Opinion-Editorial, Prehospital Care, EMS

A Letter from a Paramedic to an EM Doc

Whether it's holding up the wall while waiting to unload a patient at the hospital or sitting in the front of the truck 12 inches away from your partner after clearing a call, EMTs and paramedics (and increasingly social workers, nurses, nurse practitioners, and physician assistants) are regularly thinking about ways they can improve.

On that last call, could my handoff to the hospital have been more concise? Should I have gone further down the treatment algorithm and given that last medication instead of punting it to the ED staff? What other questions could I have asked in my history-taking to sharpen my differential diagnosis?

Occasionally, these questions bubble to the surface and you turn to your partner to review cases, kick around ideas and offer tips for improvement. These exchanges are emblematic of one of the greatest attributes of EMS professionals – the desire to support and help each other succeed.

As EMS services work to improve the care they provide to their constituencies, it sometimes becomes necessary to collaborate with their ED colleagues. However, there are often communication barriers between prehospital clinicians and the ED staff that make this difficult. Understandably, the logistics of different employers, workspaces and shifts add structural obstacles. Additionally, differences in training and experience can lead to peculiarities in mindset, perspective, and approach.

With this letter, I hope to bridge some of these difficulties and convey the ten most important things that I wish I could share with my receiving ED team, particularly the new EM doc or resident, if given the opportunity.

  1. Online Medical Control is of Critical Importance. In most systems, when we call you on the radio for medical direction, it’s a big deal and should be taken as seriously as any consultation with upstairs. Most often, we need one of two things: 1) permission to do a procedure that we already know we need to do, or 2) are genuinely seeking advice on a complicated situation and need a gut check on what we’re proposing. Listen closely, help us from getting anchored or avoid premature closure, and support what is likely to be a high acuity, low occurrence intervention.
  2. Listen to the Report from the Prehospital Crew. Listening to the patient care report from the prehospital crew during the transfer of care can lead to a more efficient transfer of information and a better continuum of care. We worked hard to obtain that information and it may be the only chance to learn about the patient's home and on-scene tidbits. Additionally, it may not be possible to rely on information from the nursing staff if there is a shift change or that person is tied up with another patient.
  3. Feedback, Feedback, Feedback. When we show up later in the day, you cannot begin to understand how much we appreciate receiving feedback on the patients we brought in earlier. Any information on diagnosis and disposition can greatly aid in our professional development and understanding. Oftentimes, it's the only feedback we get in EMS. Also, we tend to believe that if we are not told that we did anything wrong, we assume we are doing it right and those errors can be perpetuated.
  4. Be on the Lookout for Teachable Moments. We want to learn, so if you have a free moment or there is a good training opportunity, don’t be afraid to pull us aside and teach us something helpful. EMT training can be as little as 160 hours so that on-the-job training is incredibly valuable.
  5. Be Familiar with EMS Scope of Practice and Guidelines. While it’s not necessary to know the local EMS protocols by heart, having a working knowledge will give you a greater appreciation for what the EMS crew can and cannot do. Additionally, you may find that EMS crews are at the vanguard of care, especially in the areas of resuscitation and trauma. For us, it can be frustrating being criticized for practices where the hospital may be lagging behind.
  6. Understand Our Limitations. Remember that EMS providers do not find their patients laying on a hospital bed. It's a lot of work to get a patient from where they are found to the ambulance and then the hospital. Often, I find myself alone, in a non-sterile environment, on a bumpy road, while in a chaotic situation, and with limited information. Despite our best efforts, we won’t be able to perform as well as a doctor with additional staff members and the equipment of the ED. Know that we are trying to do our best with the limited resources at our disposal and sometimes that means not everything can be done by the time the patient arrives at the hospital.
  7. Patient Flow is In Your Hands. Just as a backup upstairs can result in ED boarding, holding an ambulance crew in the ED awaiting a transfer of care can create a shortage of available personnel to respond to emergencies in the community. This practice can turn a hospital patient flow problem into an EMS system problem. Whatever you can do to free up stretchers so that crews can return to service can mean the difference between a rapid response and an extended response time.
  8. Be a Clinical Leader. In the eyes of most EMTs and paramedics, the EM doc is the be-all, end-all of clinical mastery, the person who the buck stops with in terms of treatment decisions. In many cases, we operate under your license, you determine our clinical guidelines, and you perform our QA/QI. Do what you can to stay up-to-date and expect the same of the clinicians you oversee.
  9. Be a Champion for Improvement. EM docs are uniquely positioned to advocate on behalf of the rest of the healthcare team. You are the changemaker and nothing can happen to advance EMS without physician support. The expectation is that EM physicians get involved with ED operations, figure out how to effect change within the department and in the field, are in contact with local EMS medical directors, and are out there teaching CME and setting an example.
  10. Pass What You Know on to the Next Generation. To senior residents and attendings, teach the next wave of aspiring EM docs about EMS, how to value them as part of the healthcare team.

EMS and EM are both young specialties with the potential for significant growth. Each is rapidly maturing, evolving, and transforming. These changes have only been expedited by the current pandemic. It is increasingly becoming possible to envision a world where the ambulance is not only seen but operates as an extension of the ED. If we're going to be working together, we should learn from each other, support each other and collaborate on making prehospital and emergency care the best that it can be. I hope this letter is a part of that process and a spark of an expanding dialogue.

Rob Canning got his start in EMS as a high school EMT in Darien, Connecticut, and is currently a paramedic at Hyattsville Volunteer Fire Department in Prince George's County, Maryland. Prior to medical school, he was also a transactional and regulatory attorney with Latham & Watkins LLP in Washington, D.C., advising health care and life sciences clients.

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