Feedback to EMS from ED physicians - another perspective

[Bullets]

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).

I would disagree, when we have had physicians ride out with us, EM physicians included, they tend to struggle with the reality that they dont have everything they normally have within reach at the ER. Same goes for manpower, when its 2 EMTs and 2 Medics handling 2 critical patients, the Doctors seemed overwhelmed without an extra physician or PA or nursing team around.

Additionally, i find unfamiliarity with protocols the leading cause of friction between EMS and the ER. They don't know what we can do, and they ask why we didn't this or that.

When we do receive comments from the Doctors, its generally negative. My main interaction with a physician came after we brought a patient who fell, broke her femur and lost consciousness. She had neck and back pain, so we tractioned the leg and immobilized. we bring another patient in three hours later and find this woman still on the board in the triage area. A doctor comes over while we are speaking to her and asks if we brought this woman in. He then questioned the fit of the cervical collar. As if a woman lying on a board for three hours with a fractured femur is going to remain still, which she admitted. Or realizing that the issue isnt with our care, but the hospitals inability track the patient properly.

It seems like if there is a problem, its the EMSs fault.

 

[KellyBracket]

KellyBracket...
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.
...

I think a closer comparison might involve a nursing home that your service has a contract with. Imagine if you were asked by your supervisor to avoid making any future comments to the staff at this facility about, say, the quality of their CPR when you arrive at an arrest. The supervisor says that past "feedback" was viewed as rude or inappropriate by the staff, despite being (as you saw it) fully warranted. The supervisor is worried that the facility will throw their business to the other EMS service in the area if they think that that your "customer service" is poor.

Is this a reasonable analogy?

 

[VFlutter]

I would disagree, when we have had physicians ride out with us, EM physicians included, they tend to struggle with the reality that they dont have everything they normally have within reach at the ER. Same goes for manpower, when its 2 EMTs and 2 Medics handling 2 critical patients, the Doctors seemed overwhelmed without an extra physician or PA or nursing team around.

So what is your point? It is natural that any provider would struggle when changing environments. It takes time to adjust. Just like most Medics would struggle getting thrown on a Step-down floor responsible for 4 critical patients or in an ICU. I can assure you that most competent MD would be able to adjust to the hospital environment given the proper time. Judging the EM doctor who has spent the past 10 years in the ER on his performance riding out with EMS for the first time is not exactly fair.

I think a closer comparison might involve a nursing home that your service has a contract with. Imagine if you were asked by your supervisor to avoid making any future comments to the staff at this facility about, say, the quality of their CPR when you arrive at an arrest. The supervisor says that past "feedback" was viewed as rude or inappropriate by the staff, despite being (as you saw it) fully warranted. The supervisor is worried that the facility will throw their business to the other EMS service in the area if they think that that your "customer service" is poor.

Is this a reasonable analogy?

I think that is a perfect analogy

 

[usalsfyre]

I think a closer comparison might involve a nursing home that your service has a contract with. Imagine if you were asked by your supervisor to avoid making any future comments to the staff at this facility about, say, the quality of their CPR when you arrive at an arrest. The supervisor says that past "feedback" was viewed as rude or inappropriate by the staff, despite being (as you saw it) fully warranted. The supervisor is worried that the facility will throw their business to the other EMS service in the area if they think that that your "customer service" is poor.

Is this a reasonable analogy?

Errr.....yeah......this is actually a REALLY GOOD comparison....:unsure:h34r:

 

[Aidey]

It is a good analogy, but I think it also exemplifies the need for proper channels to address these issues. It kind of sounds like this doc has just given up, no matter what issue he has with EMS.

 

[Bullets]

So what is your point? It is natural that any provider would struggle when changing environments. It takes time to adjust. Just like most Medics would struggle getting thrown on a Step-down floor responsible for 4 critical patients or in an ICU. I can assure you that most competent MD would be able to adjust to the hospital environment given the proper time. Judging the EM doctor who has spent the past 10 years in the ER on his performance riding out with EMS for the first time is not exactly fair.



