Skip to content

Just a Little Note For The Rookies

16 comments

My buddy Jeff Brosius once gave what may be the shortest Trauma Activation ever: "One street pizza with pulses. Five minutes. Be ready."

While at first glance that seems flippant, while the medic is busier than a one-armed wallpaper hanger trying to keep the patient alive, those nine words do everything a pre-arrival notification is supposed to do: the ED knows they're getting a critical vehicle vs. pedestrian MVC with multi-systems trauma, and they have five minutes to gather the trauma team.

It may not win you style points (although I thought it was rather Hemingway-esque), and may indeed get you whacked on the peepee by the Monday morning quarterbacks who review such things,but it accomplished the medic's goal: to make sure adequate resources were on hand to assure continuity of care.

There's a difference between a pre-arrival notification and a handoff report, kiddies. If what you tell the nurses and doctors over your cot as you transfer patient care is not substantially more thorough than the phone or radio notification you delivered prior to arrival, you're doing one or both of them wrong.

One of the most common mistakes I see rookies make in the back of the rig (You know I'm keeping tabs on you in the rear-view mirror, right?), is that they a) have poor time management skills, and b) little situational awareness outside that patient module, and c) no sense of priorities.

It takes a while to develop the situational awareness that tells you that last bump you went over is the railroad tracks five minutes from the ED and that it's time to call report, all while you're busy doing other things. That will come with practice.

So will the time management, but the first step in doing that is learning to multi-task. You can start an IV and talk on the phone at the same time. I know, I've done it a million times.

And if I open the rear doors of the rig and you're not getting ready to unload, or you're on the phone with the ED as we sit in the ambulance bay, yet the demographic section on your run ticket is completely filled out, right down to the insurance blocks you got from the patient's wallet biopsy…

… you need to pull your head out of your ass, and remember that patient care comes first.

And that pre-arrival notification is part of your patient care.

Your pre-arrival notification needs to be concise, relevant, and most of all, timely. The ED doesn't need to know the patient's complete medical history, medication list, allergies, Zodiac sign and favorite color before you arrive at the hospital. They need no more information than what resources they'll need to continue patient care, with enough forewarning to have the time to marshall those resources. If the person on the other end of the line demands more information than that, they don't get the concept either.

Your handoff report is supposed to fill in the blanks of your pre-arrival notification. Or, phrased another way, the pre-arrival notification is a skeleton report, and you flesh it out at bedside.

Being overly detailed on your pre-arrival notification doesn't earn you any points with the ED staff; it just makes you look like you have no sense of priorities. While you're rambling on aimlessly with extraneous information, the nurse or doctor on the other end is rolling his eyes and making "let's get on with it" gestures, and God forbid you end that with asking for medical control orders, because 99% of the time they'll be denied, or so conservative as to have no clinical effect.

After all, if you can't distill what's relevant from what isn't, and paint an accurate patient picture with a clear treatment plan in relatively few words, why should they trust you with medications and invasive procedures?

Just remember that the best pre-arrival notification you can deliver is rendered absolutely useless if you end it with the phrase, "… and we're at your door." Better that you called them five minutes earlier, and given them a simple heads-up.

So keep your eyes open, be aware of how far out you are, and call the friggin' hospital in a timely fashion. Yes, I know the pre-arrival notification is purely a courtesy, but your partner can't very well defend your back for missing it now and then if you're not, well… courteous the rest of the time.

 

Post to Twitter Tweet This Post

Posted by on October 25, 2011 • Filed under: The "They Think We're Stupid" Files
  • 9-ECHO-1

    This is GREAT! This is what I have been telling newbies for years. I plan on printing this out and using it as a handout for future newbies (if that is OK with you).

    But then, you have to love the receiving ED that gets this pre-arrival notification “Mary Sue ED, Mulehead 52 inbound, emergency traffic, 65 year old male, respiratory distress, he’s intubated, I’m bagging him, see you in 10 minutes”.  Yeah, it was one of mine. I figured it was not important to include the IV and oxygen part (I was an EMT-I at the time).

    I got to the ED in about 8 minutes, and no one was waiting, the doctor was somewhere else…oh well, the funeral service was nice…

  • Cath

    I had another good advice today: The best equipment you have in the ambulance, are the ones you know how to use.

  • Too Old To Work

    People need to learn that the hospital only needs or wants to know enough about the patient to figure out what resources they need to muster. If you’ve ever been in the hospital when the radio report comes in (and I know you have) you know that after about 30 seconds the person receiving the call has stopped listening. They don’t care about PMH, Meds, Allergies, shoe size, favorite vegetable, or birth stone.

  • Fern the Fire-Rescue newbie

    After doing numerous ride alongs in the back of the ambulance (worst one out of all of them was a stroke that died after we dropped him off in the ED.) when I was a fire explorer. I was lucky enough to see patches that were good, the best, and OK.

