Perspectives on Safety
In Conversation With… Jane Brice, MD, MPH
Approach to Improving SafetyClinical AreaError TypesSafety TargetSetting of Care
Editor's note: Dr. Brice is Professor and Chair of the Department of Emergency Medicine at the University of North Carolina. She also serves as the Program Director for the EMS Fellowship and was past-president of the National Association of EMS Physicians. We spoke with her about her experience working in emergency medical systems and safety concerns particular to this field.
Dr. Robert M. Wachter: Tell us about what got you interested in the emergency medical system.
Dr. Jane Brice: I was a paramedic for 16 years. Worked as a volunteer in a very busy urban system professionally and also worked with an air medical system. I just could not get enough. So I went to medical school and became a doctor so I could do more. But emergency medical services (EMS) remained my passion because being in the field is the coolest thing ever. I'm an EMS physician now and continue to find joy in that work.
RW: Let's start with what both worlds feel like. For the average emergency medicine physician or nurse who doesn't ride the rig, what do they not understand about what happens out there in the field?
JB: People who function inside the four walls of an emergency department (ED) miss out on tons of information available to EMS providers. So much information can be gathered from being inside the patient's environment and seeing, for instance, what pictures are on the wall so that you understand their support network and whether the dishes in the sink are washed or not. So you understand something about their ability to do the activities of daily living and their mental status. To see whether it was neat as a pin and this 97-year-old woman can maintain and function in her environment, but now she's super sick. Because when you get to the ED with that 97-year-old woman and she looks very ill, an ED provider might assume she needs to be in a nursing home. But if you've been in her home environment, you would know that she just needs to get better because she's really taking care of herself quite well. A common misunderstanding among some emergency medicine physicians, nurses, and other providers is the ability of EMS professionals to accomplish an enormous amount of information gathering, treatment, and work in an unbelievably small amount of time. You may only have 12 minutes with a patient, yet you've initiated all the care that patient needs to sustain them for the next hour.
RW: How good or bad are handoffs today typically? The EMS folks have picked up someone, brought them in, and you now had this incredibly—often time-challenged and sometimes—chaotic handoff.
JB: Time is your enemy on both sides of that handoff equation. Emergency medical services providers are trying to convey as much critical information that's relevant to the patient's current condition in as short a period of time so that emergency medicine professionals can get to work and take care of the patient and make them better. Emergency physicians on the other side are champing at the bit to get their hands on the patient and to start their treatment, and they sometimes have difficulty focusing on the information being provided to them and absorbing it in a rigorous enough fashion to take good care of the patient. Because if you don't get all the relevant information from the field, then you're missing out on key pieces of information that will help you take better care of the patient.
Things that have worked are forcing a "time out," where they verify the patient's name and ID, the procedure they're going to be engaged in, and who's in the room and what information they have to relay. Forcing a time out at the time of that handoff seems to work well where you prohibit any engagement or activity during that interval and you force people to stand still and listen. We do this in the trauma bay, but we don't do this very often at the bedside when we're transferring our 97-year-old patient with pneumonia who looks terrible but actually is a very functional human in the world.
RW: Given your deep experience in the EMS world, when you observe one of your emergency medicine trainees and they're doing the handoff with the EMS, what's the most common feedback you give to them about that handoff?
JB: I have to "bonk" them on the head quite often. Because they're really focused on the blood pressure and the pulse and the O2 sat [oxygen saturation], and I want to know who was in the house, what did the house look like, where do they live, and is somebody coming? I worked last night in the emergency department, and my residents all got really frustrated with me because I kept asking "What does the patient do for a living? Where do they live? Who's in the house?" Because the social setting is so critical to understanding how this patient is going to return to their home or not, and how you're going to take care of them or who's going to take care of them down the road. It's just as critical a piece of information as their blood pressure.
