Professionalism in EMS

[Tapout 42]

Here's the deal... I posted last week all angry about the negative feedback I was getting from patients and their family members about the EMS personnel who brought them to me. I got jumped on in the ER (more than usual) about things like face piercings, neck to chest tats, full-sleeve tats, mohawks, nine piercings in each ear... the full gamut.

Then, the week ended with a local medic who brought in a septic old lady--- he had the cojones to argue with the lady's son over the fact that "she looks fine. Nothing's wrong with her." That son was a doctor but kept that fact to himself till he got to me. The medic kept telling the son he was wrong in his concerns, overreacting, not correct in thinking she even needed to go to the hospital... not knowing he has a doctor. That son went up 1 side of ME and down the other immediately upon arrival in my ER over that "know-it-all- I have Xray and CT scan-vision" medic with the nasty attitude. That lady came in with a 101.2 temp and taching at 156. Nothing wrong? Really? OK. You'll hear about it next time you bring me someone your xray eyes tell you I don't need to treat.

NOW-- to the medic who brought the very same lady back to me the very next day she was discharged from the hospital (again, with sepsis and a UTI): you were wonderful. YOU convinced her she needed to come back to the hospital and you were absolutely correct. Again, she arrived with a temp of 102.3. Again, she was taching in the 160's. She adored you. Thank YOU for exemplifying professionalism, altruism, and just everything that motivates us to do what we do for the RIGHT REASONS. I hope you get this message (ALL of you, with or without xray vision).

Off the soap box now. Good night, all. Be safe.

Tapout

[Goose 188]

The same thing happens to me every week at work, only takeout medic and insert ER nurse. Wouldn't it be more effective to grab whoever it is you're talking about to give them a pat on the back or tell them they should shape up?

[WAS967 97]

Gotta go with Goose here. Ranting to the masses on here won't get the message to who matters - the people causing the problem.

I know if I were the medic on either side of the example, I'd want someone to give me feedback on the care I provided (preferably in a constructive manner). If I gave good care (both medically and psychologically) then let me know I'm doing something right - cause frankly we don't often get to hear from "the other side" about how we affected the outcome of the patient. If I'm being a lazy douche, I'd hope someone would call me on it and set me straight before I do something that would have a negative outcome for the patient (or my career).

[Tapout 42]

Not ranting at all. Just sharing so you reading might learn from it. I already pat the good guy on the back. Bad guy medic I will catch another day.

[x635 4,066]

Ranting to the masses on here won't get the message to who matters - the people causing the problem.

Actually, you'd be suprised at the people who read this forum. And the post to the "masses" may cause some Medics and others to think.

This is why ER nurses need to be involved in call audits as well. I've also noticed that you earn a reputation with ER nurses and MD's. The better the medic you are, the better you are treated and the better you reputation with the hospital and your co-workers. Everyone knows who the lazy medics are, and who come across with an unprofessional image. Much of that is the lack of EMT's and Medics and the compensation. Down here, a Medic in my county STARTS at $60,000 a year and are civil service with 20 year retirement. But that ambulance is ALWAYS shining and the medics ALWAYS look military sharp. And, they are held to HIGH standards in all they do. You get what you pay for.

Also, working in a busy city ER as an EMT for several years myself, you really get to know the patient well and see the outcomes. And you really can see the difference a good or bad medic team makes.

As an EMS provider, you're not only making an impression on yourself, the ER nurse, and the patient, but also family, bystanders, etc. Sometimes just being nice and respectful to the patient and communicating with the family is all the patient care you need. If you know the person doesn't need a cardiac monitor or whatever else (not drug wise) but the family asks, what's the harm with putting on the monitor? Or starting the IV to save the ER staff time so the patient can be treated quicker?

Much of the blame here should be placed on EMS agencies. Many don't (or don't have the funding) for proper quality improvement and insurance on the customer service side. Many don't focus on the patient's experience with the provider, and only have the time/money for reviewing patient care reports as required.

[Mark Z 18]

Actually, you'd be suprised at the people who read this forum. And the post to the "masses" may cause some Medics and others to think.

This is why ER nurses need to be involved in call audits as well. I've also noticed that you earn a reputation with ER nurses and MD's. The better the medic you are, the better you are treated and the better you reputation with the hospital and your co-workers. Everyone knows who the lazy medics are, and who come across with an unprofessional image. Much of that is the lack of EMT's and Medics and the compensation. Down here, a Medic in my county STARTS at $60,000 a year and are civil service with 20 year retirement. But that ambulance is ALWAYS shining and the medics ALWAYS look military sharp. And, they are held to HIGH standards in all they do. You get what you pay for.

Also, working in a busy city ER as an EMT for several years myself, you really get to know the patient well and see the outcomes. And you really can see the difference a good or bad medic team makes.

