I believe it all started in the weeks following the 9/11 attacks. The transformation was subtle at first and then gradually became more palpable. The change was slow enough that lots of us probably failed to notice. What I am referring to is our interactions with EMS.

In the months following the attack, the entire country looked at our EMS providers and firefighters in a different light. We saw bravery in action and suddenly realized that these men and women have dangerous and difficult jobs. The vague understanding that firefighting and lifesaving is potentially dangerous work was made manifest when 343 died in the time it takes to brew a pot of coffee.

People started wearing FDNY hats and shirts. Young men and women found real heroes to emulate instead of the parade of empty headed idiots we get from popular culture. Firefighters and EMS providers walked a bit taller and felt even better about what they did for a living.

Along with this positive transformation, I also noticed that providing feedback to the EMS community became more difficult. Even writing what you are about to read is really sticking my neck out. What I have found, over the past decade, is that people in the EMS system tend to bristle at negative feedback and even find ways to turn it back on the person who is trying to be helpful. Suddenly the person trying to be the good guy is the bad guy.

One might argue that we should not be critical. These are, after all, community heroes doing tough and dangerous work. Why not just leave it be? That’s all well and good; however, we should recall that every paramedic operates under the license of a physician. Although we are colleagues and we should always be collegial, paramedics are in a subservient role, and it is our job to oversee their performance. The tail does not wag the dog.

Now some paramedics are quite open to feedback and often invite a critique of their performance. Others, however, are quite sensitive about criticism and will drag their hurt feelings as far as someone will listen. Some feel the necessity to grumble all the way to the office of the CEO.

Asking too many questions on the radio, questioning why a stable patient was taken to you rather than the hospital where they were admitted a week prior, and suggesting that an action would have been better taken after discussion with medical control are all offenses that can land you in hot water with your medical director or your administration.

The line from administration usually goes something like, “Hey dummkopf, don’t aggravate EMS. They bring a lot of admissions to us.” Translation – forget medical oversight, we don’t want the gravy train (bus) going elsewhere.

This only had to happen once for me to divorce myself from the proper relationship. My shift today was a good example of how my behavior has changed. EMS was called to a home where an ancient man had collapsed. The resuscitation was started and then quickly stopped when a DNR order was produced. Rather than calling the coroner, they transported a dead body for emergency care.

We proceeded to register a dead body and then I confirmed that he was, in fact, not only merely, but sincerely, dead. The tough part was getting the signature. Did I say anything to the medics? Do you slam your hand in the door more than once?

Later in the day a different crew transported someone with altered mental status who required intubation. They nasally intubated and were bagging him on arrival. Trouble was, I could hear laryngeal sounds. We pulled the tube and the resident orally intubated him. Luckily there was enough spontaneous respiration that he never desaturated and all was good. I would have liked to have a conversation about technique and confirming placement and all the rest.

Who wants to deal with the negative consequences? The distorted culture does not invite this type of interaction any more.

This was a rare day, and, in general, I feel EMS does a good job. The issue is not one or two mishaps. These things happen, and we all can benefit from feedback about our work.

The issue is that many emergency physicians just keep their mouths shut rather than have a friendly conversation about patient care. In the end this is supposed to be about the patient and everyone doing the best job they can for the patient. Instead there is silence in order to prevent ruffled feathers and wrathful CEOs.

And the patients are better for this how?

Dr. Baehren lives in Ottawa Hills, Ohio. He practices emergency medicine at Wood County Hospital. Your feedback is welcome at DBaehren@premierdocs.com.