RW: Let's turn to the particular challenges in the world of EMS. You've seen errors related to everything from the call to 911 up to the handoff. For those of us who don't work in that field and tend to focus on what happens when they finally reach our door, what are some of the common mistakes or safety hazards you've seen?
JB: The biggest ones that I have seen in the field and as an EMS physician (but also on the receiving end of the EMS patient) fall into two categories. One is centered around what we've already talked about: handoffs. It's about information gathering and information conveyance, both in a written and a verbal format—and clear communication. The second one is system issues. It's how we set paramedics up to fail in terms of how we stock the equipment boxes, how we set up medications right next to each other that look identical and both start with M—so that when you grab one when you're in a hurry and not looking carefully, you can give the wrong medication. Certainly the paramedic should check and there should be a double-check. But we set them up for failure because we don't set our equipment boxes or our ambulance stock cabinets up correctly to provide paramedics with checks and double-checks at a system level to not make errors.
RW: Those are generic issues that you face in the ED and people face in the OR. What is it about being in the back of a van weaving in and out of traffic at 70 miles an hour that make those things even more fraught?
JB: Do I need to say more than what you just said?
RW: Is that just it?
JB: Yes, that's it. But there's more. We talked about the handoff and how there was a time crunch on both sides of the equation. Everyone was really anxious to take care of the patient and to make the patient better. But forcing that time out, forcing people to stop, pause, take a breath, before they engage in patient care to gather the appropriate information and to do it correctly is the way to make a difference. So in talking about grabbing the wrong medication or wrong equipment out of the cabinet, it's time pressure. Often you're in the back of the ambulance with a patient who's trying desperately to go to God, and you only have 12 minutes between the time you pick them up and get to the hospital to make a difference. You're trying very hard to make a difference as quickly as possible, but the system may not be set up to allow you to function in that kind of time-efficient manner.
RW: Let's talk about diagnostic errors in the field. What are the most common issues that you see arise where they missed either the source of the acute abdomen or a particular bit of trauma or the kind of chest pain it was? Are those big issues, or is so much of it is just about almost generic triage to make sure they stay alive until they get there?
JB: There are a couple of scenarios in which it's really important to make the diagnosis. But they're really few and far between. It's important for paramedics to make a STEMI [ST-segment elevation myocardial infarction] diagnosis, and a few others. To be able to look at an EKG and go, "This guy is having a big heart attack. Let's get to the appropriate center and do the right thing for this guy." "She's having a stroke. Let's be sure we get her to a stroke center and some place that can take really great care of her." "He is hypotensive from a big GI bleed. Let's do the right thing." "She's hypotensive because she has a gunshot wound in her armpit that I didn't find because I didn't do a careful enough physical exam." But it's limited to some very specific time-critical illnesses like STEMI, stroke, trauma, or major hemorrhage. Other than that, I don't think that it's really important for paramedics to be able to make the diagnosis. It's important for them to stabilize vital signs as much as possible, and that's the vast majority of the patients they see. And that's one thing that makes it really hard, because 1% of the patients they're going to see will fall into that time-critical illness category. And providing them with the tools and the knowledge to be able to identify those out of the other 99% of cases they're going to take makes their job really tough.
RW: For the STEMI and the stroke examples, you indicated that they need to make the diagnosis so they go to the right place. How much of it is going to the right place versus the specifics of what they're actually doing in the back of the ambulance?
JB: To me, you have to give the STEMI some aspirin and some nitroglycerin, but you're going to do that for most chest pains anyway. Making the diagnosis for STEMI and stroke is critical. The most important thing they can do is to take the patient to the right destination and to make sure that that destination is primed to receive the patient with advanced notification. Prenotifying the receiving facility and going to the right receiving facility are the most important things they can do for stroke, STEMI, and serious trauma.
RW: Is that determined algorithmically or is that the EMS professional's choice, meaning that I've figured out that this is a STEMI, I'm driving past a local ED, and I have to drive 37 more minutes to get to a place that is really good at this. Who makes that call?