As an EMS provider, you're not only making an impression on yourself, the ER nurse, and the patient, but also family, bystanders, etc. Sometimes just being nice and respectful to the patient and communicating with the family is all the patient care you need. If you know the person doesn't need a cardiac monitor or whatever else (not drug wise) but the family asks, what's the harm with putting on the monitor? Or starting the IV to save the ER staff time so the patient can be treated quicker?

Much of the blame here should be placed on EMS agencies. Many don't (or don't have the funding) for proper quality improvement and insurance on the customer service side. Many don't focus on the patient's experience with the provider, and only have the time/money for reviewing patient care reports as required.

I agree that QI is not given the importance it should be everywhere but there is much that can be done that doesn't require funding. I am posting this link to the Medic 999 Blog because he is far more eloquent than I am.

Edited May 13, 2010 by Mark Z

[GAW6 66]

In our VAC, we send out "comment cards" to each patient after a call. They work very well, because not only do donations come with them, it is important for the crews to get a "pat on the back", since 99.999% of the cards that come back are very positive.

[NWFDMedic 58]

As an EMS supervisor, if an ER nurse got a substantiated complaint like this from a patient's family (especially a doctor), I'd expect them to be making a phone call to me. There's NO excuse for a medic to be trying to convince an elderly patient or their family that they don't need to go to the hospital. Furthermore, there's no excuse for that same patient, given the vital signs that you noted not to be an ALS patient.

In the words of the State, it is the responsibility of all EMS providers to suggest that a patient goes to the hospital for evaluation. I know there are situations that clearly don't warrant it but I've never found occasion to tell a patient that they don't need to go to the hospital. The closest I came to it was probably a patient who called because their home BiPap machine was set incorrectly when delivered that day and she was having trouble breathing in bed because of it. We fixed the problem and she immediately felt better. My response to her was "would you like to go to the ER to be evaluated?" not "now you're fixed, you don't need to go". As expected, she said no, so I then informed her that a period of time without the proper oxygen may cause problems that should be evaluated. Again, as expected, she said she was fine and didn't want to go. She was then advised of things to watch for and to call back at any time if needed.

I knew this patient needed a hospital no more than I did but it's my responsibility to do what's best for the patient, not to mention what the state REQUIRES. Stories like yours are precisely the reason why we don't have paramedic initiated RMA's in New York. It's a shame that we don't because sometimes I feel we are doing a disservice to the patient and the ER by transporting them for no reason but when you hear of medics who can't discern what a good reason is, I can see why the folks at SEMAC wouldn't want to even consider the paramedic initiated RMA.

[PFDRes47cue 653]

In our VAC, we send out "comment cards" to each patient after a call. They work very well, because not only do donations come with them, it is important for the crews to get a "pat on the back", since 99.999% of the cards that come back are very positive.

You also might get some nice slogan or motto ideas from them!

[jtarby 3]

In our VAC, we send out "comment cards" to each patient after a call. They work very well, because not only do donations come with them, it is important for the crews to get a "pat on the back", since 99.999% of the cards that come back are very positive.

Just curious, do you filter who the cards are sent to or is it done automatically regardless of the patient recovery following the call? I was thinking that this was a great idea then I had this uncomfortable thought that we should know the status of the patient before we went ahead and sent a comment card to the house. I would hate to send a card to a house asking them to evaluate our service if it turns out that the patient never made it home. The last thing they would be thinking of is giving feedback to the ambulance crew. Of course a few months later they might come back and thank us for our efforts, but timing is everything in these cases and we need to be sensitive to the family.

[WAS967 97]

You'd be surprised how often positive feedback comes back about a medically bad situation. I've seen thank you cards come back from cardiac arrests, fatal car accidents, etc. Remember when you're at a patient's home working an arrest (or any call for that matter), it's just as much about how you treat the family/loved ones as it is about how you treat the patient. I'm not saying to take focus away from the patient care, but tossing a little reassurance, explanation, etc at the family in the process does wonders for overall satisfaction scores.

[PFDRes47cue 653]

Just curious, do you filter who the cards are sent to or is it done automatically regardless of the patient recovery following the call? I was thinking that this was a great idea then I had this uncomfortable thought that we should know the status of the patient before we went ahead and sent a comment card to the house. I would hate to send a card to a house asking them to evaluate our service if it turns out that the patient never made it home. The last thing they would be thinking of is giving feedback to the ambulance crew. Of course a few months later they might come back and thank us for our efforts, but timing is everything in these cases and we need to be sensitive to the family.

We do not send cards to cardiac arrests and to calls when the patient dies. However, you would be surprised at how often we receive letters/donations from family members thanking us without receiving a comment card. The cards have worked great for us!

