Several years ago, I began researching the issue of interagency relations and the problems that arise from competing agendas at medical emergency scenes. The resulting article, "On-Scene Interagency Conflict" (May 2005 JEMS), reflected not only my interest in addressing the matter of on-scene conflict between care providers, but also in providing solutions to a potentially serious problem.
A theme that arose during my research was the phenomenon I call "intra-agency hubris"ƒthe belief that the agency one works for is superior to other providers and agencies. I found that intra-agency hubris is largely the product of care providers talking among themselves about the inadequacy of other agencies_ performance, usually complete with colorful anecdotes that reflectthese agenciesattheir worst.
This way of thinking often extends beyond field interactions and intoour relationships with patient-care providers in the clinical setting. Of particular interest was an article I came across by Bryan Bledsoe, DO, FACEP, titled "Adios, Rampart: Give Medical Control the Boot" in May 2002JEMS.(Read it at jems.com/rampart.) The piece made an excellent case for the need to reinvent the relationship between hospital providers and field personnel. These changes would reflect the education and decision-making capabilities field care providers now have (and in many cases havealwayshad) by viewing the concept of online medical control as online medicalconsultation.
Bledsoe_s proposal reflects a fundamental truth: field care and clinical care are best viewed as points along a continuum, rather than as rungs on a ladder, with neither superior to the other. As such, when field care providers contact a base hospital to discuss a case, it isn_t necessarily to be told what to do, but rather to bring other medically educated minds into play to decide on the best course of actionfor a patientƒas is routinely done among physicians.
An Ongoing Problem
Unfortunately, in the seven years that have passed since publication of Dr. Bledsoe_s article, little has changed. Although many EMS systems are allowing greater freedom on the part of field care providers to make decisions independent of the base hospital, when thereis interaction with hospital staff, field personnel are often still treated as subordinates who perform a job which is fundamentally different from that performed in the clinical setting.
Time and again I_ve witnessed (and been subjected to) unprofessional behavior on the part of hospital employees that can only be described as abominable. Some of these instances involve communications over base hospital radios, and some involve transfer-of-care situations.
On one occasion, after a doctor had invited a paramedic into a patient room to observe an interesting trauma case, a nurse, within earshot of patients and staff, yelled at the paramedic for entering the patient room "without authorization." Another time, a charge nurse literally screamed at a paramedic when a miscommunication between the base hospital and the receiving hospital resulted in a patient overload at the receiving hospital. When the paramedic attempted to diffuse the situation by asking what he could do to help, the nurse, again in full view of patients and staff, screamed at him to get out of "her" emergency room.
Each of these nurses is a high-ranking staff member. One, ironically, serves as a hospital-EMS liaison. To this day, despite their deplorable behavior, neither has been held accountable. It_s interesting to speculate on whether this would be the case if the roles were reversed, with a paramedic publicly degrading a nurse. Or what would have happened if the nurses_ verbal assaults had been aimed at an ER physician, rather than a paramedic.
The fact that this sort of abuse of EMS providers not only occurs but is tolerated is a corollary to the points Dr. Bledsoe made: field personnel are viewed as inferior to clinical personnel, despite often having an equivalent or higher level of training.
On Dangerous Ground
The consequences of permitting disparagement of EMS personnel are far reaching and insidious, not just to the esteem and well-being of EMTs and paramedics, but to their patients, for whom EMS is the first line of care. Patients and their families rely on EMS personnel to respond quickly to their medical emergencies and provide rapid, lifesaving treatment.
Consider the delay in care that occurs when a paramedic, operating under state, regional, or local protocols that mandate base hospital contact, takes time away from patient care to call up a nurse, give them all of the facts and ask for permission to administer a medication to treat a potentially lethal dysrhythmia. In modern EMS, paramedics are educated to have a thorough knowledge of various differential diagnoses, and patient assessment is undertaken with the goal of arriving at a proper working diagnosis based on these. Requiring a paramedic to get a nurse_s blessing to proceed with a course of action that has been obvious to him for several minutes or more causes an unnecessary delay in treatment and is detrimental to the patient.
Worse still are the complete omissions of care which occur when medical direction fails to grant requested orders entirely, instructing paramedics to "just transport." Or when field personnel become overly reliant on medical direction and fail to use their own critical thinking faculties to arrive at a proper course of treatment, or fail to recognize or call into question a recommended plan of action from the base hospital that could potentially harm a patient.
