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?
