Feedback to EMS from ED physicians - another perspective

[KellyBracket]

The issue is that many emergency physicians just keep their mouths shut rather than have a friendly conversation about patient care. In the end this is supposed to be about the patient and everyone doing the best job they can for the patient. Instead there is silence in order to prevent ruffled feathers and wrathful CEOs.

From "Culture of silence," in ACEP News, June 2013

An emergency physician has written an essay describing what he views as some significant obstacles to giving feedback to EMS crews, and I want to see what sorts of reactions people have to his perspective. Does this strike a chord with folks? What is the "other side" to the discussion?

Keep in mind that this physician is writing about his frustrations in a public venue, knowing he is running the risk of controversy. There are plenty of anonymous places on the web where docs can gripe un-constructively, but he chose to initiate a discussion in plain view. So, try to keep the use of combustion to a minimum!

 

[JPINFV]

Well, when you go through 150 hours or 1000 hours of war stories and being told how much of a hero you are and better you are than anyone else oints to the "doing the same ____ as doctors at 65 MPH" meme and any comments about intubating upsidedown in a car in the middle of a blizzard:, than people are going to bristle when told they aren't pooping rainbows and jelly beans. EMS has met the enemy, and he is us.

 

[chaz90]

Well, when you go through 150 hours or 1000 hours of war stories and being told how much of a hero you are and better you are than anyone else oints to the "doing the same ____ as doctors at 65 MPH" meme and any comments about intubating upsidedown in a car in the middle of a blizzard:, than people are going to bristle when told they aren't pooping rainbows and jelly beans. EMS has met the enemy, and he is us.

That meme and those kinds of sayings aren't representative of the majority of quality EMS providers. Finding a saying that is emblematic of the worst of us and trying to apply it as a generalization is no better than any other kind of stereotyping. Having an attitude of superiority on either side stifles progress. Also, "met the enemy"? Come on. There's no way physician-paramedic relationships should be that adversarial. Common goals mean we can, and should, find common ground.

I understand the point the ED physician makes in that article, and I absolutely welcome constructive criticism. He's right in saying we practice as extensions of a doc's license, and if they see an error in something I do, it is their obligation to correct it so I perform better in the future. Simply bowing down to economic factors and fear of losing a few dollars if an EMS service is briefly displeased at you is no reason to avoid any kind of confrontation. If he fails to correct these kinds of egregious errors when he sees them, he has no room to complain when they happen again later.

Like anything else, criticism needs to be handled in the right way. Physicians should first question why the medic made the choice he did and what his reasoning behind it was. Finding where the misunderstanding (or faulty thought process) begins can provide a good jumping off point for why this may not be the best way to do things and how it could be improved. Mutual respect and communication go a long way, and I for one know I would never hold it against a doc or feel slighted if they corrected something I was doing wrong in the interests of improving patient care.

 

[Wheel]

Thus makes me sad as a young paramedic for many reasons.

1. I want and need the feedback, and other providers are causing me to get shortchanged because docs don't want to deal with the whiny ones so they don't deal with any of us (of course not always the case)
2. This is how I feel when I try to have a medical conversation with the people I work with. It's frustrating when we can't have an intelligent conversation about the merits of various treatments.
3. This is the attitude that has to be overcome if we're going to move forward. You have to be teachable for doctors to want to give you a chance to do anything new and exciting.

I'm curious to see what others think about this article, but I hope we can move into an area where doctors trust us to do the right thing for our patients, not our egos.

 

[JPINFV]

That meme and those kinds of sayings aren't representative of the majority of quality EMS providers. Finding a saying that is emblematic of the worst of us and trying to apply it as a generalization is no better than any other kind of stereotyping.

Unfortunately, I don't think that that group of chest beating idiots is an extreme minority. I've seen it way too broad and coming from way too many people (both first hand and second hand accounts) to discredit it. Heck, we have a discussion going on in the directionless thread where the local fire fighters beat their chest and act like the transport medics are complete idiots.

Having an attitude of superiority on either side stifles progress. Also, "met the enemy"? Come on. There's no way physician-paramedic relationships should be that adversarial. Common goals mean we can, and should, find common ground.

I agree it shouldn't be. There's a lot of things in the world that shouldn't be, but is.

Simply bowing down to economic factors and fear of losing a few dollars if an EMS service is briefly displeased at you is no reason to avoid any kind of confrontation. If he fails to correct these kinds of egregious errors when he sees them, he has no room to complain when they happen again later.

Which is easy to say if your job isn't on the line. Who's to say that the hospital won't find a EM group to staff their ED that won't make waves if the local EMS agency decides to start diverting patient's away? Do you think the CEO of the hospital cares about patient care in the ED, or how fast they can move the widgets (to steal a term from an attending on SDN)?

