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Skip Kirkwood responds to ACEP physician issue with EMS feedback

"Culture of Silence" – meet – EMS Advocate

Dr. David Baehren posted an article in the American College of Emergency Physicians News on June 13 about the difficulty in providing feedback to EMS crews.

Along with this positive transformation (post 9/11 heroship), I also noticed that providing feedback to the EMS community became more difficult. Even writing what you are about to read is really sticking my neck out.

What I have found, over the past decade, is that people in the EMS system tend to bristle at negative feedback and even find ways to turn it back on the person who is trying to be helpful. Suddenly the person trying to be the good guy is the bad guy.

You can read the entire "Culture of Silence" here. 

Skip Kirkwood responded to the article, posting his email to a FaceBook link I posted to original article:

Hello Dr. Baehren;

I thought I'd provide some feedback on your article, off-line because I'm not an ACEP member I couldn't do it via the web page.

First of all, the EMS community seriously wants feedback – feedback about the performance of the EMS system, as well as feedback about additional performance. The latest effort in the industry is the establishment of bi-directional data interfaces between the electronic medical records systems of the EMS agency and that of the receiving hospital. It is very rewarding – and very educational – for an EMS medic to be able to (within hours or a day after a patient encounter) to look and see how well their own assessment and treatment line up with those of the receiving physician and the hospital team. I think that the questions about immediate, direct feedback have to do with when, where, and how – not the "if" – of feedback. Did the patient I thought was having a STEMI go to the PCI lab? Did they get a stent? Surgery? If not, what was the diagnosis? This level of information greatly facilitates self-learning.

It's important to remember that in most states, EMS personnel work under the medical direction of a particular physician. Some states have taken this direction a bit further, with the creation of regional and state protocols. If "feedback" means delivering negative information, it may be best delivered through "their" physician. Unlike years ago (I've been active in EMS for the last 40 years), most EM physicians are not involved at all with EMS – and many of those have not taken the time to familiarize themselves with the local and regional EMS system and its medical standards – I hear many times that medics are "called out" in the ED for not administering drugs that are not carried by the EMS system, that are not included in the local protocols.

An interesting illustration that has recently surfaced – for many years, EMS protocols required that nearly everybody with a traumatic injury be fully (and often painfully) be immobilized on a long spine board. Even knowing that this was not optimal care, medics put the patient on the board – and were greeted with derision, sarcasm, and belting comments from physician and nursing staff. Within the last few months, the American College of Surgeons Committee on Trauma and the National Association of EMS Physicians released a paper that drastically altered the standard of care and caused EMS protocols to change. Now, few people get immobilized on a backboard. All of the ED physician groups and the nurse managers were informed (and in fact they all voted to approve the protocol, via the county EMS advisory group). Now, when the medics bring in patients not on a backboard, the eye-rolling and other unprofessional behavior begins. Interactions like these have many EMS medics believing that they are in a no-win situation where they are simply a target for ED staff to vent their spleens when they're having a bad day. This, in one of the most well-recognized EMS systems in the United States, with two full-time EM physicians, EMS fellowship trained, on the staff, available for call 24 hours per day.

As I've aged I've become more about education, and I've had to learn some about the science of learning. One of the so-called "laws of learning" is the law of readiness. Adults learn best when they are ready to learn. That may not be the situation after their 13th call of a 12-hour shift, with an ambulance full of blood or vomitus that is waiting to be cleaned – like the ED staff, they may be tired and annoyed themselves, not wanting to hear "feedback" from a stranger who is not known to them, not part of their organization, not part of their chain of command. If our concerned ED colleagues took the time to document their concerns and send an e-mail to the local medical director, with supporting hospital documentation, the feedback that you'd like the medics to receive would probably be received – by a more receptive audience, and if an issue or trend was significant, by the whole EMS agency at their next M&M conference.

We all recognize that much of EMS over the years consisted of voodoo medicine. We followed protocols, written by physicians, that were not based in science. We've been "had" by the "golden hour" that is not and we've administered drugs that the scientific organizations categorize as class III or class IV – not helpful. And we've been ordered to provide treatments that we know are bad for our patients, or uncomfortable at best, because the expert physicians at the American College of Orthopedic Surgeons have prescribed them. So those who read the literature may have some built in skepticism about the value of feedback from a physician who is not known to them, not known to be conversant with the EMS literature, and not involved in the local EMS system. Finally, we actually have some evidence-based performance measures that we can look at. Evidence-based performance measures for emergency medical services systems: a model for expanded EMS benchmarking. Myers JB, Slovis CM, Eckstein M, Goodloe JM, Isaacs SM, Loflin JR, Mechem CC, Richmond NJ, Pepe PE; U.S. Metropolitan Municipalities' EMS Medical Directors. Prehosp Emerg Care. 2008 Apr-Jun;12(2):141-51. doi: 10.1080/10903120801903793. PMID: 18379908 [PubMed – indexed for MEDLINE]