I think that is a perfect analogy

My point was, do not criticize that which you do not know. And not that the doctor doesnt know the proper medicine, but what we are allowed to do. In most cases, the docs are medically correct, but our protocols suck

 

[Aidey]

My point was, do not criticize that which you do not know. And not that the doctor doesn't know the proper medicine, but what we are allowed to do. In most cases, the docs are medically correct, but our protocols suck

That is an extremely good point, and something that isn't addressed at all in the doctor's editorial. I would love to know how much he knows about the local EMS protocols. I also want to know if that DNR was valid, or if a family member over ruled it.

 

[DrParasite]

I think a closer comparison might involve a nursing home that your service has a contract with. Imagine if you were asked by your supervisor to avoid making any future comments to the staff at this facility about, say, the quality of their CPR when you arrive at an arrest. The supervisor says that past "feedback" was viewed as rude or inappropriate by the staff, despite being (as you saw it) fully warranted. The supervisor is worried that the facility will throw their business to the other EMS service in the area if they think that that your "customer service" is poor.

Is this a reasonable analogy?

That's a great analogy, with one exception: where I am, the PATIENT can chose what hospitals they go to. it's not the decision of EMS to make that decision for the patient. In fact, most of the time they know what hospital they want to go to before EMS even arrives (outside of a specialty center, which they are going to whether EMS likes them or not).

Further, I have read on here that only 20% (if that high) of all the patients in the ER are brought in by EMS. Does that 20% really matter in the overall scheme of things, when 80% are brought in by alternative means? Especially when you are only pissing one one paramedic or one agency, not the entire EMS system.

Also remember, many ambulance companies won't back their staff if their staff report bad things happening at a nursing home (for fear of losing a contract), while complaints from an ER physician, especially an objective clinical mistake, should be documented for retraining.

 

[Arovetli]

That's a great analogy, with one exception: where I am, the PATIENT can chose what hospitals they go to. it's not the decision of EMS to make that decision for the patient. In fact, most of the time they know what hospital they want to go to before EMS even arrives (outside of a specialty center, which they are going to whether EMS likes them or not).

Further, I have read on here that only 20% (if that high) of all the patients in the ER are brought in by EMS. Does that 20% really matter in the overall scheme of things, when 80% are brought in by alternative means? Especially when you are only pissing one one paramedic or one agency, not the entire EMS system.

Also remember, many ambulance companies won't back their staff if their staff report bad things happening at a nursing home (for fear of losing a contract), while complaints from an ER physician, especially an objective clinical mistake, should be documented for retraining.

EMS drives a vast number of admits. 80 percent of one local hospital I know of. The majority of the patients may come in through other means but quite alot of sick and injured admits (read:$$$$$$$$) enter through the ambulance bay.

 

[Carlos Danger]

I am also seriously turned off by him describing EMS' position as a subservient colleague.

Why are you turned off by that. Is it untrue?

the doctors only know what it's like to work in a brightly lit ER with extra help a shout a way,

This shows a serious lack of respect for what ED doctors and nurses do. If you think working in an ED is "easy", you are seriously, badly mistaken.

Why should the ED docs respect what you do if you don't respect what they do?

I would disagree, when we have had physicians ride out with us, EM physicians included, they tend to struggle with the reality that they dont have everything they normally have within reach at the ER. Same goes for manpower, when its 2 EMTs and 2 Medics handling 2 critical patients, the Doctors seemed overwhelmed without an extra physician or PA or nursing team around.

There probably is some truth to that, but so what? Being in a new environment is disorienting and takes some getting used to. Do you not think you'd be a little disoriented if you were dropped in the middle of an ICU, put in charge of the unit, and told to manage 10-20 critical patients at once? I'd bet that, given a decent orientation, 99% of EM MD's would function just as well prehospital as they do in the ED.

