The paramedic intercept is a skill just as any other. Commonly overlooked during initial training, effective communications used during the patient handoff plays a significant role in patient care. Actually, the Joint Commission concluded that 70% of hospital-related “sentinel events” involved communications, with 50% of those events occurring during patient care handoffs. (J Quality Patient Safety, 2010 Feb; 36(2)) Think of the last time you were giving report, just to have the accepting physician or RN ask questions that would’ve already been answered had they been listening, and not just hearing you. I constantly listen to gripes from my peers how they felt disrespected by hospital staff, only to arrive on a scene with them and they do the exact same thing to a lower-scope provider. This hypocrisy is avoidable.
The first question we need to address is, “Who are we intercepting with?” These volunteers sometimes include farmers, mill workers, or engineers. Other times, they could be a nurse, a cop, or that off-duty paramedic who has been on the same first responder department since before they had their name on a single certificate. Regardless of their background, when they call us they all have one thing in common: they need help. Whether that be an advanced procedure, an assessment tool, or just some comfort of having a paramedic on-board, they felt that they could not care for this patient unless you, the paramedic, were there as well. So, now that we understand there are many different types of providers we could potentially intercept with, lets discuss how we can effectively receive the patient.
When we cross the threshold of the apparatus bay, we have to make a conscious decision:
This begins at your first radio transmission. Calling for an update on the patient en route is a great opportunity to get a feel for the scene, give the requesting agency an ETA, give them a sense of calm that help is on the way, and it also gives you the chance to begin to develop a game plan with your partner. Designating roles prior to arrival to any patient contact ensures that roles are clear and will reduce your cognitive load on scene. Okay, so now we are en route and have given the requesting department an ETA, we have a game plan worked out with our partner, and we are just arriving on scene. How do we receive report?
As mentioned prior, ineffective communication techniques during patient handoff has been proven to cause harm to patients in the clinical setting, so it should be safe to assume that it is just as common, if not more common, on the scene of a motor vehicle crash, or in the back of an ambulance in podunk township. Mission critical communications cut out the proverbial bovine feces and help to reduce the amount of information that can be lost or misconstrued during report. We love lists in EMS, right?
Here is an overview for how the on-scene report should go:
• What seems to be the patients problem? • What has EMS done for the patient so far? • What is the patient’s current status? • What are the patient’s immediate needs?
There we have it. The problem, the start of a solution, and a good idea of what needs to happen. But, receiving report isn’t just about getting the right information, we also need to consider how we make them feel while giving us report. 65% of communication is non-verbal. Crossed arms, wandering eyes, constant interruptions— these will ensure that the speaker assumes you have no investment in the conversation, and cause them to want to end the conversation prematurely, possibly excluding pertinent information. Here are some tips for effective listening:
• Give individual attention (possibly excusing yourselves to step into a quieter environment) • Eye contact • Avoid interrupting (Think of our first scenario!) • Repress emotional responses (will that eye roll really solve anything?) • Requesting clarification (“you said (this), am I understanding this correctly?”) • Summarizing (“okay, so you did A-B-C, and it seemed to help, great!”)
“You have two ears and one mouth, use them proportionally.” -unknown
I remember my first patient handoff report to a trauma center. I was so nervous my foot was shaking uncontrollably, I was stuttering, and felt as if someone put the thermostat up to 110 degrees just before we walked through the door. Thinking back, it was probably a terrible report. However, there was a silver lining to this otherwise nightmarish event. The doctor listened to my report, asked some questions to clarify, then asked me to hang out for a second. After he did his assessment and gave some orders to his staff, he took me to his computer and showed me the CT scans from the sending facility, explained what I was looking at and told me what the expected clinical course for this patient was, ended with a hand shake and a, “good job.” This 2 minute interaction completely changed my outlook— I felt as though I was apart of the team, and what I did actually mattered. Now, I’ve also been on the complete opposite end of the spectrum, and that wasn’t fun at all. We take away one of two things while learning: how TO do it, and how NOT to do it.
Understanding this range of respect as part of how TO do it is important.
I can now take that good experience and pass it down to the milk truck driver giving report on a 4-month old in respiratory distress. Summarizing the report received, and giving a little overview of your intended interventions takes only a few seconds, and can create a learning environment. Need a 12-lead? Ask someone on scene to help. They don’t know how? Show them. These extra moments that we take on scene with our neighboring departments are what we call “teachable moments,” and these can have very positive effects on patient care. This reminds me of the old adage, “Tell me and I will forget, teach me and I will remember, involve me and I learn.” This can instill a certain level of confidence in the providers on scene, and your patient as well. You have just demonstrated that not only do you know how to do this skill yourself, but you know it so well that you are able to teach someone how to do it.
Winston Churchill said, “Tact is the ability to tell someone to go to hell in such a way that they look forward to the trip.” This is getting your point across, while being sensitive of your audience and delicate in your delivery. Think about that patient that is given nitroglycerin with an inferior MI and they didn’t have an IV established. You are now being requested because they can’t figure out why the patient is now unresponsive. This may be one of those teachable moments that we can use to educate, however it is important to do it with a level of diplomacy where everyone leaves with a positive experience.
As paramedics, task delegation is essential of effective scene management. Having the only paramedic on scene obtaining a blood sugar, or holding c-spine when the patient needs intravenous access and advanced medications is inefficient and reflects poor direction. Having an action plan, utilizing resources appropriately, and treating everyone involved with patient care as an important piece of the patient-care puzzle demonstrates the leadership qualities expected of the paramedic.
Interpersonal skills and communication are a requirement to be a good paramedic. Using these skills routinely during your shift will help create relationships and opportunities that will help you become a better clinician. Self reflection, when done honestly and constructively, will help the paramedic learn how they can improve these relationships. Remember that decision we make when pulling out of the apparatus bay, and take care not to condescend the people who called you for help. Sometimes the only thing these departments need from the paramedic is a hand on the shoulder, someone to tell them they did a good job and everything will be okay.
-Joel Porter NRP, EMT-P,ICI