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10 rules for EMS at the emergency department

Behave, play nice and show some respect to strive for fellowship with doctors and nurses on hospital grounds

When you’re finished with your patient, the hospital’s job is just beginning.

The first time I showed up at an emergency department with a patient, it didn’t go well. I wasn’t sure who to see or what to say. I did have the presence of mind to get paperwork signed and not leave my stretcher behind, but I had to improvise everything else. I must have sounded as nervous as a teenager on his first date.

Patient handoff isn’t something we’d covered in EMT class. Our 800-page textbook had only five paragraphs about hospitals. We were all more preoccupied with backboards and MAST suits than with ED procedures. It took me several months to stop feeling like the weakest link in the healthcare chain.

Now that I can reflect with more tact on the complex, occasionally frustrating relationship between hospital and prehospital personnel, if I were teaching my 20-year-old self to play nicely with those who inherit our patients, here’s what I’d recommend:

1. Help hospital staff with something inconvenient

It’s not unusual to build credibility in EMS by volunteering to do whatever senior partners would rather skip. The same goes for gaining acceptance in the emergency department. Look for signs of overworked staff, then offer to help with messy jobs. Even something as simple as taking a turn at compressions on a cardiac arrest shows you’re a team player.

2. Respect colleagues’ education and experience

Repeat after me: I am not a doctor. You’re probably not an RN either, and may have maxed out on EMS educational requirements with a high-school diploma. Wait, you say you’re a critical-care flight paramedic with 30 years’ experience who can start IVs inverted and intubate 400-pounders through their navels? I bet you still don’t know what you don’t when it comes to definitive care. Consider the possibility that eight years of college and at least three years of residency exempts physicians from having to compete with your self-proclaimed street skills.

3. Offer clear, concise presentations

How much time do you think you have for a radio report before your audience stops paying attention? Thirty seconds? I’d say more like 15. En-route presentations aren’t supposed to reassure ED staffs your patient’s vitals are “within normal limits.” Highlight the unusual.

4. Apply what you learn

Tips from doctors and nurses can enhance your practice. I remember many lessons I learned in the emergency department that supplemented my EMS education. You can read pages about, say, Kussmaul’s respirations, but there’s no better path to understanding than a knowledgeable clinician who says, “Have you ever seen Kussmaul’s? Let me show you.” Thanks, Dr. Miller.

5. Do what you can in the field to lighten the ED’s load

However busy you think you are delivering care in the field, you’re usually handling only one patient at a time. I know RNs who’d tell you they could do that with one NG tube tied behind their back. When you see a nurse with enough patients to qualify as an MCI, offer to help. Hospital rules probably limit what you can do, but fetching a blanket from a warmer isn’t likely to provoke a Joint Commission audit.

6. Play by their rules

Speaking of hospital rules, if you break them – even unknowingly, with nothing but sympathy and good citizenship in your heart – don’t expect a free pass. I’m thinking of the time I was handed an angiocath by an ED nurse who was the only other person working a cardiac arrest. I knew she wanted IV access, and was securing my EJ when another responder inadvertently yanked it out. It happens. Nevertheless, I was grilled by the nurse manager about who gave me permission to practice phlebotomy in her ER. I wouldn’t tell. For a few months, I couldn’t fetch a non-rebreather without permission.

7. Don’t loiter

When you’re finished with your patient, the hospital’s job is just beginning. Let them do that job. Get what you need and get out of the way unless you’re given something else to do. Hold your questions for a quieter moment.

8. Respect real-world constraints about space, staffing and services

It’s easy to feel impatient about hospital delays. Try reimagining the ED as a branch of the DMV. That’s how much control you have over your wait time.

9. Be nice

Remember that “M*A*S*H” episode when a tearful Margaret asks her nurses, “Did you ever offer me a lousy cup of coffee?” Notice she wasn’t complaining about not having enough patients, which is all we ever bring the Major Houlihans of the world. Once in a while, it’s nice to reward nurses with life-sustaining caffeine and tasty snacks.

10. Even when all eyes are on you, it’s still about the patient

Striving for fellowship on hospital grounds doesn’t relieve us of our responsibilities as patients’ advocates. If you need to ensure potentially unstable customers are treated as such by ED staff, do so knowing that most doctors and RNs I work with respect professional, well-meaning expressions of concern.

Try a few of the above suggestions and watch the world become a better place. At the very least, nurses will wonder why you’re so much less annoying than your friends.

Mike Rubin is a paramedic in Nashville, Tennessee. A former faculty member at Stony Brook University, Mike has logged 28 years in EMS after 18 in the corporate world as an engineer, manager and consultant. He created the EMS version of Trivial Pursuit and produced Down Time, a collection of rescue-oriented rock and pop tunes. Contact him at