Just by way of comparison, most flight nurses I've worked with adapted very quickly and very well to the prehospital environment, to the point that it didn't take long before they could function just as well in the field as almost any paramedic. I have no reason to think physicians wouldn't do the same.

i find unfamiliarity with protocols the leading cause of friction between EMS and the ER.

Much of the friction I've seen between paramedics and ED docs did come from the docs simply not understanding the paramedics' protocols, training, and the environment they are working in, AND/OR the paramedics not understanding where the doc is coming from with their questioning and expectations.

Most of the rest of the friction came from docs simply being pricks, or paramedics simply being pricks.

Many paramedics tend to think they know a lot more than they actually do and think that everyone else has it "easy" and couldn't do what they do (as has been demonstrated in several posts in this thread), and many docs think paramedics are undereducated blowhards and just don't want to waste their time with them.

 

[Arovetli]

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.

Thats exactly what I am saying. Sure, call the facility for prearrival alert, but making whichever guy happened to answer the radio suddenly become the patients physician and issuing order on a patient he has not examined and is under the care of a provider he is not familiar with, not credentialed under the same facility (likely), not billing for the consult, has no idea where the patient will end up upon arrival....its a recipe for the stupid that it is. If we haven't been doing it for decades, you would realize how nonsensical it is. Call your medical control, the guy who wrote in pen and paper what you can and cannot do.

The physicians doesn't know you. or your service, nor did he write your protocols, nor should he have to be familiar with them. He has no responsibility to train you or correct you. The pure laziness of the service medical director is to blame. He signed the protocols, he can be responsible for seeing them implemented. Any disagreement can route from the receiving MD right back to the medical director.

Its a pleasant fiction that paramedics are the extension of the treating MD, but its 2013. Fairy tales from the '70s didn't come true.

If, and its a big epic if, you had a corps of truly competent paramedics, how much really needs to be called in for online orders?

 

[Aidey]

Why are you turned off by that. Is it untrue?

Yes, when you consider the primary definition of subservient is "Prepared to obey others unquestioningly". This is not an appropriate attitude to have in medicine. He may have meant the second definition of subordinate, but if he did, he should have said that. I completely agree that EMS personnel are subordinate to doctors, but no one should be subservient to someone else in medicine, regardless of the titles involved.

 

[Trashtruck]

I think a closer comparison might involve a nursing home that your service has a contract with. Imagine if you were asked by your supervisor to avoid making any future comments to the staff at this facility about, say, the quality of their CPR when you arrive at an arrest. The supervisor says that past "feedback" was viewed as rude or inappropriate by the staff, despite being (as you saw it) fully warranted. The supervisor is worried that the facility will throw their business to the other EMS service in the area if they think that that your "customer service" is poor.

Is this a reasonable analogy?

This is an awesome analogy.
I know healthcare isn't all about, well, healthcare. It's a business. And it operates like any other business. It's not the Peace Corps. It's about making money and profit.
Look around. You see billboards and commercials and magazine ads for hospitals and surgeons and specialists everywhere(buses, subways, shopping malls). Competition is TIGHT.

A patient? What's that?
They are now called customers in many hospitals. Or clients.

Private ambulances have to kiss *** so they keep their contracts. You don't bite the hand that feeds you.
I've noticed hospitals trying to 'entice' EMS crews to come to their hospitals over others by way of offering nice snacks, cold bottles of water, hot coffee and tea, phone chargers, computers with internet access, and so on. They are catering to EMS for profit. They certainly aren't doing it for EMS comfort.

Like I said before, it's between a rock and a hard place. Politics and money on one side. Pt care on the other.

