Quality Corner: How to Make Better EMS Providers
What can we do to help improve the quality of patient care by our providers? That’s a question every serious quality coordinator has asked. The question is simple, the answer not so easy. The array of EMS providers at any agency will run the full spectrum of experience and skills. I’ve thought a lot about this question and discussed it with some of the people I consider to be the best EMS providers.
The three things I’ve settled on telling new medics I precept to help improve their proficiency are:
- Assess your patient early and often.
- Maintain a high index of suspicion.
- Do call research.
Assess Early and Often
The first and most important thing any EMS provider should do is assess their patient. You can’t treat them if you don’t know what ails them. Sometimes what ails them will be obvious at a glance, others it may take a whole lot more time, tests and smarts than just 15 minutes with a paramedic will allow, but we should always make the effort to figure out what’s going on with our patients.
Patient assessment is job number one of EMS. This assessment should begin without delay, immediately upon making patient contact and be documented as such. Of course, obtaining a full set of vital signs should be done as soon as possible, but occasionally obtaining a blood pressure or pulse ox may be delayed due to an uncooperative patient or the patient being entrapped, where certain interventions take priority.
In these cases a rapid patient assessment should be performed, noting the general appearance of the patient, skin color, capillary refill, and rate and quality of their pulse. This should provide a quick and fairly accurate read on the patient’s cardiovascular status. The blood pressure and pulse ox should still be acquired as soon as is practical to confirm these findings. But with or without obtaining a BP or pulse ox, you should assess your patient as completely and as soon as possible, and document that assessment as having been completed. It looks horrible if no assessment or vital signs are documented for several minutes after patient contact and leaves the reviewer to wonder what the providers was doing all that time if not performing their initial assessment.
Beyond assessing your patient early, your assessment should also be ongoing. Disease is a dynamic process. The one thing that can be guaranteed is that your patient’s condition will change from minute to minute. Changes may be as simple and inconsequential as a slight decrease in their heart rate as they’re reassured and calm down, or it may be more dramatic and critical as having a change in their level of consciousness, or degenerating into respiratory or cardiac arrest. If you are not constantly reassessing your patient, you may miss something very important.
As with your initial assessment, don’t forget to document your re-assessments. Repeated documented assessments and vital signs are proof that you did, in fact, continually re-assess your patient. And in most cases after you start treating a patient, subsequent vital signs will demonstrate an improvement in the patient condition, which will prove your treatment was appropriate and make you look good.
Index of Suspicion
At this point in time, it’s a pretty well-established practice to over-triage trauma patients to trauma centers. EMS providers consistently do this based solely on mechanism of injury and the suspicion of potential injury. As an International Trauma Life Support (ITLS) instructor, I believe one of the most important pearls of wisdom in the provider manual is the one that states, “5% to 15% of seriously injured trauma patients will initially present with normal vital signs and no sign of anatomical injury.” The obvious reason for this being you can either bleed slowly or you can bleed fast. Fast bleeds will be obvious, slow bleeds not always so. Consequently, it is rare in most places nowadays for a seriously injured patient to not end up at a trauma center.
Doesn’t it make sense to apply the same standard to medical emergencies as well? As previously mentioned, disease is a dynamic process. A patient who syncopizes or has a near syncope may bounce back to their baseline with perfectly normal vital signs by the time EMS arrives, which sometimes may lead the patient to question whether they didn’t overreact in calling 9-1-1. Not unlike the trauma patient, medical patients can be sicker than they initially present, as the body does what it was designed to do—fight to maintain homeostasis. Patients can crash fast and quick, slow and gradual, or they may alternate between compensating and decompensating. Consequently, the only warning you may get of imminent cardiovascular collapse is the initial (prodromal) event.
Many patients will experience syncope or near syncope without sequelae or further deteriorating. Unfortunately, there is no way an EMT or paramedic can know for sure which of these patients will be OK and which are on the verge of collapse. Our job as EMS providers is to maintain a high index of suspicion, err on the side of caution and not miss anything. All patients who exhibit any potentially serious symptoms, such as near syncope, sudden onset of dizziness, weakness or shortness of breath, should be considered sick until proven otherwise, rather than assumed to be OK until they prove not to be by crashing. Also beware of the patient who intuitively knows enough to call 9-1-1 but cannot offer any more specific complaint than they just don’t feel right; many times these prove to be seriously ill patients and this is actually a fairly common complaint among women suffering myocardial infarctions.
Lastly in my triad of suggestion to improve quality of care among EMS providers is call research. A good friend and colleague of mine, Layne Shore, was a combat medic with the U.S. Army’s 82nd Airborne before becoming a civilian medic. He tells his students, “If you spend just 15 minutes a day studying your occupation, you will be in the top 5% of your profession.” I’ll add a corollary to Layne’s advice, based on my own personal experience. If you look up every drug, disease and syndrome you come across during the course of the calls you run, you will be amazed at how much medicine you will learn in just one year.
For my first 20 years in EMS, if you wanted to look up a medication you had to purchase a Physicians’ Desk Reference. If you wanted to look up a medical term you had to buy a medical dictionary. And if you wanted to look up a disease or syndrome, you had to have a Merck Manual. That was a lot of books for a lot of money, and you either had to lug them around with you or leave them at the squad and hope they’d still be there for your next shift. Nowadays call research is easy, convenient and literally at the tips of your fingers. Enter anything into an Internet search engine and you’ll get numerous sources of information. Look over a few of them and you’ll have a pretty clear understanding of what it is you looked up.
There is no shortage of good advice to help EMS providers old and new improve their knowledge and skills, and I do not suggest I have the final say on it here. But after 32 years in EMS, and a decade as a quality coordinator, the above suggestions seemed to me to be a good place to start. They are three easily remembered, simply executed items, which I believe, if followed, will greatly improve the quality of patient care of any EMS provider.