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Look Inside Part II: Taking Apart Your Practice

      Just as your car requires periodic maintenance to keep it running at peak efficiency, so does your practice of prehospital medicine. Oil changes, tune-ups, transmission services and tire balances/rotations are all essential if you want to keep your car on the road and out of the shop. Periodically taking the time to sit down and really look inside your overall EMS practice, and identify areas needing a little "tune-up," will help you keep your practice on the road of quality care.

   Last month in BTB we looked at a critical thinking/decision-making model that allows you to "take apart" a call. This month we follow up with a look at how you can assess and evaluate your overall practice of prehospital medicine. For the sake of clarity and ease of dissection, I've separated the practice of prehospital care into five sections.

   Patient assessment: Without question, the platform for any quality medical practice is patient assessment. It is the one skill you use on every call, and the one skill that truly determines how well or poorly a call may go.

   When you evaluate your assessment skills, it's helpful to look at multiple elements. First, look at your ability to identify and fix life threats. This represents the initial assessment/primary survey. Can you routinely assess airway patency, breathing adequacy and assess for circulatory compromise in 30 to 60 seconds?

   When you think about the focused exam/secondary survey, do you have the ability to sift through the pile of information you have gleaned during your assessment and from your diagnostics to routinely make the bread-and-butter diagnoses of your practice that you make day in and day out: hypoglycemia, asthma, TIA/stroke, angina/unstable angina/possible AMI? It's one thing to miss a medical condition that you may see once or twice in your career (e.g., a thyroid storm). It's another to misdiagnose a diabetic in the grip of hypoglycemia. Look hard to see if there is any particular area that seems to be more challenging or an ongoing stumbling block. Find it, and that's the place to start polishing up your assessment.

   Connectivity: In order to quickly and efficiently gather information about your patient and their chief complaint, you have to "connect" with your patient early in the call. Irrespective of the patient's age, level of impairment, education or socioeconomic background, you have to be able to make that bond occur. To continue to gather information as the call progresses and to be able to provide ongoing psychological support, you need to maintain that connection.

   As you assess this area of practice, recognize that many factors come into play relative to "connectivity." A caring, compassionate attitude is the foundation. Patience and excellent listening skills are key components as well. Solid job communication skills are a must. It's all brought together with a healthy dose of diligence/tenacity.

   Think hard about this area of practice. Are there any particular groups you find more challenging to connect with than others? Getting quality information and keeping the flow going throughout a call won't happen if you can't get and stay connected to your patient.

   Fund of knowledge: This can be a tricky area of medical practice to evaluate, to be sure. One can easily argue that no matter how much you know about any given area of medicine, you can always learn more. Aside from that philosophical angle, a practical approach is to ask yourself if there is any particular area of prehospital medicine that you seem to always have in question. Seek input from your medical director as well.

   The good news about fund-of-knowledge problems is that they can often be addressed quickly and easily. Once you identify the area(s) of weakness, doing additional reading, seeking out content-specific continuing education at base station meetings, workshops or conferences, or doing online CME can all help you become stronger.

   Skills performance: Assessing your skills performance is arguably the easiest part of evaluating your practice. Many EMS providers have comprehensive data relative to their skills performance, especially in regard to IV and intubation success rates. Advanced airway procedures, electrical interventions and RSI are usually tracked as well. How do your success rates compare with those of other members of your service? If yours are lower, look to see if it's just a momentary dip in what is your norm, or if this problem is more long-term—i.e., a progressive deterioration in skills performance.

   Documentation: This is an area of practice that probably gets more scrutiny than any other because it is linked to reimbursement, the patient record and use as a defense tool when lawsuits occur. If you are having more than your fair share of patient care reports kicked back because of reimbursement problems, it will be brought to your attention. On the topic of simply the "patient care" element of documentation, ask your service QC/CQI/TQM committee to pull a couple dozen of your reports and evaluate them for completeness and accuracy.

   As for the legal element, whenever you write a narrative, read it and ask yourself if it would sufficiently jog your memory as to the essential details of this call four or five years after the call occurred, when the lawsuit gets filed. If it doesn't do the job, focus on trying to write more meaningful narratives.


   If you truly wish to polish your craft as a prehospital practitioner, it requires periodic maintenance of those inner workings that only focused effort and introspection can provide. Keep your practice running smoothly: Look inside!

   Until next month…

   Mike Smith, BS, MICP, is program chair for the Emergency Medical Services program at Tacoma Community College in Tacoma, WA, and a member of EMS Magazine's editorial advisory board.

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