 

[MikloHP]

So I am new here, and my wife is an ER Doctor. This is a recurring back and forward that we have. She feels like her job is to "clean up after our mess." Her thought is that whatever a paramedic decides to do in the field, is a mess that she will have to clean up after once they arrive in the hospital. She does not feel that paramedics should be allowed to operate within the maximum boundaries of their scope of practice, as outlined by their medical director, should the patient present with the respective criteria for procedures (i.e. intubation, etc.) Unless however, she knows you and can trust you. My argument is, you cant know every medic that comes in with a patient or calls in on the radio. As a receiving physician, you have to trust that the paramedics assessment is correct and warrants the requested procedure. Furthermore, you have to trust and understand that Paramedics operate under a Medical director who has outlined how a medic should respond/perform to given patient presentations. She is not above pulling a medic aside and providing constructive criticism, however her thought is based entirely on whether or not she know/trusts said medic.

 

[VFlutter]

As a receiving physician, you have to trust that the paramedics assessment is correct and warrants the requested procedure

Unfortunately, that is asking a lot given the quality of some EMS providers.

It is sad that I have come to the point where I do not trust any of the Rural EMS transfers that frequently bring me patients. Listening to report is nothing short of humerous and many times I have to clean up messes made during transport. If I was in a position of authority I am not sure I would authorize treatments, under my license, based off their assessments. There are a lot of fantastic EMS providers out there but you tend to fixate on all the bad.

 

[DrParasite]

This shows a serious lack of respect for what ED doctors and nurses do. If you think working in an ED is "easy", you are seriously, badly mistaken.

Why should the ED docs respect what you do if you don't respect what they do?

I'm sorry, did i say working in an ED was easy? I even reread what I wrote, no where did I say working in an ED was easy.....

What I said was ED doctors work in a brightly lit ER, where help is just a shout away. Not only that, but they have more hands available, more space to work in (well, sometimes, some ERs pack patients in like sardines), more light, and more tests they can run to assist in treating their patients. Take all those things again, and they are working with one eye closed, one hand tied behind their back, and a lot of well educated guesses with nothing to confirm (deformity vs fracture, etc), which is what it is like working in the field vs working in an ER.

Again, I have friends who are nurses, techs and doctors..... I never said their job was easy, I respect the work they do under the conditions they have and know they earn their pay every night.

Please refrain from putting words in my mouth, or making assumptions about what I am saying based on facts never presented in evidence.

EMS drives a vast number of admits. 80 percent of one local hospital I know of. The majority of the patients may come in through other means but quite alot of sick and injured admits (read:$$$$$$$$) enter through the ambulance bay.

Interesting... i think Veneficis or one of the other doctors gave that number, but it wasn't anywhere near 80%... Again, I didn't find a the source, but 80% still seems like a high number.

 

[DrParasite]

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).

First off, the "exactly like the "same at 65mph" picture the floats around FB is stupid. We don't do the same as ER doctors, and anyone who says otherwise is, well, has a much larger ego than he should.

That being said, ER doctors have much more tools at their disposal. an ER doc might be able to make an educated guess, but he still wants tests to back it up. You, being a paramedic before you went to medical school, might be able to function outside of a hospital, but without all the tools you have at your disposal in a hospital, will your fellow classmates be as confident with their diagnoses? especially with less than an hour of patient contact, no blood work, no x-rays, no labs, no surgery, only what you kept on your ALS ambulance?

If so, than I want to go to your medical school, because most doctors can't.

 

[systemet]

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.

I'm a non-US provider, so many of the issues described here don't affect my environment. It seems to me that the issues the physician faces are primarily created by his own administration.

His direct complaints regarding EMS seem to pertain to the temerity that "some feel the necessity to grumble all the way to the office of the CEO", presumably when they feel that they've been treated disrespectfully. It doesn't seem unreasonable to me that if the paramedic feels that he's been treated unfairly that he should be able to complain to his employer, who will eventually contact the physician's employer. This seems like a fine incentive for everyone to act in a collegial manner. If the physician is perceived to be rude, he will either be held accountable for it, or at least made aware that his actions were perceived as impolite. Presumably a mechanism exists for similar feedback to flow in the opposite direction.

