The e-mail that came from one of my most conscientious paramedics was similar to many others I have received as EMS Medical Director of a busy fire-based urban EMS system. It went something like this: “I am writing to give you a heads-up about a couple of runs to Generic Hospital. This doctor had a very condescending tone as he spoke to us when we brought in a victim of a shooting. After we had taken the patient to the trauma room and the trauma team had stabilized the patient, I tried to ask the doctor what his impression of the patient’s injuries was, but he had turned his back toward me and started talking to another doctor. He completely ignored me and my question. He also seemed to doubt our evaluation of the patient and whether our patient actually had a pulse when we got to the ED. I felt humiliated and embarrassed after we tried to do our best in caring for this patient in the field. I just wanted you to know about this situation.”

After corresponding with the medic and the hospital staff (who were very apologetic over the incident), we were able to resolve the situation and move on. But it made me think about the many times these situations come up and how they might be avoided by applying the “Road House” rules of engagement for hospital staff in their interactions with EMS personnel. You all remember that classic cinema production where Patrick Swayze as the intrepid hero Dalton took care of business in a small-town entertainment establishment where the customers could get somewhat rowdy. His mantra to his bouncers was: “Be nice.” And so in honor of Dalton and in the spirit of improving ED-EMS relations across this fruited plain, here are my Top Ten “Road House Rules” for interfacing with our EMS colleagues and partners:

1. They are your health care colleagues and partners. Hey, didn’t I just say that? But you really can’t say it enough times. As hospital staff, we often forget that patient care really started when the EMS personnel arrived, and we are merely part of the continuum of that care. What the EMS providers did in the field is very important for us in the ED to be aware of so we can make sure that our care is consistent with their care. Many times ED personnel routinely dismiss anything to do with the prehospital treatment that the patient received; 12-lead EKGs are ignored, initial blood results are dismissed, and EMS run reports are filed in the circular receptacle. But the smart and seasoned ED physician knows that the EMS providers can be of tremendous help in the evaluation and treatment of that patient in the ED, and that their insight and perspective can lead the ED physician down the correct pathway to the right diagnosis and treatment. So treating them as our partners – much like we do any consulting physician we may call down to the ED – makes sense and is in the best interest of the patient.

2. They appreciate feedback on their performance – privately! The worst thing that a nurse or ED physician can do is to question the EMS provider’s care in the presence of other staff, patients, or other EMS personnel. When the ED is bursting at the seams and EMS has just brought in the umpteenth patient that day, tempers are frayed and sometimes the EMS providers may get the brunt of the frustration simmering in the department. If there is a true concern on the part of an ED staff member about substandard care a patient received from EMS, that concern should be expressed in private in a professional and productive manner. If things could have been done better, most EMS providers sincerely want to know that information and will receive it well if it is delivered in a confidential setting that allows the individual to avoid being humiliated in the presence of his or her peers. So take the time to perform this exercise discretely and with dignity.

disregarding the value and importance of your local EMS providers does nothing except alienate them and ultimately has an adverse effect on patient care.

3. Understand what they can do and not do in the field. EMS protocols for your local agencies should be available and accessible in your ED. If you receive a patient who had a cricothyrotomy performed and you did not know that your EMS providers could do this procedure, shame on you for not knowing this. EMS protocol should be updated on a regular basis as medications and interventions in EMS are constantly evolving. You may disagree that a certain EMS protocol is allowed, but make your concern known to the EMS Medical Director instead of yelling at the medics about it. Be ready to share scientific data on why you feel the EMS protocol is inappropriate instead of just saying “you don’t think it is right.” Constructive and productive criticism is welcomed by EMS if it results in better patient care.

4. Positive comments to them on their care is encouraging. My mother used to say “if you can’t say something nice, don’t say anything at all.” Now if there is a case where the care was egregiously deficient and there really isn’t anything positive to say, that is one thing. But those cases are fortunately rare, so in the vast majority of EMS runs to your ED, you should be able to find something to compliment those EMS providers on. Even just talking to them is a plus, as many times ED staff ignore them and treat them like furniture or “ambulance drivers.” They are health care professionals who perform a very difficult job, and like you and me they enjoy receiving feedback that supports and encourages them.

5. Ride time may be beneficial. One of the most productive things that any ED staff can do to better understand the challenges that EMS providers face is to take some time and actually take some calls with them. Certainly it requires a commitment of time to do so, but you might be surprised how perspectives can change when you actually witness a cardiac arrest being managed in a bathtub or the excited delirium patient who is kicking and biting everyone in sight before the administration of ketamine. Even just one ride-time experience may be enough to permanently make individuals much more sensitive to the realities of rendering prehospital care.