Last, I would be remiss if I failed to mention that in most communities, the care provided by EMS personnel is probably acceptable or better 80% of the time, and problematic 20% of the time. If receiving physicians want to be able to provide feedback on the 20%, they also need some investment in the 80%. A little positivity goes a long way toward building relationships, and once there is a relationship the "criticism" is easier to receive – particularly if it is delivered privately, in a helpful and educational manner.

In closing, you've initiated a good conversation. However, it is one with two very valid sides. It would be helpful if your colleagues were able to hear both sides of the discussion, and in doing so perhaps help to improve the overall dialog between emergency medicine physicians and the prehospital community.

Mike "FossilMedic" Ward

Comments - Add Yours

  • Anthony Correia

    Well stated Skip. Glad your willing to take the time write out a very intelligent and factual based commentary that most of us are thinking.

  • mr618

    Another part of the problem — although, thankfully, it’s getting smaller and smaller — is that some doctors still don’t feel that paramedics and especially EMT-Bs should be doing anything other than transporting. We have one doctor in our general area who never misses an opportunity to point out that medics aren’t doctors and shouldn’t try to “play” doctor. As far as basics go, he calls us “hyperactive Boy Scouts.” And yet he still wonders why we ignore him when he starts in on us. And, no, he is NOT trying to help us become better practitioners by teaching us how to do something better, he is repeatedly telling us that “only doctors” are capable of providing proper patient care. Oh, and he doesn’t do it quietly either: it’s a case of “everybody listen up, our make-believe doctors have done it again…”
    Since I believe that “what goes around, comes around,” maybe one day, one of these “make-believe doctors” will save his sorry ass. THEN he might understand a little better. But probably he won’t… it’ll still be the medic’s fault somehow.

    • MerlinMedic

      I think it is time to take his comments to the hospital; he is creating a hostile work environment. : ) Either that or take your patients elsewhere if possible.

  • Joseph Zalkin

    I agree with Skip.

    Early in my EMS experience (34 yrs ago), I was instructing at the time at the then rural Cherokee Indian Reservation in Western North Carolina. I would hear an old Indian phrase that may apply here “Never criticize a man until you’ve walked a mile in his moccasins” I respect the authors opinion and hope my colleagues will see the various perspectives. We have in some ways programmed this endpoint by lack of inclusion of physicians in initial education at all levels. We don’t indoctrinate our peers in the ways of critical feedback in non confrontational means. (I am not saying that Medical or Nursing education have the total solution either) Every industry has similar “hotspots”. If we have learned nothing more with the S L O W adoption of Culture of Safety, there are STOP THE BUS moments. Know when they exist and techniques to communicate are paramount. I am happy to see the discussion – 1 step down (acknowledge the problem) – 11 to go

  • Matt Kivela

    Take these for what their worth — random ideas I’m throwing against the wall after reading through both.

    1) When I read the original article, I had to wonder if it wasn’t 9/11 so much as a generational shift. Welcome to the world where everything is T-ball and anything other then praise isn’t well received.

    2) Which was somewhat reinforced by the response that talked about “time to learn” and wanting to read computerized reports to self-learning. Egos don’t get bruised when you looking for the data that reinforces your belief.

    I would say most people, of all generations, are extremely susceptible to selective exposure. Given access to more or less raw data, they’re not going to be autodidactic and tease out the lessons in it — they’ll skip over anything contradictory to find “Look, I was right!” moments in it. Proof #1: The Internet.

    3) Most people, most of the time, are resistant to change.

    Folks like Baehren and Kirkwood no doubt get excited about learning new ways to do things in emergency medicine.

    Unfortunately, a lot of EMS providers don’t — motivation is often lacking to begin with, and learning a new way of doing something is far harder then learning to do something new, especially if they don’t personally perceive the old way as “bad” somehow. That’s a double hurdle which is difficult to overcome.

    4) And I didn’t have point 4 when I started typing, but I think I stumbled into a point — correcting someone in the ER isn’t going to work. Expecting them to find their errors on a computer screen isn’t going to work.

    Telling someone do it this way from now on isn’t very efficient.