JB: They say, "If you've seen one EMS system, you've seen one EMS system." Every EMS system handles this exact question differently. For some systems, it's protocol-driven. For some systems, you have to call and ask permission to do such a thing, particularly if you're driving past the county line. Other situations, it's the paramedic's call. They can decide what the right thing is to do for this patient in this scenario. But it varies from place to place and system to system.
RW: In general, if it's a stroke or a STEMI and the person is sick but not acutely dying and it's a 45-minute difference, is it generally the right call to go to the place with more capacity or to go to the local place and get things stable? How do you even think about that decision?
JB: In my opinion, the answer is that you go to the right place. You get the patient to the right place that can take care of their problem in the most efficient way possible. I know you're focusing on stroke and STEMI, but I would absolutely add in serious trauma. There's tons of literature for all three of those entities that says it makes a huge difference to take the patient to the right place in a timely fashion.
RW: That makes a lot of sense. One of the most challenging issues that comes up, and probably one in which there are errors made in all sorts of directions, is around the provision of end-of-life care and advanced directives and what's on the refrigerator and what's on the armband. Tell us about how you think through that issue and the kinds of errors that you see being made.
JB: So much of health care is about communication and about making sure that we hear what the patient has to say, whether that's in a DNR [do not resuscitate] form on the refrigerator or a Vial of Life in the refrigerator, where you would have a pill bottle into which you stuff the information that you want someone to know about you in the event of an emergency and you put it in your refrigerator and it says "Vial of Life." So you pull it out, open it up, and it says, "Don't do CPR" or whatever.
RW: So it's a time capsule for your advanced directives.
JB: Exactly. But again, time is your enemy. You have moments to make a decision about whether to start resuscitation on this critically ill dying patient. But doing everything you can to sustain that patient's life while also making sure that patient is heard, whether that's in a written or a verbal form from bystanders is very important. Too often we get blinders on and all we can see is VFib [ventricular fibrillation]. We don't stop to think or to ask the question "What would this patient want me to do?" I think it's as important as the electricity that you apply to their chest that you make sure this patient receives the care that they wish to receive. But if EMS isn't asking the question, then it will never be answered. If they walk in the home, just start applying electricity to the chest, take the patient to the hospital, and never ask the question, we'll never know.
RW: Are EMS people trained well to do that?
RW: Is it considered to be part of what makes a good EMS person?
JB: Yes, and I think we're getting better. I said "no" flippantly because I don't think anybody does a great job of it. In the ED, we have tons of people who could be asking the question, where EMS may have one or two people or two or three people who are available to ask the question while still trying to save the patient's life. In the ED, we have tons of resources and we don't do it well either. But I think we're getting better all the time. Movements in the 1990s and thereafter with MOLST forms and POLST and others have helped. But we need a more nuanced conversation about that. I also don't think systems are in place to support EMS providers when they do make those decisions. We have a recent example from a nearby county where EMS providers honored a DNR form, the patient died en route, and then the emergency department wouldn't accept the patient and so EMS was stuck with a guy who had died in the back of the ambulance and had no mechanism for helping this man get to a funeral home or other appropriate place. I don't think as a system we support providers in those decisions.
RW: I can imagine it happens pretty often that you're in the house and the patient is doing poorly, respiratory distress, and you're doing positive pressure or even CPR, and you want to get out of there, yet you're not sure what the patient's code status is or should be. And it's going to take you 5 minutes of discussion to even have any chance of sorting it out. How do you decide whether to stay or go?
JB: I have to disagree with your assumption that it takes time to figure that information out. I think they either know or they don't. If they don't know the answer to the question, you're not going to be able to sort that out on scene. If you ask them, "Does he know what he would want in the event that his heart stopped or that he stopped breathing" and they say, "I have no idea," then you should just take care of the patient and go to the hospital. Let somebody else figure it out, because that's not the place for that conversation.
