Patient Handoffs from EMS to the ER, a Fictional Case Study (not a rant)

November 2, 2009 | ckemtp rants, Emergency Medical Services, Emergency Nurse, Emergency room, Emergency Room Nurse, EMS, EMS Topics, ER, Ethics, medical ethics, Paramedic, Patient Handovers, Patient Management, rant, RN, Transfer of Care | Ckemtp | 9 Comments

< Rant>

One of the burdens of having a �Popular EMS Blog� is that when someone ticks you off, you have the temptation to come down on them publicly, in blog form. The chance to fire off a scathing criticism of them and everything they stand for in the name of sweet revenge is a siren song that I have resisted up to this point.

And it�s one that I�m resisting today because I�m not that kind of guy. Systems and the way they work? Yea, they�re fair game for my rantings and aren�t spared very often, but people and individuals don�t get picked on here. I just don�t play that way. Everybody has a mother, including me, and my mommy wouldn�t like me behaving like that in the sandbox.

So the following is a completely hypothetical, fictional scenario that didn�t happen. If it happened once to someone I don�t know, then it must have happened a long time ago in an area far far away from anywhere I�ve been. I�m not saying that something like this has never happened to me, but if it did, I�m not writing about it here.

Got that? No picking on individuals here. If you read this and see yourself, then it�s your guilty conscience, not mine. It�s not my job to judge you. You�re the one that has to look at yourself in the mirror my friend. If you�ve done this to someone, have fun shaving and or fixing your hair without having to look yourself in the eyes.

So say someone in EMS gets called to a motor vehicle accident. Imagine that it was a high-speed, head-on MVC and the patient that the EMS person gets called to treat is a middle aged male who is pinned in the vehicle. The patient has multisystem trauma, but is fully conscious and alert. There is one glaring orthopedic injury that looks pretty gnarly, and some other more subtle signs and symptoms of traumatic injuries. Extrication is needed to remove the patient, and it takes about 20-25 minutes to be completed. During that time, the hypothetical EMS person we�re making up here is inside the vehicle, under a blanket, treating the conscious patient. He or She assesses the patient�s injuries, provides stabilizing ALS treatment, packages the patient to protect his injuries, and provides compassion and comfort to him as well. Under the blanket in the car it�s just the hypothetical EMS provider and the scared, injured, fictional trauma patient; During that time, a strong patient/caregiver relationship if forged.

Say that the fictional EMS person takes the fictional patient to Made-Up-Big-Trauma-Center � ER after providing further stabilizing treatment in the ambulance and rapid transport to the made-up trauma center. When the fictional EMS provider wheels the fictional trauma patient into the room where the fictional trauma team is waiting, He or She begins to rattle off the handoff report about the patient to the team. That�s when this happens: One of the fictional nurses on the fictional trauma team talks over the made-up EMS person and starts asking the patient questions that the fictional EMS person had just said. In fact, the fictional EMS person only talked for about 8 seconds before He or She is cut off by the fictional nurse. So, the fictional EMS person shuts up and waits for Who-Does-She-Think-She-Is to ask her questions to the patient, the questions that fictional EMS person was going to answer in just a second or two. Then, the fictional nurse says �Oh, I�m sorry� and let�s fictional EMS person start talking again. Fictional EMS person gets three words out until Ms. Important says �Wrap it up�.

Fictional EMS person wasn�t happy.

Of course, the above story is made up and never happened anywhere in the history of EMS. Trauma Center and ER nurses never treat paramedics like second-class citizens or unpersons. Prehospital assessment findings and patient reports are taken very seriously and are given the respect they deserve. Paramedics and EMTs are treated as respected colleagues by ER staff and work together to provide the best patient care through a productive and respectful working relationship.

Ewww, I think that I just threw up in my mouth a little. Lying does that to me.

So, I figure I�ve probably got a few ER nurses that read this blog thing. How do we fix our relationship in the name of patient care?

< /rant>

http://www.999medic.com Medic999

I feel your pain Chris!
Im sure that we all have experienced this, without exception, and one time or another. I certainly have on more than one occassion, but i dont think i was as diplomatic as you were.

Possible solutions – Get the ER/A&E nurses out on ride-alongs at least every 6 months. Only then can they appreciate the unique differences that we have in delivering care in a non clinical environment.

And then there is the other alternative – Rotate Paramedics through the ER as part of their rostered duties. Radical but not unheard of!

I have just got my nursing registration back again, and will be working some bank shifts in the A&E department soon. It should be a real eye opener, which I am looking forward to experiencing and sharing…..Hypothetically of course
mmorsepfd

A big problem here is from within our ranks. Inconsistancies are rampant. You, or I or Mark would present the patient at the ER proffessionally and hand things over, but others would give an incomplete report, or worse, a wrong one.

I try to put myself in the ER staff shoes when these things happen, and they happen a lot. The previous EMS crew could be terrible, and a lot is riding on what we say. All we can do is continue to do our best and not take it personally.
http://www.sja.ca/ Rob

As a first responder with a volunteer group, we are told in our training that the Paramedics will probably do to us what you are describing is done to them. While it's not polite to talk over you, re-asking the questions is important. Why? Well as Dr. House on TV likes to say, “Patients Lie”. Someone might not bother to tell us or even the Paramedic about the little blue pills they are popping like candy, but they may change their mind as they get to the hospital. In addition, comparing the answers can give an idea of LOA and changes in condition. Lastly, people make mistakes an since the paramedic who shows up doesn't know me from Jack, I understand that he wants to cover his own ass and re-assess from the start and ignore all my work. Because of this we are told to keep our report to the paramedic as short and sweet as possible. Just the facts ma'am, just the facts.
Ambulance_Driver

I have a saying that I'm fond of: “History never repeats itself.”

