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-----Original Message----- From: Jel Coward <[log in to unmask]> To: [log in to unmask] <[log in to unmask]> Date: 14 June 1999 14:17 Subject: Re: Size Matters?? > >In my experience scene times are too long - almost every time. > >This is a result of various factors but there is nearly always a CFAT >factor (ok, I will translate otherwise some will moan - C-ompulsory A- >bout T-ime) This is a direct result of the tick boxes on our patient report forms. If we don't tick them (I won't lie), we get the forms back with another form to fill in saying why we didn't do it. (We can avoid this by making a "clinical justification" on the form - but this takes yet more time). > >We need to shift the entire emphasis - away from procedures and away >from protocols. > >If our pre-hospital providers are educated correctly then why can we not >trust them to use their judgement? Why do they have to have protocols >that say thou shalt and thou shalt not? > The odd thing is that we can be trusted to recognise and give the correct treatment for an MI as opposed to hypoglycaemia, but we cannot be trusted to say that there is nothing seriously wrong with the patient. >Is it not complete nonsense that someone with chest pain with probably >cardiac cause has to cannulated at scene - taking 12 minutes - when the >run to hospital is 5 minutes. All that is achieved is that the patient >loses more myocardium. .....and we not only teach this, but the poor >paramedic fears disciplinary action if s/he doesnt do it. Has the world >gone completely bonkers? > >Why not tell 'em it makes the patient worse in some situations but may >be worthwhile in others- and then they can choose to do it or not - or >on the way (nudge, nudge - yes I do this fairly regularly before someone >tells me it is not realistic - it is) - and expect them to be >accountable for their decisions and actions ......and audit it ? > We now cannulate only if we think we are going to use it. However, this will still leave some patients with an unused cannula. Where your figure of 12 minutes on scene to cannulate comes from, I don't know. It takes me an average of 2-3 minutes at most. (Asistance from my life-saving technican helps a great deal). If I can't get it in that time, it's away down the road for us and if I really need a cannula, I do it on the way. That being said, if the patient "fails" the primary survey, I don't even stop for the 2-3 minutes, a la PHTLS. >Another thing that drives up scene times is the need for folk to 'get >their cannulas' (or other procedure) ie tick the boxes that they have >done so many or whatever (saw this particular one last week). Sure, we >all need practice - but couldnt it be in back of the ambulance or in >casualty (I guess all the A+Es here encourage the involvement of the >pre-hospital team when they arrive ;-) Again, we can't blame the ground >troops for this - it has to be in the training and whole operating >structure. > I think we are getting away from that these days. If I want to go into hospital as part of my annual update, I can - and do. We don't actually need a specific number now as far as I am aware. > >We really need to keep shouting about getting patients to definitive >care asap - and doing only what is necessary before then. I am not sure >that muddying the picture with details such as cannula size will really >help to achieve this objective and may distract us from it. > I only use two cannula sizes, big and small. Big for a lot of fluid and small for drugs. I can't generally tell the difference in putting them in. They are equally easy/difficult and this depends on the patient, not the cannula size. If I want a big one in, I will not be going for a small hand vein in the first place. Stephen Dolphin Paramedic %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%