    Simple enough, all you need age, c/c, vitals/condition, relevant history (if any), eta, & request(s) for a special resource upon arrival. (I.e. trauma or stroke team).

    Everything else can wait until the handover in the ED.

    At least, that’s what I picked up from my time as a third-rider. If I’m an idiot, please, say something. I don’t want to stick a foot in my mouth again. 

  • Cayopyrat

    While “street pizza” may make you and your partner think he is a great pre-hospital medical provider, you may want to rethink your position.  Your partner in reality has done a disservice to our industry and to his patient.  Did you stop to think that perhaps there might be other people on the other end of the radio and/or telephone that can overhear what your “hotshot” partner has said?  Slang and such coined phrases are both unprofessional and potentially slanderous. Better yet, what about the patient themselves?  Hearing is one of the last senses to go in a critical patient, so what has your partner done for their peace of mind?  While I understand and compliment the reasoning behind writing this piece, I think you’d have been better served to provide some proper insight for all of the inexperienced providers out there who might read this and think, “Cool, I need to come up with some neat slang to describe my patient to make me look experienced.”  We struggle everyday with the negative imagery of EMS professionals and failure to use professional and appropriate terminology does nothing to help the cause.

  • Anonymous

    Good points.

    I don’t condone the speech, and he doesn’t either (although he’d probably think you’re a bit uptight). It’s one of those things one says in the heat of the moment that you only realize was inappropriate in retrospect. In this case, I was merely using the term to illustrate a point.
    On the other hand, if someone mimics a flippant or disrespectful phrase they read on a blog because they thought it sounded cool, their problems run a lot deeper than just being an impressionable rookie, don’t you think?

    Ambulance Driver

    ________________________________

  • Cayopyrat

    We are in a “heat of the moment” occupation and writing off
    the use of such a phrase as such is essential giving such actions a pass.  Would we condone administering an inaccurate
    dose of medication because it’s the “heat of the moment”?   Obviously in hindsight your partner
    recognizes the inappropriateness of the phrase, but by then the damage has been
    done.  As you correctly stated, giving notification
    is a key part of our jobs, shouldn’t as much preparation and forethought be put
    into it as we put into 12 lead interpretation or drug administration? Does it
    take that much more time to say, “Car versus pedestrian.  GCS x, Trauma activation required, see you x
    minutes?”

    In regards to the use of slang and other phrases, remember,
    imitation is the highest form of flattery. 
    If a senior person uses the language without caution, then it is going
    to be seen as acceptable by all. And while I do agree that someone who imitates
    others may have other issues, we all know that bad habits beget bad habits. 

    And finally, if my belief that we should be professional and
    collected under moments of stress makes me uptight, I’ll take it J.  

  • Anonymous

    Everybody has their own method of maintaining their calm. Personally, I tend to joke even more on a stressful scene, but it’s not flippant. There’s a purpose behind every wisecrack and wink, especially if the others on the scene are too tight.

    I’ll often joke with the patient to lighten the tension, and I cannot count the number of times I’ve cracked a patient up on scene – and some of those offhand comments leave my partners dumfounded that I dared to say such a thing, much less got away with it.

    And I’ve gotten complaints about inappropriate behavior towards patients over the years – seven times in 18 years – and in every single instance, the complainer was a fellow medic or a nurse, and never the patient in question or a family member.

    So what does it say about some provider’s idea of professional demeanor when they get all butt-hurt over a statement, when the patient to which the statement was made actually says, “Hey, I appreciated the moment of levity, it made me forget to be scared for a moment?”

    In all of those seven instances but one, the patient took my side. In the one exception, I was disciplined without an investigation, and the patient was never asked if they considered my behavior inappropriate.

    Case in point: I eat lunch once a week at a local Picadilly cafeteria. My lunch is comped by the manager, who I cared for during an anxiety attack one night. Her nurse neighbor called the ambulance, and was of the opinion that I should sedate her with Versed or Ativan – a point she made several times during the encounter.

    The patient wanted no such thing, and begged me to simply hold her hand and talk to her. She responded well to coaching and relaxation exercises, but what really did the trick was a little joke I made: “Did you hear that Mickey Mouse is divorcing Minnie? The judge told him he couldn’t divorce his wife on grounds of mental instability, but Mickey told him, ‘I didn’t say she was mentally unstable, I said she was fucking Goofy.’”

    That got a guffaw from the patient, and she forgot to hyperventilate for a couple of minutes while I went on a long riff about how if everyone looks goofy when they have an orgasm, then Goofy must look *really* funny when he has one, complete with my spot-on impersonation of Goofy spanking his partner’s ass and saying, “Who’s your daddy? Say my name, bitch!”

    The nurse neighbor was mortified, and filed a complaint about my unprofessional behavior. The patient, however, wrote a very thoughtful thank-you note to me and sent it to my supervisor, and offered me comped meals at Picadilly whenever I wanted them.

