Take Your Time

Almost everyone in emergency medicine experiences the excitement of a serious trauma or a fast-paced medical call. The civilian community and the television shows call it the "adrenaline rush."

"That's why you're an ER doc right?" "You love the adrenaline rush don't you!" "You became a medic to be in the middle of the action?" "It really makes you feel alive!"

This may be a silly question, but how many times have you heard silly questions like that?

Do we really like having to be 100 percent at the top of our game after consuming a big meal, or awakened in the middle of the night to arrive at an ambulance call half asleep? It is bothersome enough when we are well rested and have fully digested our most recent meal.

Many times the only "rush" that we encounter is anger precipitated by an annoying patient, an overly aggressive family member, a pain-in-the-neck bystander, a hovering supervisor, or a clueless co-worker.

The reality of our job as pre-hospital providers is that most of the patients we treat are non-emergent followed by the poor souls already dead, followed by the occasional serious medical patient followed by the lights and sirens trauma case.

Trauma is straightforward. Our job is to keep the patient alive or to treat the traumatic cardiac arrest until we deliver the patient to the ER. ABCs and maintaining or re-obtaining vital signs are the only thing we should be doing. We have to work fast or we will lose our patient. "Load and go" and "play on the way" is a good rule of thumb. Medical patients are a whole other deal.

As prehospital providers, it is sometimes difficult to get out of the emergency mode. In the system where I first worked, my medical director wanted us to "stay and play" for as long as was prudent.

At the advanced level, EMTs can do as much on the ambulance or in the patient's home as can be done in an ER, within reason. We can't do cardiac caths, but we can get IV access, a round of nitrates and narcotics on board, probably a whole lot faster than a busy ER staff can. Although, time is muscle, if we just load up the patient and take them for an expensive, fast taxi ride, doing nothing could cripple the patient before we arrive at the hospital.

What about the moderately acute patient? How much time should we spend on scene? The answer to this question is, "as long as it takes."

I see many hands going up in the back of the room so let me finish.

There is an exception to every rule. Please don't write me and tell me of the exceptions and I won't tell you the obvious. There are as many exceptions as there are patient care scenarios and an experienced EMT will have to use their own judgment regarding who can go and who can stay. The key to good patient care is assessment.

How many times have you arrived on a scene, interviewed and examined a patient and found out that you missed a critical piece of information? An individual in pain is either going to inadvertently leave out information or deliberately leave out information.

If we could get inside our patient's heads, it might sound something like this:

"I don't remember what kind of medications the doctor gave me. My wife said it was some kind of water pill."

Or

"I don't want the adenosine because I know how lousy it makes me feel, so I'll tell you that I just ran 5 miles." (I would feel the same way if you were going to stop my heart for a few seconds.)

Or

"I'll tell you that I didn't take heroin, because I don't want the narcan." (If I was a substance abuser, I might not want to come off a good high, especially if I already knew how bad the withdrawal symptoms would be.)

And

"I don't want to voluntarily tell you that I use Viagra in front of my children. Besides, what does it have to do with the heart attack I'm having?" (Nothing. Except the nitro pills that I am about to give you might bottom out your blood pressure and kill you.)