By Julia Isaacson, MD, and Andrew Mittelman, MD, EMT-P
Every emergency department has a patient uniform. When patients present for care, we strip them of social identifiers in the form of clothing and ask them to instead wear a one-size-fits-most gown. As such, patients in a given emergency department can look quite similar to one another.
This type of homogeneity runs the risk of training our minds to forget the often very medically-relevant differences in where our patients come from. EMS is imperative in helping in-hospital providers better recognize these differences.
When EMS brings patients into the resuscitation bays, they give detailed, systematic handoffs. They tell the hospital team what they were dispatched for and what the patient’s chief complaint was. They inform the doctors and nurses what they know about the patient’s medical history, medications and allergies and they report the findings of their physical exam.
But, the cardiac monitors and electronic medical records work faster than anyone can speak. Sometimes, before EMS has even completed their handoff, our nurses have obtained an updated set of vital signs and another member of the team is ready to read the room all the relevant information from the patient’s medical chart.
What if, instead of expecting EMS to tell us what we are moments away from seeing an updated version of, we repurposed the prehospital handoff to focus on the aspects of patients’ situations that we will never otherwise know: what EMS saw on scene. The EMS handoff is usually the only opportunity for conveyance of such valuable information and too often, we fail to take advantage of it.
Consider the recent case of an elderly woman who presented via ambulance to the emergency department with a rash. On secondary assessment, there was an area of redness on her right lower leg. We were unsure what had caused her skin abnormalities.
Thankfully, one of the EMTs informed us that he and his partner had found the patient lying on a power strip and that her family had left her there for so long that she urinated on herself. He went on to propose that she may have subsequently been the victim of electrical shock, resulting in the perplexing skin findings. This was a diagnosis made possible only by EMS’ handoff.
As in-hospital emergency medicine providers, we will never see the power strip that caused the rash or the apathetic response from the family that never presents to the bedside. We will never see the handgun sitting on the entryway table in the home of our patient who presents with a flat affect. We may fail to recognize his increased suicide risk and refer him to appropriate psychiatric care.
We will also never see that the single mother who just gave birth to her eighth child lives in a one bedroom apartment without electricity as her illiteracy has made it difficult to find sustained work. We may fail to recognize that she is going to be unable to read the instructions on any prescription we provide for her.
These missed opportunities aren’t the fault of hospital providers but rather an unfortunate consequence of healthcare sometimes being a siloed entity wherein we are blinded to the important discoveries others make.
While hospital staff don’t see patients in their own environments, EMS does. As such, they gain valuable information about patients’ circumstances which often offers insight into their social determinants of health (SDOH). Defined by the World Health Organization, SDOH are the “non-medical factors that influence health” such as education, healthcare access, social context, economic situation, and living environment.1,2
We know that the implementation of programs that address SDOH in the emergency department improve patient outcomes.3 Therefore, understanding patients’ SDOH is an inarguably crucial component in the provision of comprehensive emergency care.
“Open the fridge” is advice sometimes offered to new EMTs. The simple act will quickly answer multiple questions: Does the patient have electricity? Do they have the money to afford groceries? Are they physically able to go to the store? If not, do they have support from family, friends, or neighbors? Is their judgment intact enough to get rid of expired food?
The EMS handoff may serve as the last time to obtain this history about patient circumstances. However, a recent analysis observing EMS-to-ED handoffs demonstrated that only 58% of handoffs included a description of the scene.4 As a community determined to bridge SDOH barriers, emergency medicine providers must partner together to ensure a more productive patient handoff.
Regarding our elderly patient with the leg rash, without the EMT’s insight, we may very well have considered discharge after her workup resulted quite unremarkably. However, given the context provided by EMS, she was admitted for consideration of placement and an elder abuse investigation was initiated.
Our EMS colleagues are a vital connection between in-hospital emergency medicine providers and the community as they are uniquely positioned to provide us with critical and often disposition-changing information about patients’ home circumstances and SDOH.
In-hospital providers: The next time you receive an EMS handoff, maybe instead of clarifying the last set of vital signs, consider asking for a description of the bedroom or even the fridge.
EMS providers: please continue to help us understand what we will never see. We can repeat the vitals, and we will. Soon, we will have the unabridged medical history. But, if not communicated during handoff, what you saw will forever be left to our speculation…so please relay that.
About the Authors
Julia Isaacson, MD, worked as an Advanced EMT for four years for ambulance services in Maine, New Hampshire and Vermont. She also was an American Heart Association BLS instructor, helped teach EMT classes, and served as an ED Tech. For the past two years, she has worked as an emergency medicine resident at Boston Medical Center, interfacing with EMS every shift and assisting with the provision of online medical control for Boston EMS.
Andrew Mittelman, MD, EMT-P, is currently an attending physician at Boston Medical Center. In his current role, he helps provide online medical control for Boston EMS and has taught extensively on optimizing the transition of care that occurs upon EMS arrival in the ED. He previously served as a paramedic in Vermont and also held licensure in Massachusetts and Pennsylvania. Although he presently works in the urban setting, his practice is very much informed by the five years he spent working in prehospital rural environments.
References
- Social Determinants of Health. World Health Organization. 2024. https://www.who.int/health-topics/social-determinants-of-health
- Social Determinants of Health. U.S. Centers for Disease Control and Prevention. 2024. https://www.cdc.gov/about/priorities/why-is-addressing-sdoh-important.html
- Selby S, Wang D, Murray E, Lang E. Emergency Departments as the Health Safety Nets of Society: A Descriptive and Multicenter Analysis of Social Worker Support in the Emergency Room. Cureus. 2018. Sep 4;10(9):e3247.
- Goldberg S, Porat A, Strother C, Lim Q, Wijeratne H, Sanchez G, Munjal K. Quantitative Analysis of the Content of EMS handoff of Critically Ill and Injured Patients to the Emergency Department. Prehosp Emerg Care. 2017. Jan-Feb;21(1):14-17.