 

[chaz90]

Unfortunately, I don't think that that group of chest beating idiots is an extreme minority. I've seen it way too broad and coming from way too many people (both first hand and second hand accounts) to discredit it. Heck, we have a discussion going on in the directionless thread where the local fire fighters beat their chest and act like the transport medics are complete idiots.

Which is easy to say if your job isn't on the line. Who's to say that the hospital won't find a EM group to staff their ED that won't make waves if the local EMS agency decides to start diverting patient's away? Do you think the CEO of the hospital cares about patient care in the ED, or how fast they can move the widgets (to steal a term from an attending on SDN)?

You're completely right that this group of morons isn't some small, inconsequential number. Some people are beyond rehabilitation. Rather than fighting a futile battle of attrition in trying to change minds that are stuck in the rut of ways we've always done things, let's change the culture so they're forced to leave when they refuse to adapt. Change will be slow, but hopefully eventually for the better.

What's easier for a hospital/EMS service to recover from? Losing a few patients and the money that could come from them, or fighting a lawyer with deep pockets when someone dies due to negligence or malpractice? This is how ED physicians and their representatives can present their reasoning for correcting EMS providers actions to bean counting bureaucrats. Misplaced ET tubes and (probably emergent) transports of corpses in need of a signature are major issues of liability in need of being addressed.

Physicians, especially those in medical director roles, have power that they should utilize. Stop granting practice privileges to incompetent providers in your system. Explain to management that you're worried about the danger (and again, legal liability) of allowing these people out in the field, and lay out a plan of education and training to bring them up to acceptable levels. If management refuses, move on to a better system that lets you have an active role in true QA/QI and oversight.

 

[Arovetli]

EMS in general is poorly receptive to criticism. In the recent past on these forums I've read folks become aghast that a physician correct them or have a different treatment plan than theirs. The doctor gets assumed to be a rural bumpkin or is criticized because the paramedic his ridden the truck longer than little Dr. Sam has been alive.

That's pretty brash. Though not indicative of all, just a few recent examples on the home front.

How about the whole set up is messed up to begin with. Simply being an ER physician should not make you responsible to oversee the prehospital care and actions of every provider of every patient that land at your facility.

 

[Akulahawk]

EMS in general is poorly receptive to criticism. In the recent past on these forums I've read folks become aghast that a physician correct them or have a different treatment plan than theirs. The doctor gets assumed to be a rural bumpkin or is criticized because the paramedic his ridden the truck longer than little Dr. Sam has been alive.

That's pretty brash. Though not indicative of all, just a few recent examples on the home front.

How about the whole set up is messed up to begin with. Simply being an ER physician should not make you responsible to oversee the prehospital care and actions of every provider of every patient that land at your facility.

I would tend to agree, EMS (especially Fire-based) isn't all that receptive to criticism from what I've seen. In the County I'm in, they seem to be generally OK with that though... but they also tend to look down at the private providers. Individual EMS providers can be (and I'm one of them) quite receptive to feedback. I used to (and still do, actually) actively solicit for feedback, be it good, bad, ugly or otherwise. Even if I'm doing something the right way, if there's a better right way, I want to learn that way too, so that I can become better.

 

[Trashtruck]

Doctors view of EMS: They know not what they do(but think they do)

Nurses view of EMS: Don't piss them off. It's worse for us if we piss them off.

Hospitals view of EMS: $$$ so keep them coming to us.

EMS's view of EMS: Omnipotent.

EMS's view of the hospital: Dumping grounds.

We all walk a fine line between pt care, satisfying our bosses(or keeping them at bay), keeping our jobs, and balancing the economics and politics involved. It blows.

I liked the article and the doctor for being so candid and speaking out like he did.

As for the other side of it: I wish our doctors would be more vocal either in berating us, praising us(I know, I know...), educating us, or 'broadening our horizons' We get zero feedback whatsoever. I don't know if it's because the docs are too busy, or if they believe we don't give a :censored::censored::censored::censored:, if they think we'll take something as criticism, or if the hospitals truly want them to 'leave them alone' lest the gravy train slows down. We're like robots transporting pts into the ED and then we're gone, usually without even seeing a doctor at all.
I wouldn't be the least bit salty if a doc commented on something. I would encourage it.

Is this a common sentiment amongst ED docs? I know this is his article, but to the docs on here, how is it in your system(s)?

 

[RocketMedic]

email i sent the good doctor.
Doctor, I think your article was very on-point. In the vast majority of American EMS, there is no real education (1500 hours of tech school and war stories including clinicals), no mentorship (meetings with Clinical or QI are nearly always negative) and there is no feedback from our hospitals or advice on adjustment of practices (a mix of HIPAA, lack of interest on all sides and a lack of education). Add in doctors who routinely ignore our requests and paramedics who buy into that "same as doctors, but at 80mph" crap and we will never have professional paramedics, just vocationally-trained technicians.