[Tapout 42]

Great feedback from all of you. Thank you. I, as the receiving ER RN, promise to continue to provide the following:

I will immediatley, upon arrival and hand-off, thank you for your wonderful, kind care and the line/bag-o-bloods: or

I will ask you why you didn't start a line on an old lady with a baking temp or a young dude after a drug OD ( there have been several of those over the past month); and

I will tell you why you need to apologize to the family who is pissed off at ME for YOUR insensitive, unsympathetic pre-hospital care.

Fair enough?

So, WAS967, is this all still ranting or is it now constructive discussion? Just curious.

[WAS967 97]

Sorry if my comment landed too hard - perhaps ranting was the wrong word? But I would indeed call it constructive discussion. Let's continue.

On the note regarding IV starts on drug ODs, here's my thoughts as I've had a related call not too long ago. You have a young man who recently relapsed into his heroin addiction....found unresponsive by family (who gave rescue breaths for a brief period) but now conscious and alert but still slightly somnolent (barely if at all - converses well). Patient is nonviolent and cooperative but refuses a line or IM narcan. Transport is uneventful, patient remains awake with good vitals and SPo2. Do you force a line and meds on this patient risking him becoming uncooperative, or do you transport as is and respect his refusal despite his drug abuse in the interest of crew and personal safety.

[Mark Z 18]

Sorry if my comment landed too hard - perhaps ranting was the wrong word? But I would indeed call it constructive discussion. Let's continue.

On the note regarding IV starts on drug ODs, here's my thoughts as I've had a related call not too long ago. You have a young man who recently relapsed into his heroin addiction....found unresponsive by family (who gave rescue breaths for a brief period) but now conscious and alert but still slightly somnolent (barely if at all - converses well). Patient is nonviolent and cooperative but refuses a line or IM narcan. Transport is uneventful, patient remains awake with good vitals and SPo2. Do you force a line and meds on this patient risking him becoming uncooperative, or do you transport as is and respect his refusal despite his drug abuse in the interest of crew and personal safety.

Pt conversing well, good vitals, it is possible a line is not neccessary and why risk dealing with an uncooperative pt. I would agree with your choice given the information you have given me, but would ask just one question; how was the pt trending? Did he have periods of diminished responsiveness or was he slowly becoming more and more alert?

[ny10570 745]

If he's breathing well he doesn't need narcan. Our job is not to ruin someone's high.

[Tapout 42]

"Sorry if my comment landed too hard - perhaps ranting was the wrong word? But I would indeed call it constructive discussion. Let's continue. "

Duly noted and totally forgiven. Now let's move on.

Regarding the young man awake and alert, I completely agree-- let the line wait till you arrive in the ER. For the young man I mentioned, however, he rolled in looking pale as if he was lying in a casket, totally unresponsive to anything but my ratty knuckles rubbing into his sternum- hard. Would you have lined THAT guy?

And for the older woman who OD'd on over 40 pills (2 different kinds) of antidepressants and was twitching and babbling incoherently, with a very irregular HR in the 150's and a BP of 80-90 systolics, would you have lined her too?

For the record, neither came in lined. Both survived just fine- the younger AMA'd when his high wore off and the lady spent 24hrs in the ICU on a Cardizem drip for 12 hrs of that stay. Both will very likely be back.

Please share your perspectives on both scenarios.

[Mark Z 18]

"Sorry if my comment landed too hard - perhaps ranting was the wrong word? But I would indeed call it constructive discussion. Let's continue. "

Duly noted and totally forgiven. Now let's move on.

Regarding the young man awake and alert, I completely agree-- let the line wait till you arrive in the ER. For the young man I mentioned, however, he rolled in looking pale as if he was lying in a casket, totally unresponsive to anything but my ratty knuckles rubbing into his sternum- hard. Would you have lined THAT guy?

And for the older woman who OD'd on over 40 pills (2 different kinds) of antidepressants and was twitching and babbling incoherently, with a very irregular HR in the 150's and a BP of 80-90 systolics, would you have lined her too?

For the record, neither came in lined. Both survived just fine- the younger AMA'd when his high wore off and the lady spent 24hrs in the ICU on a Cardizem drip for 12 hrs of that stay. Both will very likely be back.

Please share your perspectives on both scenarios.

1rst male pt;

Pale, unresponsive to painful stimuli, Yes and probably used Narcan as well. I would suggest he be on a cardiac monitor and Hi-flow o2 as well. I might consider an NPA as well.

2nd Pt:

I am going to assume that she was on a monitor, but add hi-flow o2 and yes she would have gotten a line and depending on transport time and what medication she overdosed on, dealt agressively with the arrythmia.

[Goose 188]

Titrate the narcan @ 0.4mg intervals until his respiratory rate is sufficient. Second lady should get a line as well, maybe a 250 cc bolus to see if that pressure can't come up?

