Quality Corner--Part 4: The 10 Commandments of Quality EMS

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The face of EMS is diverse. Multiple types of systems provide emergency medical services to American communities: fire service-based, hospital-based and third-service. These systems also deliver varying degrees of performance. Systems fortunate enough to have strong management, active medical direction and a comprehensive quality improvement program can provide higher-quality EMS than those that lack them.

But at the core we all share many of the same basic problems: attitude, varying degrees of proficiency and a need for continuous quality improvement. The more clearly you can articulate your agency's values and expectations, the more likely your providers will exhibit the desired professional behaviors.

To tackle big problems, plan strategy or think big thoughts, it helps to get away from the distraction, noise and day-to-day chaos of EMS. I prefer to sit on the back deck of my house and smoke a Macanudo cigar. I've found a good cigar relaxes me, slows me down and somehow helps me think creatively.

I lit up a cigar one night not long ago while contemplating the myriad of quality improvement challenges facing my agency. As I sat back, gazed out at the stars and took a draw of my cigar, I saw the constellation of Orion. My mind wandered from the stars to the heavens to the gods and finally the imaginative answer I was seeking (and in record time, I might add). The 10 Commandments! If they're good enough for God, why not EMS? I started scribbling down ideas, and within minutes I held in my hands a (paper) tablet: The 10 Commandments of Quality EMS. I tweaked the wording a bit over the next few days, but in 10 short sound bites, I succeeded in capturing what I believe are the key concepts of quality patient care.

1. EMS is not just a job, it's a profession.

Back in the 1970s and '80s in my neck of the woods--Bucks County, PA--EMS was all volunteer. And we were all out to be the best. Nowadays, for many providers, EMS is nothing more than a paycheck. It's apparent in their attitude, but some will even confess their feeling that "It's just a job." But it's not, no more than a physician's or police officer's career is just a job. It's not an overstatement to say the importance of our job is life-and-death. That surely warrants a little extra effort and care…and caring.

2. Average, minimum and mediocre are not good enough in EMS.

Doing no more than you absolutely have to--the minimal amount of continuing education, a mediocre job of patient care--is not good enough for EMS. EMS is the highest-stakes practice of medicine there is. At the advanced life support level, we practice physician-level medicine--though a more restricted and focused practice. But we operate in uncontrolled and many times dangerous environments, and without the safety net and backup support of a hospital staff. If a critical intervention is required and we can't get it done, the patient dies, which is why every EMS provider has a moral obligation to go above and beyond the minimum requirements of education, preparation and readiness.

3. Always remember your patients are trusting you with their lives.

People have seen EMS portrayed on television and in movies and have expectations similar to those we all have of the rest of medicine. No matter what the problem is, once the patient gets to the doctor or hospital--or EMS gets to them--they believe we'll be able to fix what ails them and they'll be okay. That expectation of course may not always be realistic, but at a minimum all patients deserve to be treated by highly trained and highly motivated providers who will do everything they can to help those patients in their time of need.

4. Everyone gets to pick their primary care physician, but no one gets to pick their EMS provider.

We all do indeed get to pick our primary care physicians, as well as all other physicians, surgeons and physical therapists. But when people are in their most dire need of medical care, they do not have the luxury of shopping around or choosing who shows up. They get whomever happens to be on the shift rotation in their coverage area. Given the literal life-and-death stakes of many of our calls, doesn't it make sense that anyone in that position be highly motivated, well trained and well prepared for the extraordinary challenge of EMS?

5. Remember, the S in EMS stands for service.

We are here to serve our community in general and our patients in particular in any way we can. Sometimes that may call for the use of our most cherished medical skills: IV, defibrillation or intubation. Other times it may require interventions that are less exciting but every bit as important to our patients, such as simply helping them up from the floor and putting them back in bed.

6. You don't win points by guessing right in EMS. You win points by maintaining a high index of suspicion, finding problems that aren't so obvious and always erring on the side of caution.

