The Brown 20
- Sam Ireland
- May 18, 2018
- 7 min read
I once worked with a prehospital practitioner who at one time worked for a service that drilled 20 minute scene times in their head. If they didn't make a 20 minute or less scene time, the service would question the crew as to why it 'took them so long.' I was never a fan of this. I would frequently be internally irritated when someone would remind me of how long we have been on scene.
"15 minutes"
"20 minutes - we gotta go!"
For certain types of calls, time does matter. I used to tell one of my partners that there are four reasons we speed up scene time and transport lights and sirens. I call them the the 4 S's.
1. Surgical need (trauma, abdominal emergency, etc)
2. STEMI
3. Stroke
4. Sam (me) has to use the bathroom (most common reason)
In these cases, I fully support a quick and smooth approach to optimize scene times to a certain goal number (although I understand when we do not meet that goal for various reasons).
Do Longer Scene Times Kill People?
It is very difficult to assess the impact of scene times in the prehospital environment to determine if they make a difference in the outcome of a patient. Why? You can look at studies all day long that might say something like: 'scene time longer than 35 minutes in pediatric arrest codes worse clinical outcomes for patient.' Or perhaps the opposite: 'longer time spent on scene with asthma patients decrease hospital admission.' Why is this type of clinical data not very useful?
Think of the last easy call you had. You got there, the patient was easy to find, it was an easy diagnoses to make, you had a great partner, the patient was light weight, easy veins, no artifact on the 12 lead, etc.. I am willing to bet you were not on scene for very long at all. You decided on a working diagnosis, implemented appropriate treatments, stabilized to the best of your ability, and then transported so that the patient could receive further workup and treatment at the hospital. Nice job! What about when things don't go so smooth?
Now think of the last hard call you had. The patient was not easy to access, they had crap for veins, unstable vitals that required prolonged resuscitation, the sweat from the skin made it hard for the 12 lead electrodes to stick, the SPO2 pleth wave sucked, etc.. Even the simplest treatments probably seemed like they took twice as much time and effort to accomplish correctly. What does this tell us?
Someone get Geraldo on the phone, because I've got some breaking news... Sick patients take longer to care for!
This is why clinical data on scene times is difficult to interpret. The easy patients are going to take less time on scene, and the sicker patients are going to take longer to stabilize prior to transport. It goes without saying that the patient who were easy to treat (shorter scene time), were probably less sick, leading to statistically better outcomes. The same is true with the sick patients. If they were difficult to treat and stabilize, they were probably much sicker, and therefore will likely have worse outcomes.
If Not Scene Time, Than WHAT?
Some people are die-hard scene-time nazis. Perhaps you have a manager that believes that if you go over 20 minutes on your scene time that you are incompetent or are simply not proficient with your time. This might be true, but it doesn't make it okay to zero in on scene times alone. I will give you two examples.
1. 16 Y/O M with Asthma. His chest sounds extremely tight, and he has severe dyspnea. The crew stays on scene with him and manages his asthma with:
bronchodilator therapy (albuterol and atrovent) and oxygen
starts an IV and gives a small amount of fluid
provides steroids early in the treatment since they take a little bit to kick in
does a trial of forced exhalation
perhaps does a trial of NPPV
crew works with calming voices and coaching his breathing until he is more calm
Scene time: 35 minutes
Outcome: There is a marked reduction in his WOB, he seems much more calm, and is now ready to be transported for further evaluation and possible change in his home medications and rescue MDI.
2. Same patient. Different crew. 16 Y/O M with Asthma. His chest sounds extremely tight, and he has severe dyspnea. The crew decides to 'load and go' with him because he is technically a sick ped, and 'the children's hospital will know what to do with him.'
bronchodilator therapy (albuterol and atrovent) and oxygen
could not get an IV while bouncing down the road
did not want to give steroids IM
difficulty assessing if the patient needs manual exhalation
the patient remains very anxious through the ride
lung sounds not reassessed until at the hospital because you cannot hear lungs adequately during transport (so no secondary treatment administered)
Scene time: 10 minutes
Outcome: The patient is delivered with minimal treatments from EMS and remained mildly hypoxic still with increased WOB. Not to mention the EMS crew looks like a bunch of donkeys with blue shirts on, giving us all a bad name.