6. Education from you can set new standards of cooperation and good will. EMS personnel usually appreciate efforts from hospital staff to provide continuing education. For example, if you recently instituted induced hypothermia in cardiac arrest in conjunction with your EMS system, you might want to consider a periodic educational session on how that is going in your hospital. Or give an inservice about the changes in stroke care and what benefits are being realized by stroke patients. Even better, start a monthly EMS Educational Outreach Session and make it a part of the local culture of your health care community. Providing food at these sessions may be a worthwhile investment.

7. Never make disparaging remarks in front of staff or patients. See #2 above. But it can’t be said enough. If you do have a concern about any care being given by EMS providers, take your concerns in a productive direction. It is understood that in times of stress and tension, we all can lose control and let slip comments that we wished we could take back. But the potential destruction of the “loose lips” can definitely “sink ships” in regards to lost credibility, hard feelings, established biases, and, more seriously, litigation against EMS systems. There is a way to direct your concerns that will result in a change for the better.

8. Direct your care concerns to the EMS Medical Director. When an ED nurse or physician has observed a situation in which they feel EMS care was either inappropriate, inadequate, or just plain wrong, that issue should be forwarded to the EMS Medical Director. If you don’t know who the EMS Medical Director is … well, shame on you. You should have posted in your emergency department the names and contact information for all of the EMS Medical Directors of every EMS system that transports patients to your ED. In many cases, there is a form that you can fill out and submit online that will be sent confidentially to the EMS Medical Director for their review and disposition. They should contact you to let you know the ultimate resolution of the problem. Our ED staff members in our community are critical and valuable components of our continuous quality improvement process. They let us know about the great cases where the care was exemplary, as well as the ones that are opportunities for improvement. Without feedback from the institutions that receive our patients, our ability to improve the system would be greatly handicapped. So taking the time to bring areas of concern to the EMS Medical Director results in a healthy and effective local EMS system.

9. Be discerning of the differences among EMS agencies. In some communities, there is a mix of paid and volunteer EMS providers who may be able to provide advanced life support (ALS), basic life support (BLS), or a combination of the two. ED staff should be educated to the nuances of their EMS community and, by looking at the identifying information on the shirt or jacket of the EMS provider, be able to know things like whether they can intubate, read EKGs, start IVs, or just provide transport. That way you are not taken aback when a patient arrives in cardiac arrest without an endotracheal tube when those providers are only BLS and cannot perform that procedure legally. It also is helpful when you have a volunteer service come in with a very difficult trauma patient and you know that this particular system takes only one run a day and maybe one bad trauma a year. These providers were called in from home or their jobs and were thrust from a safe and familiar world into a horrific and strange one in a matter of minutes. These EMS providers differ from the paid EMS providers who do this type of thing day in and day out and are comfortable with just about anything. Those differences are important to realize and take into account in communities with a varied tier of EMS providers.

10. Invite them to observe continuation of care on patients they bring you. Most EMS providers want to know what happened to the patients they bring to the ED. So if they can be accommodated without compromising patient care and safety and do not have to get back into service right away, invite them to observe the ongoing care of the patient (procedures, cath lab, stroke care intervention, etc.). In cases of cardiac arrest, let them watch the continuation of the code through final disposition of the patient. With a trauma patient, they could observe the surgical interventions in the trauma room until the patient is taken to the operating room. Or in the case of a patient with a STEMI, maybe invite them up to the cath lab to watch the procedure unfold. Nothing is more powerful in impressing the importance of “time is muscle” on EMS personnel than watching blood flow being restored to a portion of the heart that was deprived due to a coronary clot. Allowing EMS providers to participate as active observers costs the ED and hospital nothing but results in untold dividends of good will and partner building with EMS. It also helps to reinforce the concept of the health care team and the inclusion of EMS into that team.

Providing care to patients in an emergency department can be a stressful and frustrating task, but disregarding the value and importance of your local EMS providers does nothing except alienate them and ultimately has an adverse effect on patient care. Or to recall another memorable “Road House” quote: “Calling me sir is like putting an elevator in an outhouse. It don’t belong.” In other words, disrespecting and mistreating our EMS colleagues just “don’t belong.” Dalton’s advice to “be nice” can reap lasting benefits for your emergency department staff and EMS relations.

Dr. Keseg is Medical Director of the Columbus (Ohio) Division of Fire EMS.