    It needs to be a guided process. For well motivated individuals, that’s a lot easier to do.

    But perhaps you need to aggregate those computer reports to first establish “this is bad because” to develop some buy-in under motivated providers as to why they need to learn new ways.

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  • DaGonz

    ER physicians should be required to spend some time on the streets with the EMS crews and see what they deal with on calls. In an ER, the docs have justr about everything at their disposal, in the field the amount of equipment and meds is nowhere near what they have in the ER. I have also found that some doctors “talk down” to EMS personnel as if they are bastard stepchildren and don’t know anything; it is no wonder that EMS personnel get defensive when asked why they did what they did.

    • Traumamedic

      I also think nursing staff should have to do some ride outs as well… Many, many misconceptions about what we do and don’t do, what we have to work with and don’t have available to us exists here as well.

  • Nathan Stanaway

    I love that there are ED docs out there who care enough to provide feedback. Skip, as always brings up some really good points. This point he brings is, to me, the crucial point. Just because someone has something after their name does NOT mean they are current on best practices. Its a trust issue.. :)

    “So those who read the literature may have some built in skepticism about the value of feedback from a physician who is not known to them, not known to be conversant with the EMS literature, and not involved in the local EMS system.”

  • Brandon Oto

    Great response from Skip. A few other points I think are worth making:

    1. The word “subservient” should probably never enter any kind of professional discussion. It begs for a hot response.

    2. Despite that, if we’re going to reserve the right to get bothered by this kind of thing, we probably also have a responsibility to look for the truth behind Dr. Baehren’s words. Many of us don’t take criticism well. There are a lot of valid reasons for that, but also some that are less valid.

    3. The underlying problem here may not be anybody’s poor rearing, but rather, the lack of any effective or appropriate channel for this type of feedback. When there’s simply no good way to create a back-and-forth except extemporaneously in the ED hallway, even the best results will be sub-par. There should be comprehensive, continuous, and automatic avenues for feedback and follow-up to flow in both directions, and it’s absurd that this isn’t the industry standard in all areas and for all types of service.

    • Greg Friese

      Spot on about the use of “subservient”

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  • Greg Friese

    I think it is fairly common for just about anyone to bristle at negative feedback. This is especially common in relationships with a significant power and status differential.

  • Tom Bouthillet

    Here’s a hypothetical for you. Let’s say that a paramedic who happens to be the STEMI coordinator for an EMS system is performing routine review of 12-lead ECGs and comes across a textbook isolated acute posterior STEMI that didn’t appear on the quarterly STEMI report. On further investigation it turns out that the STEMI was missed by the treating paramedic, the ED physician, and the cardiologist (patient cathed 2 days later with 100% occluded LCX and diagosis of “non-ST elevation myocardial infarction”). How receptive do you think the physicians involved will be to “feedback” from EMS? It’s a two-way street, and Greg Friese is on to something when he brings up the status gradient. If you really believe in continuous quality improvement it doesn’t matter where the report of a possible error comes from.

    • Brooks Walsh

      Tom –

      I think many EM physicians and nurses would share your perspective. While we in the “ED fishbowl” often feel like we are critiqued daily by every other service and floor in the hospital, we have few opportunities to discuss the patient’s care after they leave the ED. The solution to this is, as you suggest, creating a “two-way street” culture, through committee appointments, joint projects, QA, etc.

      It seems as though many people are not commenting on what may be the most interesting part of Dr Baehren’s essay. He expresses frustration with the hospital’s role in creating this “culture of silence,” making it too risky for him to offer feedback, even in seemingly egregious circumstances. Otherwise, this might be viewed as just another “what doctors REALLY think about us” article.

      Not sure is this resonates with anyone else – thoughts?

      • Tom Bouthillet

        I don’t what to think, Brooks. It’s hard for me to imagine that legitimate attempts at respectful communication are rebuffed by the majority of paramedics. I also think it’s entirely possible for physicians and paramedics to have legitimate differences of opinion as to whether or not a particular treatment was appropriate under the circumstances. For example, I often have disagreements with our ED physicians as to whether or not a King LT is a “real” airway. Clearly this gentleman wants EMS to view itself as “subservient” and take whatever criticism is given as gospel. That’s not quite the same as being “collegial” is it? If he’s worried about EMS transporting pulseless patients to the ED then it seems to me he should take the time to ask the paramedics why they transported the deceased patient with a DNR to the ED. Perhaps there was a reason. The rightness or wrongness of the answer is less important than understanding what motivated the action. Then it can be addressed with the Medical Director. I don’t know Dr. Baehren. He may be the most diplomatic and sincere patient advocate in the world. Or, perhaps he’s an arrogant SOB with a God complex. Maybe he’s both. The truth is often complicated sometimes it’s helpful to consider that there are legitimate views and concerns on both sides. Without knowing exactly what transpired between Dr. Baehren and the EMS crew(s) in question it’s all just speculation but as a general principle there’s no reason that an ED physician, nurse, family member, or patient shouldn’t feel free to report a concern about patient care to an EMS system for the purposes of quality assurance and process improvement, and they should also be prepared to receive criticism. When it comes to quality it’s not the people. It’s the process.