I've seen answers change too many times to be offended when an ER nurse or doctor asks the patient the same questions I've just given them the answer to.

OTOH, the fictional nurse in your fictional case was obviously being a condescending bitch.

In such fictional cases, I have been known to, hypothetically, give the fictional nurse ZERO information thereafter. I'll hand off the patient, smile ever-so-sweetly at them and say, “They're all yours!”

If they ask me for information, I make it a point to provide the information… to someone else, preferably while still in their presence.

We used to have a nurse who wanted to know everything from the patient's favorite color to their Zodiac sign when you called in a pre-arrival report – anything but relevant information. So, when I recognized her voice on the phone, I'd say, “Howdy, Gail! Five minutes out with a bad one!” or when she'd ask why we were bringing the patient to their particular hospital, I'd reply with “Because the zoo is closed and there's nothing good playing at the movies.”

It took about a week for the ER director to buttonhole me and ask why I did that, so I told him.

Gail is forbidden to answer the ambulance phone now.
http://www.sja.ca/ Rob

As a first responder with a volunteer group, we are told in our training that the Paramedics will probably do to us what you are describing is done to them. While it's not polite to talk over you, re-asking the questions is important. Why? Well as Dr. House on TV likes to say, “Patients Lie”. Someone might not bother to tell us or even the Paramedic about the little blue pills they are popping like candy, but they may change their mind as they get to the hospital. In addition, comparing the answers can give an idea of LOA and changes in condition. Lastly, people make mistakes an since the paramedic who shows up doesn't know me from Jack, I understand that he wants to cover his own ass and re-assess from the start and ignore all my work. Because of this we are told to keep our report to the paramedic as short and sweet as possible. Just the facts ma'am, just the facts.
Ambulance_Driver

I have a saying that I'm fond of: “History never repeats itself.”

I've seen answers change too many times to be offended when an ER nurse or doctor asks the patient the same questions I've just given them the answer to.

OTOH, the fictional nurse in your fictional case was obviously being a condescending bitch.

In such fictional cases, I have been known to, hypothetically, give the fictional nurse ZERO information thereafter. I'll hand off the patient, smile ever-so-sweetly at them and say, “They're all yours!”

If they ask me for information, I make it a point to provide the information… to someone else, preferably while still in their presence.

We used to have a nurse who wanted to know everything from the patient's favorite color to their Zodiac sign when you called in a pre-arrival report – anything but relevant information. So, when I recognized her voice on the phone, I'd say, “Howdy, Gail! Five minutes out with a bad one!” or when she'd ask why we were bringing the patient to their particular hospital, I'd reply with “Because the zoo is closed and there's nothing good playing at the movies.”

It took about a week for the ER director to buttonhole me and ask why I did that, so I told him.

Gail is forbidden to answer the ambulance phone now.
minnock

Sorry that happened – it should never…You are out there first to be attending to the patients, nurses need to listen, respect what you are informing them of. A factual,presentation of the patient chief complaint, medical history, medications and what treatments were administered.
Accuracy, accountability and facts help both EMS and ER provide the best possible care for the best possible patient outcomes. Isn't that why we do this?
There is a renewed appreciation for EMS when ED nurses do ridealongs. I did several. As a Director of an ER, it is strongly suggested when joining the ER – part of their orientation is a ride along in an ALS unit for a shift. No room for disregard and rudeness in this line of work!
edrn76

I have been in the ER for 9 years now and have observed the realtions between medics and RNs. I am an RN and have the utmost respect for medics. I for one could not do what you guys do in the field. My hat is off to you guys and gals in the field. I recently took over as the Trauma Coordinator for my hospital. One of my first goals was to improve the relations between medics and RNs. I am almost complete with my ride-a-along program here at our facility. I am going to make ED RNs do an 8hr ride-a-long with EMS during peak times. This will be part of their annual check offs and also part of orientation for new hires. I am also trying to talk the RNs to let the medics c-spine package them so they will know what the patient is going through when they are strapped to a board and have a collar around their neck. I think these things will be a real eye opener for some of the nurses. Thanks for the post and keep up the awesome work that yall do!
edrn76

I have been in the ER for 9 years now and have observed the realtions between medics and RNs. I am an RN and have the utmost respect for medics. I for one could not do what you guys do in the field. My hat is off to you guys and gals in the field. I recently took over as the Trauma Coordinator for my hospital. One of my first goals was to improve the relations between medics and RNs. I am almost complete with my ride-a-along program here at our facility. I am going to make ED RNs do an 8hr ride-a-long with EMS during peak times. This will be part of their annual check offs and also part of orientation for new hires. I am also trying to talk the RNs to let the medics c-spine package them so they will know what the patient is going through when they are strapped to a board and have a collar around their neck. I think these things will be a real eye opener for some of the nurses. Thanks for the post and keep up the awesome work that yall do!
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Chris Kaiser aka "Ckemtp"

I am a paramedic trying to advance the idea that the Emergency Medical Services can be made into the profession that we all want it, need it, and know it deserves to be.

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