    All the point of this is to say – and I agree that “street pizza” is hard to justify – that inappropriate is in the eye of the beholder. If it accomplished my goal – relieving the patient’s anxiety – then who’s to say my behavior wasn’t *totally* appropriate for the occasion? The patient certainly believed so, and that’s whose opinion matters the most.

    Ambulance Driver

    ________________________________

  • Tj

    Pre-alert…

    ASHICE.

    Age
    Sex
    History

    Illness/injury
    Condition
    ETA

    Handover…

    MIST

    Mechanism
    Injuries
    Subsequent obs
    Treatment

    That’s all.

  • J Brosius

    With a national intubation success rate of almost 80%, paramedic education reaching abysmal levels of monkey-see/monkey-do, and pre-hospital providers that still think blood pressure means something and that saline is a perfectly good way to maintain a blood pressure, you’re biggest concern is that I used the term “street pizza”?  

    OK.  

  • J Brosius

    *Sigh…. “your biggest concern…”.  Not “you’re”.  

    I hate Auto-Correct. 

  • BH

    I got to the ED in about 8 minutes, and no one was waiting, the doctor
    was somewhere else…oh well, the funeral service was nice…

    Ayup.  Apparently “Pedestrian struck, head dented the windshield, he’s combative, no vitals, no IV, jaw’s clenched, we’re 10 minutes out” isn’t enough to get a trauma team in the room for us, but boy do they fall all over themselves prepping for a GSW to the foot for the urban FD. 

  • Cayopyrat

    The blog has nothing to do with the current decline in prehospital education and therefore not the proper forum for such a discussion. I’d love to have that conversation, but I suspect that we would both be on the same page concerning many of the issues.  My concern, in the current atmosphere of monkey-see/monkey-do, is too many newbies who thinks its cool and/or acceptable to use slang and other phrases to identify, label, or disparage their patients.  It is a disservice to the profession, the service which employs them and the patient.  I’m not talking about levity, AD hits that topic perfectly in his reply and I, too, use it. I am talking about those phrases that one would have to explain if they were sitting on a witness stand in front of a jury.

  • J Brosius

    Mr. Cayopyrat:  

    I’m not sure you’re as familiar with the environment in which this happened as I am.  I worked there for a decade.  Maybe you did, I don’t know.  Anonymity on the interwebz is a wonderful thing… one can slam others as lesser individuals without having to put one’s own record up for inspection.  At any rate, I’ll offer this, and you can take my word for it or not… I really don’t care:
    Nobody was offended, nobody thought less of us paramedics because of it, and nobody changed their mind about the level of professionalism we had based on this one comment.  One nurse actually told me “Pity that more of your fellow medics don’t give a radio report like that.  Save us a lot of time.”

    Again, you can think I’m unprofessional.  I don’t mind.  I’ve been called worse by better people.  And, of course, you are entitled to your opinion.  I’d never think to deny someone their opinions.  Tis what makes this country great, no? 

    I’d only ask that you base your opinions on facts.  And, good sir, in this situation, you have no facts.  

  • Cayopyrat

    First, you obviously care since you’ve taken the time to defend the comment that was the basis for the blog. I don’t judge you as a lesser individual regardless of the anonymous nature of my posts and if you’d like my 20 year CV in EMS, I’d be happy to provide it. Second, I don’t discredit your abilities as a paramedic.  You are correct I, don’t know you and it’s doubtful we would ever meet.  My point, originally, was to provide a counterpoint for the noobs that the blog was directed to by AD.  Therefore, I was only commenting on the facts provided by AD, and the statement that he attributes to you and that it was I was basing my comments on.   Finally, whether you’ve done this job in a busy urban setting, a sleepy suburb, or a far flung rural community; on a “bus”, ambulance, rescue or chopper, you come to realize that job doesn’t really change, just the broom used to clean up the mess.  

  • guest

     Why does history matter over the radio? How will the patient’s history immediately determine what the hospital has to muster up for resources. A radio report for urban hospitals that get frequent EMS arrivals should take only about 15 seconds.
    I work in an urban-downtown ED part time and am a 911 fire-medic full time. I take radio reports. I can tell you once I have the sheet filled out with CC, Age, Gender, Rx given, and ABNORMAL vitals or s/s, I start doing other things cause frankly because our ED is understaffed and busy as all get out.
    The pre-arrival report is to WARN the ED of what is to be coming so that WE CAN MUSTER THE APPROPRIATE RESOURCES. Who cares if the patient has had a stemi in the past? They’re having one now. Who cares if the patient broke his bone before? Its broken now. The history you can go over one-on-one with the nurse once you get there. The issue is primarily clogging up the radio when 3 other ambulances are ready to give their report, plus it makes you AND YOUR AGENCY sound stupid with long transmissions.

Vote for me! Click Here

Polarized sunglasses, Flashlights, and Hiking boots.