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Patient Care

The Patient-Provider Experience: The Silo Struggle

Have you ever been a patient in an ambulance, before or after becoming an EMS provider? Have you witnessed a loved one become a patient? How did it alter your perception of patient care? EMS World’s series, “The Patient-Provider Experience,” shares the stories of both patients and providers who have been impacted by their respective experiences with EMS—on or off the cot—and how these experiences changed the way they provide care.

There’s a reason why different grains don’t come off the farm and get mixed in the same silo. Ever get the stink eye at the grocery for putting almonds and pecans from bulk in the same baggie? Even if they’re the same price? Organized humans enjoy divvying things into matching sets because it brings comfort and a sense of satisfaction. Some of us need a good snuggle under a warm blanket of symmetry, please and thank you. Sometimes it’s an absolute necessity. Try working in the posterior of a disorganized ambulance without cursing a lot. Good @#$%-ing luck!

Divided We Scan

The specialties of modern medicine are a prime example of folks staying in their lane. Pulmonology, podiatry, and plastics just for a few options under the letter P. A recent effort to get a diagnosis for my long-term shoulder pain has reminded me of how a single specialty gets further sliced and diced.

I went to see an orthopedic surgeon who specializes in shoulders—yeah, just shoulders. Some Q&A, a physical assessment, and finally a steroid shot with an adios. I reported no joy, and an MRI was scheduled. Visit No. 2, and the news was “Your MRI is unremarkable, Mr. Cohen.” So now I have to get another MRI and see another orthopedic surgeon. She specializes in necks. Yep, just necks! And if that doesn’t work, I can move on to any other specialist in their practice. Doctors Handsy Harry, Betty Back, Nelly Knee, and Hip Henry are at my beck and call.

This level of specificity should allow them to perfect their diagnostic and surgical skills. It likely makes their practice highly efficient too. What about me, the patient? I may get bounced around with more appointments and MRIs. If I’m lucky, these two doctors in the same practice don’t wait till the annual Christmas party to talk to each other. If I’m really lucky, I get a timely diagnosis and treatment option. If not, there’s more pain in store, but at least it won’t kill me.

Let's Disagree to Disagree: A Cast Study

Let’s hop into our EMS silo: Four months ago a patient began to have bouts of epigastric pain that soon became constant, with spikes that left her writhing with discomfort. Now you’re assessing this 70-year-old woman with abdominal pain in the back of your ambulance. She complains of nausea, almost no appetite, and an increase in pain when she eats or drinks anything. She hasn’t had a bowel movement in two weeks. She denies vomiting, chest pain, shortness of breath, syncope, obvious hemorrhage, or recent trauma. She’s been taking leftover opioid pain medications from previous surgeries to take the edge off. Her abdomen appears bloated, and there is a slight but positive fluid wave when it’s tapped on her side. It’s tender to palpation, especially in the epigastric area. Otherwise her pain radiates diffusely to the rest of her abdomen. Her skin is pink, warm, and dry, and her vital signs are all unremarkable. Aside from arthritis she has a history of hyperlipidemia and DVT and takes meds related to it all. She doesn’t drink alcohol, use illicit drugs, and has never smoked. She has a family history of heart disease and pancreatic cancer. What’s in your differential?

This patient never actually called 9-1-1 for her chief complaint. Her husband took her to a GI doc, who performed a colonoscopy and said, “You’re constipated.” Her lab work indicated a slightly elevated CA-19, a marker with a high correlation to pancreatic cancer. Still the GI doc was unfazed. The patient, in ever-increasing pain, visited her trusted internist. He suggested another GI doc, who scheduled an ultrasound with guided needle biopsy to get a definitive answer. She was discharged to await the news over a long weekend. The results: pancreatic cysts and a liver hemangioma, both benign. GI doc No. 2 said, “This isn’t cancer,” and left the patient to writhe in pain.

A few more weeks of desperation, her pain ever-worsening, and they went to a local ER where a CT was performed, revealing tumors on her liver and pancreas. A urologist in the ER came by and said, “I don’t know why I’m here, this isn’t a urology issue,” all the while pressing on her abdomen, causing great pain. Quickly satisfied that she wasn’t his problem, the urologist whizzed out of the room.

She was admitted and referred for an oncology consult. Again, GI doc No. 2 said, “This isn’t cancer,” and she was discharged.

With a definitive “We don’t know what’s causing your pain” from GI doc No. 2, the patient’s husband asked her longtime internist to look at everything. His response: “This sure looks like pancreatic cancer. Go to hospital [xxxx] in [xxxx],” because that big-city facility is the best. A few days later they drove five hours from their medium-size city to that big city. The ER diagnosis: “You have cancer.” They drive back to their medium-size city. The patient’s husband angrily drops off every piece of paper, diagnosis, film, bill, and whatnot at GI doc No. 2’s office. The doc himself calls the husband, apologizing profusely, and schedules the patient for another ultrasound and biopsy within 48 hours. Another long, painful weekend for the patient, and she gets her diagnosis: stage 4 pancreatic cancer with metastasis to the liver. Finally, she has a diagnosis and gets into a care plan that includes appropriate pain management.

About 18 months ago this patient’s appetite gradually waned. This was not typical for her, but amid her near-constant pain from rheumatoid arthritis and joint replacements, it flew under the radar. No weight loss, no big deal—or so she thought. So also thought her husband, her oncology nurse daughter, and I, her paramedic son. The doctors weren’t alone in missing some things.

A Mixed Bag Can Be a Good Thing

I think I know what you’re thinking here: That’s terrible, I’m so sorry, you are in our prayers—empathetic responses we can all value in tough times. Why was my parents’ experience so difficult? It would be easy to say the GI doc was to blame for an inaccurate original diagnosis. None of us are right all the time. In my perfect world, someone in an organization looks at failures and inquires, “Was it our system that made this error possible?” That’s really difficult to do since the “organization” in question is our partitioned giant hairy sasquatch of a healthcare system. It’s hard to pin down or even see clearly unless you’re a little tipsy on a moonlit camping trip in the Pacific Northwest.

Let’s take just one small bite of the Bigfoot in the name of improvement. What if we developed an expectation of community among healthcare providers that insisted on routine connections from silo to silo? Had any of the physicians involved in my mother’s care spoken to one another in a meaningful way, her diagnosis and care could have been dramatically less difficult on my family. So, folks, open your silo doors! Let your lanes merge! Cardiologists, say howdy to hematologists. Nephrologists, nuzzle a nurse (but not in a “me too” way). Paramedics, shake hands with a proctologist…and then perform hand hygiene.

Capt. Dan Cohen is a provider of clinical education for Williamson County EMS in central Texas.

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