[WAS967 97]

Hell yeah, I would have lined both patients. Narcan for the first (SLOWLY and in the aforementioned small (0.4mg) doses. Fluids for the lady (making sure she's no going into APE), try to ID the pills, consult with MC and PC, and treat what we can. Did they find out what antidepressents they were? Some ODs, especially psych meds, can be tricky.

Related: How many people make use of end tidal capnometry on non-intubated patients? (IE....the nasal detectors). I would likely have used such on both patients as well.

EDIT: Oh yeah, don't forget to 12-Lead the lady.

EDIT EDIT: To play devil's advocate, there could well have been reasonable explainations on why they had no line in the field. Short TXP times (where did they come from?), difficult vasculature (did they at least TRY?), busy doing other things (BLS before ALS - were they by themselves in the back and getting the basic stuff done and just didn't have time to get the LINE done?), etc etc. But I'm sure in many cases it does come down to laziness which is disturbing.

Edited May 21, 2010 by WAS967

[JohnnyOV 2]

If he's breathing well he doesn't need narcan. Our job is not to ruin someone's high.

Or ruin your night

[MerlinMedic 5]

Since we are talking about professionalism, how about letting the Sups & Management know when someone does right? The transport crew is early? They help clean up an other patient, help the techs lift a patient into bed? Just yesterday I had to order an EMT badge for our newest EMT. Unfortunetly, I lost the number of the company we order from, BUT, I had the name of manufactuer of the badges. A very nice & patient young lady dug thru 12 years of orders to find out which company we order from (can't go direct, Washington State requires Letterhead etc). She found the company we do biz with, their number & who I needed to talk to. Needless to say, I put a call back to her boss to compliment him for his employees hard work. He was very happy to hear about this, AND she will be very happy with the $50 bonus in her next pay check.

So, nurses, docs, not just from the ER, but the floors & whereever you see EMS: when you see us screw up, deal with it, when you see us doing right, let our bosses know!

[Goose 188]

Such a great post. Couldn't agree more about giving the attaboy or girl to that person at the very moment you made me feel you earned it. I tell the ems folks when they did a great job now more than ever. It's so well received.

Not to be a jerk or anything, but these posts are getting really bothersome to read. If you care that much, why don't you just pull this person aside and talk to them about it. I've said this over and over again, this is a personal beef between you and whoever this provider is. I don't really see the point of posting it up here. Frankly, it's getting annoying.

It's ironic. You talk about being professional but airing this stuff on EMTBravo doesn't really strike me as all that professional.

[INIT915 1,119]

Not to be a jerk or anything, but these posts are getting really bothersome to read. If you care that much, why don't you just pull this person aside and talk to them about it. I've said this over and over again, this is a personal beef between you and whoever this provider is. I don't really see the point of posting it up here. Frankly, it's getting annoying.

It's ironic. You talk about being professional but airing this stuff on EMTBravo doesn't really strike me as all that professional.

Why? It's a legitimate query. You yourself frequently mention why EMS garners little respect and always find themselves in a distant third place behind FD/PD, right? Well, these are among the reasons. No self respecting FD/PD that I'm aware of would allow someone in uniform with multiple face piercings, excessive tattoos, or a mohawk. Since 2008, you can't even get hired where I work with ANY visible tattoo, no matter how classy or conservative it is.

Career EMS cannot have it both ways. They cannot complain they are not taken seriously when they make no effort to present themselves as serious members of emergency services.

[Tapout 42]

You have missed my point entirely. There is no vendetta against anyone here and I am only airing my point of view. Why do you always seem to feel the need to take a positive, mature discussion to somewhere negative and "bothersome" to you personally? Seems unfair, given your own often polarizing and opinionated remarks here on these forums. I am here to vent the same as anyone else, not defend myself to you every time I post.

To anyone who finds themselves regularly offended by my comments here and find my opinion so bothersome, don't read beyond the big fat Tapout logo. It's your right.

INIT915, well-said, as usual. Thanks.

[WAS967 97]

To go back to the Narcan discussion, I was just talking to one of the docs the other night. She wondered why I called for her preference on using narcan on an overdose. I told her that while protocol says use it if you suspect it, I know many docs (and QA people) would just use it for the hell of it. Thankfully she agreed with my outlook of not using it and even said, if the patient is breathing and vitals are stable, let em be - you don't want em yacking all over the back of your ambulance and risk having an unstable airway to boot.

So, nurses, docs, not just from the ER, but the floors & whereever you see EMS: when you see us screw up, deal with it, when you see us doing right, let our bosses know!

THIS.

Way too many times the only time we hear from people is when they have something to b**** about. Why not call if there is something GOOD to report. One company I work for recently put into the public a form where people (anyone, but mostly other providers) can report back on positive feedback. I dunno if it's been used yet or not (I'd be saddened if it hasn't) but I think it's a step in the right direction. Would be nice to see some thick employee records not because of bad write ups, but good ones.