Another problem caused by allowing ourselves to be regarded as subservient to clinical personnel is the effect it has on our own professionalism. It_s still all-too common to see EMS providers dressed in a slovenly fashion, smoking in uniform, or wearing costumes that look better suited for an ice cream parlor worker than a trained professional operating on the front lines of emergency medicine.
I_ve lost count of how many times I_ve gone to work on an ambulance or rescue squad and found damaged, malfunctioning or missing equipment, medications that have expired, or an overall condition of the unit that suggests a complete disregard for how one is perceived. Whereas there_s no excuse for this kind of complacency, I have no doubt that tolerating disrespectful treatment significantly contributes to an overall sense that we_re not professionals and don_t deserve any better.
Quagmired in Tradition
A logical question to ask is, how did this situation develop, and more importantly, why do we allow it to continue? Why are those with training that has little if anything to do with field medicineallowed to reign over EMS professionals, directing not only the administration of EMS systems, but their scope and development? Why haven_t we moved to change a system infused with those who not only have little understanding of the realities of our profession, but oftenappear to regard it in a manner that can only be described as contemptuous?
Many years ago, when EMS was in its infancy, hospital personnel did operate in a field care capacity. As part of an experimentation process that at various points included medical residents and physicians, these clinicians filled the role that paramedics occupy today. Out of the failure of nurse-, resident-, and physician-based field care emerged the recognition of the need for professionals who were trained in, and practiced, field-based emergency medicine exclusively, rather than simply taking clinical specialists and providing ancillary training. The resulting paramedic model, based on educating these field care providers how to work under the direction of physicians, proved to be far more successful than any previous plan.
Today, in terms of ground ambulance and rescue service, the Mobile Intensive Care Nurse (MICN) certification exists in large part as a credential only, with relatively few systems employing nurses to routinely respond to medical emergencies. In a patient care capacity, MICNs have resumed their in-hospital roles, with their actual field responsibility today largely limited to aeromedical care and critical care interfacility transport.
Ironically, despite these sweeping changes in field care, very little has changed in terms of nurses_ involvement with EMS systems. From initial training through certification, from continuing education to quality assurance (QA) or continuous quality improvement (CQI) programs, to field-hospital interface, and even into the realm of peer review and disciplinary actions, nurses continue to have significant, and in many cases, virtually exclusive, dominion over field personnel in many EMS systems. This is a questionable design at best, given that paramedic education and practice is, and should be, based on a medical model, intended to function under guidance of physicians.
In order to put our profession on the right track and begin providing the public withthe best EMS system possible, there areseveral key points that need to be implemented in EMS nationwide:
EMS education should be provided by EMS.Many EMS educational programs are not only staffed by nurses, but in many cases, directed and administered by nurses as well. Truth be told, nurse-based EMS education was never an ideal design: the nursing model, based on practice under continuous clinical supervision, is essentially and necessarily different from the one that paramedics follow, which involves operating in the field as the highest level of medical care available in that setting.
At one time, there may have been insufficient numbers of experienced EMTs and paramedics able to teach the essentials of medical science, but that time has long since passed. There are plenty of qualified, tenured EMS providers able to be involved in EMS education today, and it_s unnecessary, and in many cases inappropriate, to put nurses in these jobs.
EMS should oversee their own QA/CQI programs.More troubling than leaving EMS education in the hands of those who have scant understanding of the realities of life in the field is leaving the development and administration of EMS systems in those same hands. With physician medical directors providing the necessary clinical oversight, EMS QA/CQI programs should be developed, implemented and administered by EMTs and paramedics exclusively.
Field training officers (FTOs) should assume a dynamic, proactive role in EMS organizations, rather than a static, reactive one.More field oversight is needed in EMS systems, and EMS supervisors need to have their roles supplemented by FTOs that act as adjunctsupervisors. As employees who set astandard and lead by example, FTOs would be responsible for ensuring that specific ambulances and/or squads within their realm of supervision are maintained at a high operational level in terms of inventory, functionality and appearance, and that crews are performing at a high operational standard.
This task-oriented plan is intensive and ongoing, and cannot be reasonably handled by field supervisors according to realistic models of mid-level management. In addition, the FTO would be an approachable, positive leader, always available on an ongoing basis to those personnel who feel they would benefit from additional professional development and mentoring, thereby ensuring that deficiencies are corrected before they manifest into patient-care issues.