Who gets the better review from their service? The crew with the longer scene time and appropriate treatments, or the idiots who did a 'load and go?' In many services, the idiots who did the 'load and go' would get a pat on the back for being efficient, while the crew with the longer scene time would get a lecture about how they could do those treatments on the road. What a shame.
We need to start looking at our patients conditions on an individual bases, and stop looking at them like they are just big wrist watches. I frequently hear stories of crews who have response areas just minutes away from hospitals. The crews often say 'so we just transported because the hospital was 3 minutes away.' This is faulty reasoning. I want you to imagine that you are an ALS unit, surrounded by BLS units. The BLS units have the ability to take vitals, do assessments, get a good history, perform some life saving measures, etc. However, because they are only a few minutes away from you, they choose to skip all of the above and give the patients to the ALS unit because you're so close. See my point? We have the ability to treat patients NOW - but some people choose not to because they could easily make it someone else's problem really fast. Does getting a patient to the hospital quickly really get them treatment as fast as we could give it?
I just had a discussion some clinical educators. They have been experiencing some difficulty conveying the message that time to hospital does not necessarily mean time to treatment. Why not? That hospital may have other serious patients that they are currently taking care of, or may simply already have a lot of patients relative to the amount of staff they have.
Example 1:
1000 at patient
1010 transporting
1015 at hospital
1020 transfer of care
1040 doctor sees patient and is able to give orders - treatment time (time to quality treatment = 40 minutes)
- Here it took the doctor 20 minutes to see a patient who needed emergent treatment because he was busy with an involved sick patient in the other room.
Example 2:
1000 at patient
1010 treatments initiated - treatment time (time to quality treatment = 10 minutes)
1020 treatments reassessed and secondary treatments initiated
1030 transporting
1035 transfer of care
1055 doctor sees patient
- Here it took the doctor 20 minutes to see a patient who needed emergent treatment because he was busy with an involved sick patient in the other room. But, it didn't impact the patient nearly as much because you initiated treatment that made a difference and carried over to the beginning of the patients emergency department stay.
Do not assume the hospital immediately has the resources to care for your patient. Something that is very special about EMS is that we have great provider to patient ratios. There is usually two of us for every one patient! At the hospital, patients normally don't even get 1:1 care unless they're in ICU (and are very sick). We have 2:1 with every patient! Keep in mind that you might be bringing your patient to a hospital where the nurse is helping with 3-4 different patients, and the doctor has the whole ED to worry about. When you make patient contact, make the most out of this amazing ability you have to give such individualized and detail oriented attention to your patient. Don't make it someone else's problem just because they're close by.
If Not 20, How Long?
"Scene time" tells us nothing about how long we spend at the bedside. In addition to clinical tasks, our scene time includes how long it takes to find, move, secure, and move the patient again. I do not believe these times should impact our clinical responsibility. Perhaps there should be a goal "bedside" time to shoot for. What do I mean by this?
Once you find your patient and place them on your cot (generally the first thing you should do), that would start your bedside time. You would then have 20, 25, maybe even 30 minutes to completely devote to assessing, diagnosing, treating, and reassessing the patient (if they don't need a cath lab or surgery). My goal is not to put out there an arbitrary number that we should be spending with our patients. That already exists - it's called scene time. My goal is make people focus more on the diagnosis and treatment of the patient once they are able to really get their hands on the patient and get their brain working critically. This is why we should focus more on a bedside time than a scene time.
Think about a 20 minute scene time - now subtract the time it takes you to unload your equipment, move the cot, walk to the patient, transfer the patient, secure the patient, move the patient to the ambulance, and then finally load the stretcher. After you subtract those, how much time are you really spending critically thinking about your patients diagnosis, assessing them, and deciding on what treatments you should perform? The answer is... not enough.
What Really Matters?
When we look at EMS as a profession, we have to decide what we personally believe our job is. If you believe our job is simply to transport patients from point A to point B as quickly as possible, you probably care a lot about scene times. However, if you believe that our job is treatment (transporting being a small side point of our job) then you probably care much more about the quality of care provided rather than the scene time. I call the 20 minute scene time goal "the brown 20" - because it's total crap. Focus on the care your patient needs, not the clock.
