Taking EMS Care to the Patient

In the early days of EMS, it was stressed that the sooner prehospital care was administered, the better it was for the patient. Today, many EMS instructors are teaching students to place the patient on the cot and take them to the ambulance to initiate care. Although this practice is warranted in some cases, it can also be detrimental, as vital care may be delayed significantly.

There is no argument that this practice is proper for trauma patients, but for many medical patients, delaying treatment in the field can have adverse effects. Depending on local protocols, many patients can and should receive care to help stabilize their condition. Why aggravate the condition of a patient in severe pain by delaying pain medication?

When providers around the country have been asked about this practice, many say they are taking the patient to "their (EMT's) environment" because it is easier to provide care in the ambulance. While this may be true, EMS is not about what is best for the provider. EMS is about delivering fast, accurate and compassionate care. The EMS provider's environment is wherever the patient may be. This could be in an upstairs bedroom, in the backseat of an automobile or in the middle of a shopping mall. If the care being provided in the back of the ambulance is truly important, why is it being delayed?

While it is important to reduce scene times and expedite transport, EMS providers must not hesitate to provide needed care. Waiting 5 minutes to intubate a patient is not always the best choice.

Following are several actual cases collected from around the United States where treatment was delayed until the patient was placed in the ambulance. You decide if the patient received the best care.

Case 1: On EMS' arrival, a 48-year-old male experiencing severe back pain is sitting in a chair. The patient says the pain is a 10 on a 1-10 scale, and he is unable to move without increasing pain. His BP is 168/88, pulse 102 and respirations 28. The patient is placed on a backboard and transported to the ambulance, where an IV is started and 5 mg of morphine sulfate administered. How much pain did the providers allow this patient to suffer before administering pain meds? Would the patient have tolerated movement better if he had been medicated?

Case 2: A 77-year-old female passed out while attending church services. On EMS’ arrival, the patient was awake but somewhat disoriented; her skin was pale, cool and clammy. Vital signs were pulse 98, blood pressure 77/48, and respirations 20, and she complained of weakness and nausea. Her only history was high blood pressure. The patient was walked about 20 feet to the cot and taken to the waiting ambulance. She had difficulty standing and walking, even with assistance.

After being placed in the ambulance, she received an IV with a fluid challenge. The patient's blood pressure improved to 110/78 and she became more alert. In this case, treatment was delayed by 9 minutes. Although this delay did not cause any long-term adverse effect, how much better would she have felt if treatment had been initiated at her side in the church?

Case 3: A 59-year-old male arrived at an urgent care center with chest pain, left arm pain, neck pain and dyspnea. An ambulance was called and a medic unit was dispatched. On arrival, the medic crew did not evaluate the patient. He was placed on the cot with 4 lpm O2 by nasal cannula and moved to the ambulance for further treatment and evaluation. As the patient was being placed in the ambulance, he experienced cardiac arrest. The medic then called for additional help. Arrival time to cardiac arrest was 11 minutes.

The two-person crew now had to catch up on patient care. There was no IV, the patient was not on the monitor and CPR needed to be initiated. Did this cause a significant delay in ALS procedures? If treatment had started at the patient's side, could the arrest have been prevented? If not, could ALS procedures have been initiated more quickly following the arrest?