The Customer's Perspective - @

The Customer's Perspective

A Chief Walks a Mile in the Their Shoes



David Travis, MPH, EMT-P | | Monday, October 13, 2008

Jessica Holloway is a 35-year-old single mother of two living in theBrandon area. She spent the last three years working her way through nursing school atHillsboroughCommunity College. Being a first-year RN, she was unable to get a pool position at a hospital, which has been her goal since she started the nursing program. Childcare issues preclude her from working full time at a hospital.

She was able to obtain a pool position with the Martin Nursing Agency. She normally works three eight-hour shifts per week, though the staffing office is always trying to get her to work more. On some days, she assists at a health-plan clinic. Other times, she's assigned to work at a nursing home. She hasn't yet had the opportunity to work in the hospital, but she's looking forward to it.

On a Friday afternoon while she is picking up her kids from school, her cell phone rings. The staffing office from Martin is calling and they're desperate. A number of agency nurses have called in sick and she's needed at work. Although Jessica had originally agreed to work only in theBrandon area (so she wouldn't be too far from her kids), the agency needs her to report to a nursing home inNorth Tampa. She protests, but the staffing office is insistent. Ultimately, she accepts the assignment.

Later, she drops her kids off at her sister's on her way out to the nursing home. After having trouble locating the facility, she pulls into the less-than-impressive building's parking lot. As she walks in, she hears someone screaming from a distance down the hall. She's quickly informed she will be the charge nurse and the only RN working on the facility's second floor.

As she begins to assess her patient load, a CNA reports that a patient in room 204 has been having trouble breathing all day. Jessica quickly moves to the patient's room and sees an elderly, cyanotic woman lying flat with noisy respirations. The patient is only semi-responsive and appears to be in respiratory distress.

Jessica has never seen a patient in such a critical condition. She tells the CNA to call 9-1-1 and gets some help putting the patient in Fowler's position. She calls for oxygen and begins further assessment. She listens to lung sounds and hears crackles in all fields. Soon, an assistant arrives with a portable oxygen tank and a nasal cannula. She asks for a mask and someone goes off to get one.

The Crew

Rescue 15 has had a busy day. They've already had eight calls and haven't seen the station since noon. The crew is anxious to get back to the station as they return from Tampa General. They're almost back to their station when they get dispatched on a difficult breathing call at Whispering Pines Nursing Home. The last call this crew ran at this facility didn't go well. The nurse taking care of the patient had little information and was unable to locate a DNRO form for the patient. The acting rescue officer relates to his relatively new partner that this is one of the worst nursing homes to which to run a call. They learn on the way that the engine company responding with them is coming from a distance. They arrive within three minutes.

As they arrive on scene, they gather their equipment and pile it on the stretcher. They go inside and find the patient's room.

As they walk into the room, they see a cyanotic elderly patient in acute distress with a nasal cannula in place. The acting rescue officer, shaking his head, snaps to his partner, "replace that cannula with a non-rebreather." He then turns to the RN who's trying to get a blood pressure. "How long has she been like this?" The RN replies, "Uh I'm not sure ... I think all day." The acting rescue officer, remarks with a smirk, "didn't think about calling us till now huh?" He asks what the patient's medical history is. The RN says she's not sure, she sent someone for the patient's chart. He asks about medications and allergies, and again the RN replies she doesn't know. As he begins assessing lung sounds he asks out loud "whatdo you know?"

The crew provides high-level care, including intubation and IV medications. The patient's condition improves dramatically. As they prepare for transport, the acting rescue officer tells his partner, in front the small group of staff members, "Now you see why I don't like to come here?"

The Patient

Mary and Bill Johnson have been married for 55 years. Both nearing 80, they have been blessed with good health, except for Bill's high blood pressure.

On a chilly Saturday morning, Bill is reading the morning paper while Mary is fixing breakfast. The two have plans to go golfing later and have an 11 a.m. tee time. As Bill gets up to stoke the fire, his footing slips on a piece of newspaper, and he comes crashing to the ceramic tile floor. The pain in his hip is excruciating. He tries to get up but can't. His right leg is useless. He rubs the emerging bump on the back of his head. In addition to the pain, he feels dizzy.

Mary rushes over to him and sees that his leg is rotated at a strange angle. He asks for her to help him up but she just tells him to be still. She calls 9-1-1 for the first time in her life.

The call-taker in the emergency dispatch center is full of questions. "Did he lose consciousness?" ... "Not sure." "Is he bleeding?" ... "Yes." "Is he having any difficulty breathing? ... "I'm not sure." The dispatcher sends a delta-level response, including an ALS engine and rescue unit.

Engine 54 and Rescue 53 are dispatched on the call. The address is in the most northwesterly portion of the county; the response time will be lengthy. After 14 minutes, the engine arrives first. The engine company pulls all of their gear and approaches the residence, not sure what they're in for. Mrs. Johnson meets the crew at the door and directs them to her husband, who is loudly moaning in pain.

The paramedic then assesses the patient and determines he has a possible hip fracture and a hematoma to his occipital region. The company officer starts taking down the patient's history, medications, allergies, etc. Mrs. Johnson asks the engine captain why they aren't taking her husband to the hospital. She replies, "We don't do that ... we have an ambulance coming."

The rescue unit arrives a few moments later and members let themselves into the home. As they approach, the engine medic, kneeling beside Mr. Johnson, yells, "We got a hip." The rescue officer yells back, "Why didn't you cancel us?"

Before doing anything else, the rescue officer gets on the radio and asks for a BLS unit. Dispatch comes on the air a moment later and advises there's a unit available with a 15-minute ETA. The rescue unit requests it be sent.

Mr. Johnson's pain is intense; he asks if they can give him anything. The paramedic explains that they can't because they won't be transporting him. He has now been lying on the floor for a half hour. He's cold and miserable.

The rescue crew explains to Mrs. Johnson that they can't transport because they need to stay available for a "real" emergency. They then ask the engine company, "You got it?" After a nod from the engine captain, the rescue crew loads up its equipment and leaves.

The BLS unit finally arrives almost an hour into the call.


These two scenarios illustrate the type of calls which generate complaints within our department. I'm sure many chiefs, EMS managers and administrators recognize these themes as set-ups for the types of complaints received byEMS organizations across the nation. Of the complaints our department receives, 80% relate to perceptions of an uncaring attitude among the providers.

FewEMS providers would likely rank a call to nursing home among their favorite types of responses and it is easy to let past negative experiences influence our perceptions of staff members at such facilities. Although it may be difficult, it's our responsibility to be professional, courteous, and respectful in such situations. Considering their point of view for a moment may help.

I've seen many paramedics over the years who were great at patient care, but lacked human skills. Personally, I don't like to think of patients as customers, but the principles of good customer service do apply to our profession. Although it may be appropriate for a paramedic to summon a BLS unit to transport a patient with a fractured hip, it may not be what's best for the patient, their family or others in all situations. The patient in the scenario above would have been much better served by a crew with a positive attitude, pain management and early transport.

Both of these scenarios provide opportunities which can result in a positive or negativeEMS experience for those involved. If we consider the perspectives of those on the scene, it may enable us to be an advocate for our profession as well as for the patient.

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Related Topics: Pain Management, Patient Management

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