I think that on a whole, people who work in the ED (doctors, nurses, techs alike) really don’t know how much your average EMS provider is trying to do the best job with each call – recognize all concerning exam findings, make smart decisions on treatments, and communicate all of that in a useful way to the ED. Being on both sides, I’ve noticed quite a few ways EDs send mixed messages that can be confusing to even the most seasoned EMS provider.
1. Stroke – time is of the essence
Or is it? At every level in EMS, we’re taught that a stroke is a “load-n-go” patient, that speed of arrival to the ED, potentially to receive tPA, is what counts as there’s a 3-4.5 hour window for the therapy to be administered safely (although more evidence surfaces daily questioning this).
Still, the standard of care is rapid transport, yet how many times have you transported a stroke patient and waited 5, 10, even 30 minutes to get a bed and give turnover? Certainly obvious strokes get alerted and the patient assessed in the desired timeline. But what about those that fall in a gray zone? How does your ED handle these patients? What message does it send to your EMS providers to have them drive lights & sirens (inherently dangerous in itself), only to wait wait wait? Do you want them to start making decisions about patients with a positive Cincinnati Stroke Scale for say, slurred speech, but without hemiparesis? As both an EMS Provider and an ED Doc, I’d rather let the ED make that call.
2. Handwashing is the best prevention
Plenty of studies have proven this. We hear it every year in Blood Borne Pathogens training, and it’s posted all over the hospital. Yet, how many EMS workrooms at the ED have a sink in them, or even close by, to encourage convenient and frequent handwashing? This is a no-brainer. We’re not talking about adding free Red Bull or a Starbucks machine (I’m looking at you VCU), but something to keep everyone safer and healthier.
In all seriousness, VCU did do an awesome job with the EMS room (which does have a sink). Now if only I could get access to the Starbucks machine…
3. Removing patients from the backboard
I think this one is about to self-resolve with the trend to move away from spinal immobilization in the field. Flash back to 10 years ago when I was a new EMT-B. Somehow, somewhere in my mind, I got the impression that spinal immobilization was intended to immobilize not just the head and c-spine, but thoracic and lumbar as well. Time after time I would transport a patient fully immobilized, and before I had finished saying “23 year old fema…” someone would be unclicking straps and removing the backboard. This often left me wondering, why I had spent that extra time on scene carefully packing the patient, only to have my handiwork undone? More groans and moans from nurses, “they could have gone to triage if it weren’t for this backboard.” I was following my protocol, wasn’t I? Was I doing the right thing?
We care about cervical spine injuries more than thoracolumbar injuries because they can kill you. The nerves C3, C4 and C5 in your cervical spine compose the phrenic nerve, which innervates and controls your diaphragm, the main muscle of respiration. Damage or sever these, and you stop breathing. Easy way to remember: “C3,4,5 keeps the diaphragm alive!” In reality, the meat of immobilization is in the c-spine immobilization with a c-collar, and the backboard is more of a transport device to pick the patient up and safely transfer them to a stretcher and hospital bed. EMS protocols have lagged behind in philosophy and approach to spinal immobilization in blunt trauma, but with current chatter surrounding its efficacy, I think we’ll finally close the gap.
What mixed messages have you seen where you practice?