There should be continuous reinforcement of the concept of patient care as a continuum.Clinical and field personnel need to understand and accept that EMS is a unique profession withcharacteristics that make it fundamentally distinct from clinical care. It should be recognized that EMTs and paramedics are the first level of contact in a continuum of emergency medical care that may terminate either with an admission to the hospital, a discharge from the emergency department (ED), or a release after treatment in the field. In many instances, the assessment processes, diagnostic impressions and treatments based on the diagnostic impressions arrived at in the field are identical to those obtained in the hospital, with the only difference in terms of care being the setting.
Toward this end, we need to stop using the term "prehospital care."That this phrase is used interchangeably with "field care" or is considered synonymous with EMS, implies that our identity, our only real value, is inseparably tied to our relationship with a hospital. The hospital shouldn_t define us; we should define ourselves. The fact that a patient may need further evaluation and treatment beyond the field should not imply the inferiorityof an EMT or a paramedic, just as transferring a patient who requires surgery from the ED to the operating room doesn_t suggest the inferiority of the emergencyphysician.
Field-hospital interface should become physician driven, rather than nurse driven.As Dr. Bledsoe and other medical leaders have stated, online medical control needs to be replaced with online medical consultation, and, in order for such a relationship to be effective, base hospital communications need to be between field care providers and physicians.
With paramedic education being at the level it is today, there_s no reasonable expectation that a highly educated and competent paramedic or their patient will benefit from consultation with a nurse. Such interactions are frequently a source of frustration and delayed patient care. If a facility wants to function as a base hospital, it needs to understand that it will have to make the requisite physician resources available in order to be of reasonable benefit to the EMS system that it serves.
How would we justify tying up physicians with routine call-ins? As protocols are modified to reflect the change from medical control to medical consultation, call-ins would decrease dramatically, and the "routine call-in" would go away altogether. Receiving facility notifications could be, and are in many EMS systems, handled by non-physician hospital personnel.
Mistreatment of field personnel should not to be tolerated, and those who engage in it should face serious, tangible consequences.In the two examples of abuse given earlier, the question is raised about the likely consequences if a paramedic disrespected a nurse or physician, or if a nurse was verbally abusive toward a physician. EMS and hospital administrators have an obligation to ensure that those who engage in inappropriate behavior are held accountable for their actions, and that the consequences for inappropriate treatment of EMTs and paramedics are brought to bear swiftly and certainly, particularly if the behavior is carried out in front of patients or in any way compromises patient care.
Toward a New Standard
I_ve received numerous calls, letters and e-mails over the years from EMS professionals interested in improving the public image of their agencies. Many of them want to know what they can do to bring EMS into a position where it enjoys the same respect and high esteem as fire and police agencies.
My answer has always been the same: We need to hold ourselves to the same standard that those agencies hold their people to. Demand professionalism not only from yourself, but also from your contemporaries. Don_t allow your colleagues to engage in behavior that wouldn_t be tolerated by the agencies that enjoy the respect you wish your own agency had.
I_ve seen many of the changes I have sought come to pass, and I_m now very happy with the caliber of EMS professionals I_m privileged to work with. Unfortunately, despite tremendous strides in the capabilities of EMS, all too often we_re regarded with disdain by those who view field care as inferior to hospital clinical care. Those who see themselves as benefiting from such a mindset perpetuate this fallacious outlook. Ironically, many are the same people who today play a significant role in EMS.
As such, this manifestation of hubris, not practiced at a firehouse or EMS station but within the confines of the hospital, is the most damaging of all, for it targets not merely one particular crew or agency, but all of EMS.
It_s time for us, as EMS providers, to take control of our profession. By implementing the changes called for herein, wecan put EMS on the path to greatness that it so richly deserves to be on. One that honors the dedicated professionals who comprise EMS and one that is best equipped to serve those who matter most: our patients.JEMS
Mark Rock,BA, NREMT-P, is a graduate of the University of Oregon and did post-graduate work at Portland_s Neurological Sciences Institute. A member of the JEMS EMT and Paramedic Advisory Committee (EPAC), Rock practices as a paramedic in Ventura, Calif. Contact him firstname.lastname@example.org.