  • jason buc


    I understand and appreciate your point about the laws of learning and readiness to learn. That said I would appreciate and prefer the ED physician to at the very least ask me to accept their feed back prior to taking it to my organization. I think most would agree with me there but I’m not sure.


  • Ginny Renkiewicz

    I agree with Skip. And I would also like to state that it is not Physicians v. Paramedics, but the culture fostered in the healthcare system that creates such a nonexistent feedback loop. I have had interactions with physicians that treated me as “subservient” (as an aside: what a VILE word) and have had much more positive interactions with physicians that saw me as an equal human being with a much different specialty. I would recommend that this particular physician read a risk management book entitled: “Safe Patients, Smart Hospitals” written by Dr. Peter Provonost who challenges the current cultural practices in the medical field that often lead to such derision between providers of differing training levels.

  • MerlinMedic

    How about docs that actually have a clue about EMS, our capabilities and our limitations? Or better yet, have read our protocols? I recently discovered one of our med control hospitals did not have a copy of ANY version of EMS protocols. I handed them mine from my pocket but, really? It would be great if nurses rode a shift or two with us just as to familiarize themselves to some of the reality of an ambulance as well, but… : /

  • Bob Sullivan

    Spot on Tom, and I swear, I wrote this before reading your comment…

  • ackabby

    a great discussion but in a brief search on Facebook..

    • ackabby

      ED physician and president of a cosmetic surgery company…….

  • PARAMEDIC70002

    I would love to get feedback on all my patients. The problem as I see it, we are trained to be emergency specialists for short term initial care. To a lot of medics, that makes every chest pain look like a critical cardiac emergency. Certainly we have no protocol for costrocondritis or pleurisy. Likewise we do not get in depth training on such things. At best there is a passing mention of non-emergent complaints in the EMS texts, while we hammer in the ACLS protocols. Is there really surprise that non critical complaints are misdiagnosed and mistreated as emergent illnesses? No EMS program is going to train providers to the same level as an emergency physician, but we really need better training in non emergent complaints so that we can develop a knowledgeable list of differential diagnoses. And ED physicians need to remember that we do the best we can with limited time, tools (labs, ultrasound, x-ray, CT, MRI), and education. We can run a Code just as well as a Doctor, other diseases, not so much. If I am approached at the ED by a Physician (or nurse) about my care or the patient’s complaint, I would like for him to discuss the issue in private and in a positive manner, so that we can all improve aqnd better care for our patients. When a Physician makes a mistake, there is a discussion, and everyone moves on. When a Paramedic makes a mistake, he is quite often crucified even though his training level is far below the Physician that gets a pass. I have one ED Physician that in the past couple of months has publicly (in front of staff and patients) and loudly castigated several EMS providers for either following, or not following, protocols, as the case presents, depending on what he thinks we should have done, or not done, for the patient. But when you call them on the phone or radio for a consult, they usually tell you to “follow your protocol” or “I can’t assess over the air” or they deny orders because “If he has to ask, I don’t trust his skills.” It’s very true that EMS is in a lose/lose profession. Whenever something goes wrong, blame EMS. They are the low man on the totem, and the supervisors frequently take the punishment to stay in the good graces of the Gods. This is true more often than not in 911, and even more so in transport roles. BTW and off topic, with a large number of medics working in transport, why is EMS education still centered on 911?

  • Burned-Out Medic

    i see nurses and physicians ask stupid questions and do dumb things all the time. i’d like to see them gracefully accept some feedback once in a while.

    I’d also love to see them find some manners when offering feedback to others.

    on a more admin level, my experience is that the only feedback i ever get is through informal backchannels via relationships i’ve carefully cultivated over years. every single time i request feedback or follow-up through formal channels, i get nothing, just that bullshit HIPAA excuse some hospital lawyer obviously doesn’t understand.