As doctors, you need to increase your standards. We work for you- force eachother and EMS agencies to require degrees, education, mandate intensive quality improvement and refuse to allow those who do not comply to practice. Then you, as doctors, can really control what we do. As long as you allow "experience" and a culture of medical providers with grade-school educations and "traditions" like stand-up 24s, hobbyist volunteering and an active disdain/avoidance for knowledge and responsibility beyond transport to operate, you cannot expect better.

Crack the whip.

 

[MMiz]

Good article!

What group of medical professionals is receptive to feedback and criticism in a non-educational environment?

Hopefully systems are progressive enough to have a quality QI team that provides EMS providers candid feedback.

I'm not sure EMS is different than any other profession in that professionals opt not to confront others about potential lapses in judgement. People don't like confrontation, it's not an EMS thing.

 

[Handsome Robb]

Haven't had a chance to read the entire article but I think this is location dependent. We *generally* have great relationships with our ERPs and they're always giving us feedback whether it be "awesome job!" or "maybe think about this next time" or "what about doing this this way?"

Obviously there are bad apples in every system and that goes for both sides medics and docs. I've met docs that couldn't give a rat's *** about what I have to say and there are lots of others that consistently seek me out after I've given my report to the nurse so as to not "play the telephone game."

Looking forward to reading the essay!

 

[Aidey]

I know this is going to sound like I'm not taking criticism, but the doc is coming off as a bit of a sissy. He uses examples of what are basically minor complaints as why he would get in trouble with management, but then glosses over serious clinical issues. I am also seriously turned off by him describing EMS' position as a subservient colleague. Also, is part of the issue is that the doctor is not taking criticism well from his management?

I hate it when they ask a ton of questions on the radio. Generally the questions aren't relevant, they are taking me away from my patient and they are tying up a radio channel some 20 other ambs are using. If I didn't tell you my fall pts blood sugar it is because it doesn't matter and I am trying to get off the shared radio channel.

In my area, if one hospital goes on divert, the others are notified. So, when I bring you a pt who was admitted at St. Mary's last week, and they are on divert now, please do not harass me about it. If they have been on divert for the last 4 hours you have been on shift you have had plenty of time to figure that out. If I tell you they are here now because they didn't like St. Mary's, or their doctor wanted them here instead, please do not roll your eyes and sigh theatrically.

He doesn't mention it, but since he isn't talking to EMS, is he bringing up the serious clinical issues with those crews medical directors? If he isn't, he is just as much part of the problem. Also, does he know the protocols of the crews he is working with? That is an issue here too. The docs want to know why we didn't do x or y when those things aren't even close to being in our protocols. And by want to know I mean they say things like "You should have done this!!!" and then walk away, so I have to chase them down and explain that this is not in my protocols.

I agree with his basic premise that the culture towards EMS *coughfiredepartmentscoughcough* has changed a lot since 9/11. However, based on his essay I don't think he is doing anything to fix the problem.

 

[DrParasite]

Doctors view of EMS: They know not what they do(but think they do)

Nurses view of EMS: Don't piss them off. It's worse for us if we piss them off.

Hospitals view of EMS: $$$ so keep them coming to us.

EMS's view of EMS: Omnipotent.

EMS's view of the hospital: Dumping grounds.

wow, that looks strangely accurate, except the doctors only know what it's like to work in a brightly lit ER with extra help a shout a way, not on the floor of a crack den when you are dealing with someone who collapsed between the toilet and tub.....

As for the article, I think part of it is bull:censored::censored::censored::censored:. For example, the transporting of dead bodies, only for the ER to pronounce. Why is this being done? Was it the paramedics decision, the front line supervisor's decision, the management's decision (ie, by policy or trained practice), or the medical director's order to bring him in?

Now, if the paramedic made the sole call to bring him in, than absolutely, pull him aside and have a few choice words. But if he's just doing what he was told by his supervisor/manager/medical director, than what is the chat going to do, other than piss him off, because now you want him to do something that can jeopardize your job (despite it being the better decision).

As for the second scenario, if they did in fact screw during the intubation process (and to be honest, I have never heard of laryngeal sounds meaning you need to pull a tube), than absolutely he should have had a word with the paramedic. If it's a clinical :censored::censored::censored::censored:up, than it needs to be documented, especially if there is a pattern (remember, in hospitals errors are reported to make patient care better, not to be punitive).

I will say, I have been pulls aside and had a heart to heart with an ER doctor.... I was being lazy, thought a patient was BS, and she ended up being admitted to the ICU (not for something I did, but because of an underlying condition she had). I learned from my mistake, and didn't make it again.

