Treat Here? Treat There?

Walking through the door of the well kept home you can hear the patient gurgling every time they suck air into their lungs. He’s breathing fast and those lungs sound wet. When you round the corner, you see the man sitting in the tripod position working, really working hard, to breathe in and out. He’s sweaty, his legs are swollen as big as an elephant’s, and he tells you “I’m tired” when you ask him what is wrong.

Obviously a sick one, right?

Definitely in need of some immediate intervention, I’d say.

But here’s the question: Do you treat him here in the house? Or do you scoop him up onto the cot and haul him right out to the rig to begin the care? Treat in the house? Or Treat on the street?

I firmly believe that the days of Hearse/Ambulances driving patients to the hospital really fast are over and that the point of an Advanced Life Support ambulance is to bring advanced level care to the patient. When done right, in my opinion, there are very few things that cannot be given immediate stabilizing care in the back of the truck. If it needs surgery right now, drive fast. If it’s just well beyond your capability, by all means treat them with diesel. However, the above patient is well cared for within the scope of my protocol system where I work and I can make this patient feel better right here and now with the tools that I carry with me.

So I “stay and play” a lot, and only beat feet to the ER when there is clearly more benefit to the patient to do that than there is to working on them for a while to stabilize them in the truck and then giving them a smooth, safe ride to the hospital.

But generally, I do most of my stuff in the back of an ambulance and provide only minimal treatment inside of the location where I find the patient. Even though I may start an IV, give o2, and maybe even give a medication or two to the patient, I like the more controlled and more sanitary environment that I provide in the back of my truck. It’s definitely more comfortable to me and all of my equipment is within easy reach. It’s safer for me and the patient, in my opinion.

However, there are a few things that will make me drag my stuff into the house, kneel down, and treat the patient where I find them.

The first would be something like this patient. I’d most probably throw him on a non-rebreather at 15 Litres for high flow oxygen, listen to his lungs to confirm the rales throughout, send my partner out to the truck to get the CPAP machine, and pop in a line while someone was getting vital signs. If there were just the two of us I’d make sure he had a strong radial pulse (and it’s my scenario, so he does) and then start the IV. If the blood pressure’s good and the pulse rate’s good I’d then push 40-80mg of Lasix (furosemide), pop in a sublingual nitro tab, and then slap him onto the CPAP machine as soon as it became available. After that, comes the cot and the move to the truck. Probably this would result in a lights-and-sirens transport, but it wouldn’t be at breakneck speeds.

Other than someone who is going to die without immediate treatment, or who is currently in cardiac arrest, the other things I treat in the house for is an orthopedic injury in need of splinting (a lost art), someone who is very nauseated and is going to throw up on me (I love Zofran so much!!!), or who is in real pain that would be aggravated by movement.

So when I find an elderly person down with a hip fracture, I pop in a line and give a few mg of Morphine (or a few mcg of Fentanyl) to take the edge off of the patient’s searing pain before I splint them. I think that it’s inhumane not to.

What do you all do?

  • medicblog999

    Pretty much the same as you CK, although we don't have the choices you do (i.e no CPAP etc). I always take my time with the pain patients (as long as there is no concern for life or deterioration in condition), with the very SoB patients I tend to go a little slower but mainly because rushing them can make them even more short of breath, so calm and easy is the way forward.

    It's all about clinical rationale. If you show you are a thinking paramedic who has sound reasons for his/her actions then you should always to right by your patients.

  • EMS Chick

    My first two considerations for this patient would be where my ALS is coming from (while I am somewhat ALS, I can't give Lasix. I could give the IV, Nitro and Albuterol but that's it) and where the patient's house is in relation to the ER. Sometimes we are easily 30-40+ minutes from the closest ER.

    Our medics don't have CPAP, either, they are discussing getting it but I think it's still a few years off for us.

  • Ckemtp

    Go get CPAP. Do it right now. I was reluctant at first to use it when we got it a few years back, but now I wouldn't dream of treating a bad CHF'er without it. It's a miracle cure. Patients that I used to scream with to the hospital at breakeck speeds with while pushing high-dose lasix and maxing nitro to avoid intubating are gone. They never happen any more.

    Really, I haven't had a complicated CHF'er since we got CPAP. Once it's in place, the patient is recovered and it's an easy trip.

    Go get it. Fight for it. A lazy medical director is a poor excuse to not have it. In my perfect world view (that doesn't exist yet) EMS owns EMS.

  • The Happy Medic

    Totally agree on the CPAP CK, we slap on the mask and dump NTG q3-5, blood pressure allowing, which is the treatment they need.

    The lasix and albuterol…
    We're phasing out lasiix here, no pre-hospital benefits of doubling or even tripling their dose. The hospital can give a more targeted diuretic if needed, or so I've been told.
    With the CPAP we don't even reach for the lasix anymore.
    I stay and stabalize, not stay and play, but then again, I have 9 hospitals in a 20 minute drive time.

  • Ckemtp

    9 hospitals in 20mins… Yea, I actually worked in an area where we could be at any one of 3 hospitals in between 10 – 15min. However, I tend to believe that care stops for at least 20min once a patient gets to the ER. With all of the paperwork and the formality, a lot of things can be missed sometimes.

    I honestly can't remember the last time I gave Lasix… in fact, when doing drug inventories at one of my jobs I can't remember the last time I checked and we didn't have 3 still in reserve. I used to give it a lot… but not lately.

    I'm very much in favor of pushing pain control on the ground before we move, or even splint the patient in most cases. I think that it's most humane to treat them before we touch them, in severe cases, that is.

  • TOTWTYTR

    Somehow, I managed to post this comment under a different post. Duh.

    Anyway, here are my comments.

    Get your system to buy Nitro Spray. By itself, it will make your patient better faster. Our protocol allows for double NTG sprays (0.8mg) if the systolic is over 150 mmHG. We usually will give two sets of those, move the patient to the truck and put on the CPAP. In our area, it's often as fast to move the patient to the CPAP as it is to bring the CPAP to the patient.

    If we give Lasix these days, it's the lowest priority. As of right now, it's falling out of favor and I expect ACLS to de-emphasize it at some point.

    Other than that I'm with you. Remember, "Transport is part of the treatment.

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Chris Kaiser aka "Ckemtp"

I am a paramedic trying to advance the idea that the Emergency Medical Services can be made into the profession that we all want it, need it, and know it deserves to be.
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