

Edited March 10, 2013 by 1EMT-P

[chbare]

The context of my statement should have been obvious however. I stated in the setting of clinically significant hyperkalaemia, transport time will not matter much when it comes to initiating treatment. Clearly, times may effect other decisions, but if you have identified significant (potentially life threatening) hyperkalaemia, I would expect you to at least initiate treatment if you have the ability to do so.

[medicgirl05]

I have a 30 minute transport time at a minimum. Staying on scene for me varies by patient presentation. If I HAVE to get a line and am concerned about getting one en route then I will stay on scene to do that. I generally get 12Ld en route. Patients woth low blood sugar generally get fixed before we even put them in the ambulance. I don't really have anything set in stone as to who I will load and go and who I will stay and play with. I guess it's more of a gut feeling, but it hasn't failed me yet so I'll stick with it.

[scubanurse]

I understood your point, the issue I had was with the OP's statement in http://www.emtcity.com/topic/24057-hyperkalemia about how there should be no difference in treatment with regards to distance from the hospital. It's blanket statements like that, that annoy me.

I think there is a huge difference in the types of protocols and treatments you will see in urban vs rural areas.

[systemet]

I think this depends on a lot of factors:

* What sort of ER are you transporting to?

If you've got a predicted difficult airway, and you're 5 minutes from an ER with board-certified EM physicians, that handles a decent volume of patients, and has anesthesia service, then doing an on-scene RSI probably isn't in the best interests of most patients. If it's not a crash intubation, it's better deferred and passed on to more experienced and better-trained hands.

If I'm 90 mins from a trauma center, and 10 minutes from a remote "ER", that's not full-time staffed, and maybe calls in an FM doc from a local FM clinic, who might be there in 20-30 minuets, and might not be comfortable with this airway, and my patient needs trauma surgery, then doing a field RSI, and transporting 90 mins to the trauma center might be a better option than rushing to the local FM "ER", waiting for the physician to arrive, coordinating fixed wing, and taking 3-5 hours to get the patient to the trauma center.

* Is what you're doing on scene actually reducing the time to definitive care?

I can sit 5-10 minutes from a hospital, consult with a cardiologist and either give thrombolytics, or do an ER bypass to a cathlab. This saves time. The nearby ER might not have PCI, or might have a patient on the table, or might be on after-hours call-in. By waiting, starting adjunctive treatment, coordinating with existing resources, I will save time to reperfusion therapy in most patients. On average, upwards of 70 minutes in this region -- we don't have a lot of cathlab resources.

* Is the patient actually in need of time-sensitive medical care?

Because if they're not, scene time becomes largely irrelevant. If I have a palliative cancer patient, the palliative care team is unreachable or unavailable, and they've got breakthrough pain / nausea, etc., then maybe 30 minutes giving some analgesia and antiemetic, and discussing transport options with the family is time well-spent, versus hauling off an upset, scared, puking, palliative patient, in acute pain (*not suggesting that anyone is advocating this).

[ChaseZ]

It seems that a lot of medics are reluctant defer treatment until the ER even with short treatment times. Just because you can do something does not necessarily mean you have to do it. I am not sure if it is just a matter of professional pride or what. There is nothing wrong with waiting until the patient is in a more controlled environment with better equipment or allowing a higher qualified provider to take over. Like systemet stated RSI is a great example of a procedure that should be deferred when ever possible.

[medicgirl05]

If you are competent in your skills then why should you defer them to someone else?

If you have a patient that needs to be RSI'ed and it is within your scope and you are proficient at the skill it seems like you should do it rather than waiting for someone else to do it. You should have protocol in place to cover what you will do if you are unsuccesful at the intubation, so I don't see the part where you are waiting for someone else to do it. If you are maintaining good stats without RSI that's great, but if you aren't your patient needs an intervention and I don't think you should wait.

[Arctickat]

Just because you can do something does not necessarily mean you have to do it. I am not sure if it is just a matter of professional pride or what. There is nothing wrong with waiting until the patient is in a more controlled environment with better equipment or allowing a higher qualified provider to take over.

I disagree, and so does our College. Medics have been disciplined for not providing adequate care within their scope. Deferring care to the client until hospital arrival is an unreasonable delay in patient care. I will not allow my patient to suffer their condition one minute longer than he or she must and to use the excuse that "I'm only 2 minutes away from the hospital so I'll let them do it." is simply nonfeasance. I've been trained to do a job and I will do it.