First Arriving Network
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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

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