By Mick Messoline
Previously, we talked about foundations of medicine. Being prepared mentally and physically is critical for success, as is ensuring that all your equipment is present and functioning. The value of a quick and accurate field impression from a well-orchestrated initial assessment was emphasized. Ultimately, selecting the appropriate treatment path for any given patient is fundamentally the most important thing a paramedic can do. Putting all these parts together and deciding how to prioritize patient needs is fraught with controversy for the engine company medic.
Deciding which interventions should happen on scene versus during transport has been a longstanding debate. There are many field providers who argue that every intervention should be completed prior to transport. Others argue that only the most vital interventions should happen on scene with the balance completed during transport. Before delving into this debate, a few definitions are justified.
Clinical protocol: another word for medical guidelines
Guideline: A statement or other indication of policy or procedure by which to determine a course of action (www.thefreeonlinedictionary.com).
You may wonder why I chose the above definitions. It's actually quite simple: EMS providers have become very protocol-driven. There is a common belief that the medic will face punishment if every component of the protocol is not completed. It is important to remember that the guideline (your protocol) is designed to aid in decision making. If the best option for a patient is rapid transport, then the components of the protocol that CAN be completed are the priority. Those that do not get completed will be managed at the emergency department. So the question is, "How do you prioritize treatments?"
The simplest answer is, "Do what the patient needs now!" As an engine company medic, many advanced life support interventions can be performed. The inability to transport is often your sole limitation (and, sometimes, the patient's greatest asset). That limitation will be eliminated by the arrival of the transporting unit. There are some things that can almost go without saying. Airway and circulation issues need immediate intervention. Other simple solutions like giving a hypoglycemic patient glucose or medicating an overdose with naloxone should happen without delay.
Some medical patients benefit greatly from on-scene interventions. Respiratory distress patients can improve greatly with a nebulized bronchodilator and some supplemental oxygen. This intervention is quick and simple and has a high yield to patients with acute bronchospasm. Consider patients with suspected acute coronary syndrome (ACS). Aspirin, analgesics, and nitrates can dramatically improve outcomes.
Other on-scene interventions may include establishing an IV, obtaining a 12-lead ECG, and gathering blood samples for the receiving hospital. The interventions performed are limited by your efficiency and the amount of time spent waiting for the transporting unit. Keep in mind that every intervention you complete while waiting for the transporting unit leaves more time during transport for additional interventions. Time management is key to optimizing patient care!
The trauma patient presents an entirely different situation. The Golden Hour has been a benchmark in the industry, although the preponderance of recent evidence suggests it may apply to a very small subset of critical trauma patients. The so-called "Golden Hour" begins at the time of the injury, not the time of arrival of field providers. Lacking X-ray vision, ultrasound, or CT scanners on our engines, we manage critical trauma by minimizing scene time and expediting transport. Interventions like spinal immobilization, airway management, and hemorrhage control should be rapidly delivered prior to transport. The balance of trauma interventions should take place during transport to an appropriate trauma center. In patients with significant internal blood loss, arrival in the operating room is the only definitive intervention that matters. Consider everything you do for a trauma patient on a time-versus-benefit gradient. A patient may benefit more from fewer interventions and a rapid delivery to an appropriate trauma center.
A final consideration is the number of usable resources on scene. It is not uncommon to have more than one medically trained person on most incidents. If your decision is to perform interventions on scene, then use all of your available resources. Intervention delegation can greatly increase the treatments that get completed. This will ultimately decrease the work load of the transport medic. By decreasing the transporting workload, you free them to perform additional interventions and an expanded assessment.
Sir Isaac Newton hypothesized that "for every action there is an equal and opposite reaction." There are few places in society where that is more accurate than in medicine. The interventions we choose to perform or not perform can drastically affect outcomes for our patients. As the medic on an engine company, you can do an awful lot to improve patient outcomes. In some cases, you will make the critical difference between life and death. Diligence is the key to success, and your good decisions will yield the very best results. Remember, time management and resource allocation will attain the desired results for your patients.
Mick Messoline has been in the fire service since 1985. A paramedic and an educator, he has worked for the Denver (CO) Paramedics, Sacramento (CA) Fire Department, and Sacramento State University. He is a firefighter in Thornton, Colorado.