That all being said, I know paramedics who won't take criticism form EMTs, know paramedics who think doctors don't know what they are talking about, EMTs who think they are perfect and never make mistakes and doctors who treat all prehospital personnel like crap, just because they can. And there are quite a few doctors who are acting as medical control and don't know what medications paramedics even carry on their trucks, or what tools they have at their disposal. And yes, I know PEMS providers who if they feel they have been mistreated by an ER nurse, will have all the crews in the area make their life a living hell, just out of spite. And I know paramedics who will berate EMTs as stupid when they put oxygen on everyone, despite that their protocol says to do just that....

I used to have a great relationship with most of the ER docs at my old job. I know quite a few paramedics that are on a first name basis with some of their medical attendings, and I have gone drinking with them in post shift or social settings.

If the ER doc doesn't have the balls to approach a crew about a clinical problem, than they are part of the problem. But if he or she wants to have a chat with them about an operational issue, such as transporting dead bodies, than talking to the field provider won't help (and will probably piss the person off, because they can't fix the problem), and the issue should be discussed higher up the chain of command.

 

[Dwindlin]

What group of medical professionals is receptive to feedback and criticism in a non-educational environment?

M&M doesn't end once residency is over. Attendings present cases as well.

wow, that looks strangely accurate, except the doctors only know what it's like to work in a brightly lit ER with extra help a shout a way, not on the floor of a crack den when you are dealing with someone who collapsed between the toilet and tub.....

This is another logical fallacy (exactly like the "same at 65mph"). I'll be honest I used to feel the same. But having gone through the process I promise you the overwhelming majority of residents/attendings would be just fine working outside the hospital (from any specialty, especially EM).

 

[Arovetli]

You do have to admit that it is a bit off kilter for a physician to owe duty to monitor and critique the actions of another provider with whom the physician has no affiliation.

Just because the doc is attending the ED doesn't mean he knows any service or their protocols and shouldn't mandate that he do so.

EMS shouldn't rotate around whichever physician happens to be on the other end of the radio.

 

[Dwindlin]

EMS shouldn't rotate around whichever physician happens to be on the other end of the radio.

What do you mean by this? Do you mean you should be calling the same physician for orders all the time? If that's the case I very much disagree, you should be calling where the patient will ultimately be treated, and hopefully the physician you spoke with will be the one seeing the patient.

 

[KellyBracket]

The compelling part of the essay, and the chief reason I linked it, was the physician's description of the economic and administrative disincentives to risking complaints from EMS. His point is that perhaps EMS has a privileged position, able to control the flow of customers/patients to the hospital.

So, while some of his concern is with the EMS providers, I think he expresses more frustration with the non-clinically oriented hospital administration, that they would subvert efforts to QA or critique EMS, if those risk losing the revenue stream that EMS provides.

So, do you feel privileged, playing a critical role in the financial health of the receiving hospitals? Does this (or should this) affect the EMS-hospital relationship?

 

[MMiz]

The compelling part of the essay, and the chief reason I linked it, was the physician's description of the economic and administrative disincentives to risking complaints from EMS. His point is that perhaps EMS has a privileged position, able to control the flow of customers/patients to the hospital.

So, while some of his concern is with the EMS providers, I think he expresses more frustration with the non-clinically oriented hospital administration, that they would subvert efforts to QA or critique EMS, if those risk losing the revenue stream that EMS provides.

So, do you feel privileged, playing a critical role in the financial health of the receiving hospitals? Does this (or should this) affect the EMS-hospital relationship?

KellyBracket,

I understand that part of his argument, but it's the same challenge every business faces. Balancing a desire to make money with a desire to do the "right" thing often leads to internal and sometimes external conflict. EMS services face a similar challenge when determining whether a long-term patient really needs ambulance transport.

Weighing the economic impact of one's decisions is part of life, and as an idealist I'd hope that one's obligation to the betterment of medicine takes a precedent over financial rewards. Unfortunately such victories don't pay the bills.

I would hope that this doctor and all doctors would take a leadership role in the QI process and would have an active role in shaping progressive EMS systems.

One day.

 

[Clipper1]

I would hope that this doctor and all doctors would take a leadership role in the QI process and would have an active role in shaping progressive EMS systems.

One day.

Probably not worth the hassle. Even when Medical Directors try to get more involved by enforcing standards and higher training requirements they are met with resistance. EMTs and Paramedics will run to their union reps or complain while "just not doing" it. Or they post on forums like this saying what a horrible company the work for and sometimes give the name of the company or the hospital who has "wronged" them. They want their Medical Directors fired and the hospitals cited or even closed. Hospitals don't like publicity especially when it hits the Social Media which some people now value more than any respected journalist.

Even here, when I mentioned some of the factors which went into purchasing a nasal cannula some got their panties into a knot. It is not unreasonable to ask what type of service you provide even if it is BLS since not all or the same or what type of vendor arrangement the company has. Like it or not but there is more than just what the Paramedic wants (and there will be several Paramedics wanting different things) but also what the company can get or the patient needs. I pity the poor doctor who might ask the same questions I did.