Sometimes, as we've all boasted, we can tell sick people are sick just by looking at them. Unfortunately, the opposite is not true--you can't tell someone is not sick just by looking at them. You have to assess them. Disease is a dynamic process. Patients can crash hard and fast, and they can crash slowly and gradually. Sometimes they're obvious, sometimes not. And then there are some patients waiting to make a fool out of you. These are the patients who have a decompensating event, maybe a syncope or near-syncope. Their body, fighting to maintain homeostasis, recovers by the time you arrive on scene. They frequently have perfectly normal vital signs and may even question whether they overreacted in calling 9-1-1. With all your immediate findings unremarkable, you blow off the precipitating event…

Sometimes you guess right, and nothing else happens. Then there are times when the patient unexpectedly crashes during transport, or just as you move them to the hospital bed. Some providers may proclaim relief that it happened at the hospital and not during transport, completely missing the point that they missed something important. They did not listen to the patient or did not appreciate what the patient told them. Quality EMS should be more than a guessing game. It should be based on a comprehensive patient assessment, which includes special emphasis on the history of present illness, even if everything seems OK upon your arrival. Sometimes the HPI will provide the only clue there is that the patient is more seriously ill than they appear. High-quality EMS should include overtriaging medical patients to advanced life support for the same reason we overtriage trauma patients to trauma centers: to ensure we don't miss anything.

7. There are no excuses in EMS. You either get the job done, or you don't.

If you miss an IV or an intubation, it's not a big deal--no one is 100% successful. Failure in EMS is not failing a specific intervention, it's failing to effectively manage your patient to the best of your ability. Plastic doesn't save patients. Air moving in and out saves patients. Nowadays, we are fortunate to have backups for most critical interventions--the Combitube and King LT as rescue airways, for instance, and the intraosseous drill for vascular access. If a patient is critical and requires immediate lifesaving intervention, doing no more than rushing them to the hospital could seal their fate. Competent EMS providers should know their capabilities, be proficient with their equipment and constantly be reassessing their patients for signs of decompensation. If it really, truly needs to be done and you fail to do it, the patient is the one who will suffer the consequences.

8. In most cases, patients will be more appreciative of how you treat them than the treatments you give them.

To most paramedics, successfully identifying a dysrhythmia, establishing a difficult IV or intubating a patient is the cat's meow of EMS. But most patients have little understanding or appreciation for these skills. What every patient does understand and appreciate is how they or their family members are treated as people. EMS providers should make a special effort to demonstrate they care. Talk to your patient and their involved family members and reassure them, without lying or being disingenuous. Most patients will have some degree of anxiety associated with whatever is going on. Some may be downright scared. In many cases a kind word, caring attitude and little reassurance will be the most important thing you can do for them.

9. EMS is the first hour of medicine in the first 30 minutes.

High-performance EMS is the first hour of medicine in the first 30 minutes. Hospitals typically have dozens of patients and have to constantly juggle resources and prioritize treatment between them. In most cases, EMS has the luxury of having just one patient on whom to focus. We can therefore get a lot more done a lot quicker than the hospital, especially if we work as a team and fully utilize the capabilities of our partners.

10. Always treat your patients the way you'd want EMS to treat you or your family.

Finally, the golden rule of EMS: We should always treat our patients the way we would want EMS to treat ourselves or our family members. Most people, including you and your family, will at some point need EMS, so perfecting it now may even end up being of direct personal benefit to you later.

If you're a quality coordinator who has discovered or developed a successful quality care initiative or program, write it up and share your brilliance with the rest of EMS as a guest columnist at Quality Corner. Submissions should be about 900 words, and please also include a short biography and head shot. Remember, none of us are as smart as all of us.

Joe Hayes, NREMT-P, is deputy chief of the Bucks County Rescue Squad in Bristol, PA, and a staff medic at Central Bucks Ambulance in Doylestown. He is the quality improvement coordinator for both of these midsize third-service EMS agencies in northeastern Pennsylvania. He has 30 years' experience in EMS. Contact Joe at jhayes763@yahoo.com.