Patient-Centric Practices

     Customer service is a concept familiar to consumers. We purchase products and services, have good and bad experiences, then decide which merchants we continue to patronize. Those rules don't apply to regional monopolies like EMS--patients usually aren't able to choose which agency will provide their emergent treatment and transport. In many cases, the decision to dial 9-1-1 is the first and last time callers participate in planning their own prehospital care.

     The absence of competition can promote top-down corporate complacency, a sign of which is employees who allow their own preferences to supersede customers' needs. We who deliver prehospital care should occasionally remind ourselves that EMS is about providing services, not serving providers.

     Patient-centric systems discourage "cookbook" medicine and recognize that patients and their families are valuable resources during assessment and diagnosis. Our tone and body language can reinforce patience, empathy and a desire to be of service. By discussing rather than dictating treatment options, EMS personnel can encourage a team approach to problem-solving, including shared responsibility for prehospital care decisions.

     Let's see what it would be like to ride in such a system.

     Dispatch receives an alarm for a 28-year-old female complaining of shortness of breath. The patient's chief complaint and brief medical history are transmitted to the closest ALS unit, whose GPS receiver directs the driver to the correct address. En route the providers prepare, psychologically and strategically, for a patient who has been taking amiodarone for an unspecified arrhythmia.

     Pattern recognition is responsible for many of our prehospital conclusions, correct and incorrect. Limited by time, pressured by patients and peers, yet emboldened by experience, we confront and process decision points--sometimes superficially--in mental flow charts of differential diagnoses.

     Even when we lack sufficient data to make informed decisions, we still try to fit scenarios to familiar patterns. Sometimes we discard conflicting or ambiguous details prematurely to "confirm" a match. When we hear "28-year-old, short of breath," what patterns come to mind? A respiratory scenario, such as asthma? Anxiety? A lot depends on what types of calls we've handled recently, and the extent to which our diagnoses were reinforced by outcomes.

     Knowing the patient has a cardiac history should make a big difference in our evaluation of differentials. The unspecified arrhythmia certainly is worth noting. It could be atrial or ventricular; amiodarone is prescribed for both. Also, we know myocardial ischemia occasionally presents atypically--with shortness of breath, for example, instead of chest pain.

     We'll have to wait for an on-scene assessment to narrow our diagnosis for this patient, but at least we've chosen a plausible pattern: cardiac instead of respiratory.

     The ability to review patient profiles can be an important element of en route preparation. The technology is not complicated. Database management systems permit storage and retrieval of medical history documented on patient care reports. Some agencies use "homegrown" software developed with generic packages such as Microsoft's Access. Others have purchased large-scale CAD systems. Both should offer not only priorities and locations of alarms, but also summaries of previous calls, including presenting problems, treatment, transport decisions and outcomes.

     Limitations of electronic data are as old as computers. Patient details must be updated promptly and accurately to reap the benefits of prearrival profiles. A realistic goal for the next decade would be to share patient information between EMS, medical facilities and private practitioners. Administration, cost and confidentiality--not technology--are the impediments.