You are dispatched to a 70-year-old male with shortness of breath. On arrival, you see a man sitting in his bed with labored breathing. After you examine the patient and take his medical history, you decide the patient has pulmonary edema, and treat him per your EMS protocol. After 20 minutes of driving to the nearest hospital, you deliver the patient to the ED and go to your next call.
Was your diagnosis correct? Did you treat the patient correctly? Is there any system in place to help you learn from your success and mistakes?
Remarkably, in 2017 most of us in EMS do not receive routine feedback on our diagnosis. Imagine receiving an email or a phone call when the patient is released from the hospital with the diagnosis that was made in the hospital and relevant information about the course of treatment in the hospital. Would this help you improve as an EMS provider? Is the lack of feedback preventing us from learning?
Clinical skills improve over time as we gain more experience and learn from our mistakes or success. If we look at acute pulmonary edema (APE) as an example, research from Australia found concerning evidence about the accuracy of identifying APE by paramedics in the prehospital setting. In the retrospective research done by Williams et. al.1 in Australia, 495 patients who were transported to an ED with APE identified by paramedics were compared to the diagnosis in the emergency room. Only 168 received an ED discharge diagnosis of APE, i.e., a positive predictive value of 41%. Of 631 ED presentations with APE, paramedics identified 186, i.e., a sensitivity of 29%.
Recently Van Der Wekken etal2 from the Netherlands found that almost 40% of patients with sepsis were not diagnosed correctly (i.e., sepsis was not recognized) by EMS.
Could we improve our diagnosis? Is there a way for an EMS provider to improve and learn from patient to patient?
While many systems today have feedback implemented in them, EMS providers are in the dark regarding their patients. If we have no feedback, we can almost never learn from mistakes and never improve. An EMS provider can think he or she has the best diagnostic skills, and be wrong most of the times and not even know it. So why is regular feedback not common in EMS systems?
There are considerable limitations in EMS diagnosis (and treatment) compared to hospitals. We have less knowledge, usually less experience, less equipment and diagnostic equipment, and a suboptimal treatment environment. On the other hand, we usually have only one patient at a time. Unlike hospitals, our encounter with patients is usually limited to a short time, and we do not see the results of our treatment.
The technical challenges for providing feedback to EMS providers can be overcome when EMS systems recognize the importance of such feedback. A dedicated professional who can follow certain cases and provide feedback to EMS providers with all the information needed to understand the case can also improve communication between hospitals and EMS systems.
EMS systems that want to implement a feedback systems for providers should look at ongoing education. The information should not be used for punishing or measuring individual providers, rather it should only be used for learning purposes.
As we advance and improve our EMS systems, decision makers should start implementing systems that provide feedback for EMS providers. Providing feedback is a crucial step in advancing EMS systems toward better practices and care. Ongoing education is a crucial part of any EMS system. One of the best ways to learn is from our own success and mistakes. While the demand for EMS providers is increasing due to higher call volumes, less experienced providers need to handle older and more complicated patients. Thus, the need to provide feedback and improve clinical skills and learning is essential.
Oren Wacht, EMT-P, MHA, PhD, is faculty of health sciences, Ben Gurion University of the Negev, and a representative of Magen David Adom, the Israeli national EMS.
Eyal Oz, EMT-P, BEMS, is faculty of health sciences, Ben Gurion University of the Negev, and a representative of Magen David Adom, the Israeli national EMS.
Raphael Strugo, MD, is a representative of Magen David Adom, the Israeli national EMS.
1. Teresa A. Williams. (2014). Paramedic identification of acute pulmonary edema in a metropolitan ambulance service. Prehospital Emergency Care.
2. Lena C. W. van der Wekken, etal. (2016) Epidemiology of sepsis and Its recognition by emergency medical services personal in the Netherlands. Prehospital Emergency Care.