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.

This is how I read it as well. However, I'd argue that as Spiderman's Uncle Ben once said (in a fictional alter-universe), with great power comes great responsibility. One of the physician's responsibilities is to provide feedback to colleagues and to (as much as this makes my teeth grate), "subservients". If events are occuring where there's unskilled practice, e.g. the esophageal / hypopharyngeal nasal ETI, then they need to be identified and put through a risk management / clinical education system, to protect future patients.

If the physician's administration is interfering with a necessary part of providing good patient care, then the physician is indeed right to complain.

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?

This relationship doesn't really exist in my environment. The same person writes both paycheques and funds both budgets. Most of the feedback I receive from physicians is offered in a friendly and collegial manner, which makes it much easier for me to listen, and frankly, more likely that I'll learn from it. As far as I'm concerned, I don't receive enough.

Over the years there's been a few problem physicians who have been consistently rude and inappropriate. They've generally been outnumbered by the large number of physicians who've been willing to answer my often ignorant questions and try and teach me to do my job better.

 

[Bullets]

So I am new here, and my wife is an ER Doctor. This is a recurring back and forward that we have. She feels like her job is to "clean up after our mess." Her thought is that whatever a paramedic decides to do in the field, is a mess that she will have to clean up after once they arrive in the hospital. She does not feel that paramedics should be allowed to operate within the maximum boundaries of their scope of practice, as outlined by their medical director, should the patient present with the respective criteria for procedures (i.e. intubation, etc.) Unless however, she knows you and can trust you. My argument is, you cant know every medic that comes in with a patient or calls in on the radio. As a receiving physician, you have to trust that the paramedics assessment is correct and warrants the requested procedure. Furthermore, you have to trust and understand that Paramedics operate under a Medical director who has outlined how a medic should respond/perform to given patient presentations. She is not above pulling a medic aside and providing constructive criticism, however her thought is based entirely on whether or not she know/trusts said medic.

At least in my service, your wife is more then welcome to ride out with us and learn what we do, what we cant do, why and how we do it. I always welcome someone who is willing to expand their knowledge of the EMS system on my truck. Especially Doctors. I have found that is the fast way to change our protocols, when you explain we do Treatment A because of Rule B. Its how we got epi-pens before most other services

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?

This doesnt hold true in my area either. Most patients know where they want to go, and they choose. Plus the hospital is in my town, so its a pretty simple choice. Even the contiguous towns let the patient choose. EMS may bring the patient, but they dont decide the destination in most calls, only the specialty cases

I dont feel privileged, because people would find a way to get to the hospital without us, we just happen to be free

 

[Carlos Danger]

Yes, when you consider the primary definition of subservient is "Prepared to obey others unquestioningly". This is not an appropriate attitude to have in medicine. He may have meant the second definition of subordinate, but if he did, he should have said that. I completely agree that EMS personnel are subordinate to doctors, but no one should be subservient to someone else in medicine, regardless of the titles involved.

There are many definitions for "subservient".

Given the generally positive tone of the author's article and his apparent good faith, I do not think it reasonable to automatically assign the most negative possible meaning to his intent.

Maybe this is part of what he was talking about?

I'm sorry, did i say working in an ED was easy?

Please refrain from putting words in my mouth, or making assumptions about what I am saying

What you originally wrote was:

"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....."

They have "more help". They have "more light". They don't work "on the floor", or in a "crack den".

All technically correct, of course.

However, combined with the context of the rest of your post, those terms absolutely imply that doctors "don't have it tough like we do". And that's a common sentiment among paramedics, anyway.

If you don't want people to make assumptions about what you mean, then you need to take pains to make sure your communication is very direct and clear. I'm a smart enough guy that if I interpret a given statement a certain way, it's a safe bet that I'm not the only one.