Quality Corner: Call Critique

One of the most valuable yet unappreciated tools of quality improvement is actually something that occurs constantly and is self-administered by providers. It is also the best proof that most providers really do care about learning and sharing what they’ve learned; I am referring to the call critique.

No matter what type of EMS system you work in—whether prehospital emergency medical care is delivered by ground ambulance, helicopter or ski patrol—post-call critique by EMS providers themselves is pretty much universal. After almost every call, and especially after a challenging or unusual call, without much delay or fanfare EMS providers will invariably begin a self-critique. To be a quality coordinator or medical director and listen to one of these self-critiques is quite impressive and satisfying. Post-call critiques usually include everything any performance improvement advocate could want; a review of key assessment findings, treatments, the provider’s logic behind their treatment decisions and lessons learned from the call, including many times an admission that something was missed or could have been done better.

Post-call critique is casual quality improvement. It is typically fully and freely initiated by the treating EMS provider, and when performed it is the ultimate in self-administered peer review. The advantages of this type of quality improvement are many. It gives the presenting provider an opportunity to review the call and his or her own performance after the fact with the benefit of 20/20 hindsight. Other providers who were not on the call can weigh in with any related experience they may have had, or learn from the experience of the call without having been there themselves. 

Call critique is also the perfect opportunity for experienced providers to teach less-experienced providers tricks of the trade they’ve learned over the years. One of my favorite lessons to impart on others is recommending they routinely look into their patients’ mouths. While every EMS textbook continues to repeat the age-old adage of checking skin turgor to determine dehydration, I’ve personally found this to be all but useless in most circumstances. Young and otherwise healthy people will typically have good skin turgor until a day after they’re dead from dehydration, while older people’s skin turgor will frequently tent despite being in total fluid overload. I’ve found it much more accurate to look in the patient’s mouth and at their tongue. The mouth and tongue should always be moist. If a patient’s tongue looks dry, they’re most likely dehydrated. In extreme cases of dehydration where the patient’s tongue looks like an old, red, cracked eraser, dehydration is obvious.

One corollary to the call critique worth mentioning is to beware the quiet crew member who does not talk about calls and does not participate in conversation afterward, especially if a student, rookie or inexperienced ride-along.

Many years ago, I had a nurse show up at the beginning of a shift for a ride-along. It was a slow day, just one call in fact, but that one call was a self-inflicted gunshot wound to the head.  Although I didn’t think much of it at the time, the nurse was much quieter after the call than before and not participating in the call critique despite an occasional invitation or two lobbed her way. The call came in just about noon, so our very next stop after the call was to pick up lunch. The nurse did not join us in picking up lunch and instead remained in the ambulance. We got back to the station and dug in to our food, but halfway through lunch we noticed the nurse had disappeared without so much as a goodbye. Upon mentioning the incident to the ER doc on our next call, he reminded us that not all medicine is emergency medicine and not all nurses are ER nurses.

The nurse never came back, but worse than that, she likely suffered some degree of emotional trauma that could and should have been managed much better by me as the senior EMS attendant. 

In conclusion, casual call critique is probably the most common and one of the most effective forms of retrospective quality improvement, and it’s a freebie. It is not administered or managed by the quality coordinator or medical director. But we should take note of it. We should also encourage and appreciate it and be aware of potential problems if there is a lack of it.