RW: Tell us about the EMS system. Is any of it digitized? Are they still writing on clipboards and then does that create some disconnect between what they're doing and the information transfer to the institution?
JB: Some places in the United States are still scribbling on paper, but in North Carolina everybody has been digitized for a long time. We have a statewide database. It's set in rule that every EMS response has to be documented in our state database within 24 hours. A number of software vendors are working hard on health information exchange; some notably well. One of the vendors in our area has recently accomplished a health information exchange between EMS and the hospital so that there is a two-way dataflow. Their PCR [patient care report] populates immediately into our electronic medical record as soon as they file it, usually within minutes of receiving the patient. They subsequently can get a dataflow about what happens to the patient during their emergency department visit. That two-way data exchange has been extremely meaningful and impactful for our EMS providers in understanding what happens to patients after they deliver them to the department. Electronic medical records are making an enormous difference for patients here.
RW: When you say they file, are they filling stuff out electronically in the ambulance and it's entered into your record into the ED?
JB: That's right. The other night I had a patient that I had some questions about. I went to the electronic medical record, and within 5 minutes of receiving the patient, I had their patient care report and was able to look it over and answer my questions. It was fantastic.
RW: When you said they needed to make the diagnosis of STEMI on the EKG, are they making the diagnosis themselves or that is generally an automated EKG reader?
JB: That varies from EMS system to EMS system. In our EMS system, it's both. The computer or the machine tells them what it thinks it is, but they're expected to look at the record too and make an independent decision about whether it really is a STEMI or whether the machine didn't call it a STEMI and it is. So they're expected to do both.
RW: Are they doing things in the field where you worry about whether they have the wherewithal and the training to do them? I'm thinking about thrombolysis, and you see more and more things being pushed into the ambulance because it's time sensitive. Do you think we have that balance right?
JB: I do for now. I think we're in a good place. I think that EMS providers have the capacity to do more. Ultrasound is a device that is working its way into EMS diagnostics in the field. Emergency medical services providers absolutely have the capacity to use ultrasound and other technologies. Maybe someday we'll have a tricorder and be able to do diagnostics and make better decisions about patients. But EMS has the capacity to do more, for instance with ultrasound.
RW: What are a couple of the use cases that you think they could use ultrasound for in the ambulance?
JB: As an example, a 22-year-old woman has a syncopal event and complains of belly pain. Slap an ultrasound on her abdomen. Find that she has a belly full of blood because she ruptured an ectopic pregnancy. Now you know you have a big emergency on your hand, and you can let people know in advance that they need to be alerting the OR and other places that you have a problem. It's also useful in trauma, you can look for a belly full of blood or a tension pneumothorax or a hemothorax and treat them appropriately.
RW: So is it just again triage and alerting? Or are there cases where what they find will lead to something that they will do in the ambulance?
JB: If you had a hypotensive trauma patient and you found that they had a big tension pneumothorax, you put a needle in their chest and make it better.
RW: Do you have a vision for how all of this is going to play out over the next 5 or 10 years? Do you think any fundamental differences are on the horizon?
JB: I'm thrilled about CMS's new ET3 model of reimbursement of EMS providers. Because EMS has over the past 10 to 12 years started to stray into the territory of community health care, through the community paramedicine programs and alternative destination programs. It's very difficult to support and finance those kinds of endeavors when nobody is reimbursing you for going to somebody's house, providing health care, and keeping them out of the health care system or into a more appropriate environment like their primary care provider's office or an urgent care. The new ET3 model of reimbursement is not yet enacted, so we'll see how this all plays out. But it's very encouraging that people are starting to look at EMS as a potential triage system for getting the patient to the right place. We talked about super sick patients going to the right place for their stroke and STEMI. There's also the concept of getting the not really sick patients to the right place so that they get the best health care. Sometimes that's not the emergency department. Sometimes that's their primary care physician's office, sometimes it's a mental health facility. I'm very encouraged by this concept and eager to see what happens.