When the EMS provider has to convey patient information, there are 3 distinct settings in which this should occur. You don’t want to waste time on the phone when you (and they) need to be doing other things, and you don’t want to leave out critical details when you need an order or you are handing off care to another provider.
- Report to the receiving hospital to obtain a bed and mobilize any necessary resources, such as a trauma team.
- This report should be brief and include only enough information to mobilize the appropriate resource.Details such as what medications have been delivered need not be given, as well as the details of how the injury occurred or an explicit history of present illness. Key thing is that this should be BRIEF. You have better things to do than talk on the phone, and so do they.
- In the case of a trauma, it requires a report of mechanism of injury, MAJOR injuries (can exclude most bruises, lacerations, and abrasions), vital signs, GCS, and whether or not the bleeding and airway are controlled. This is enough injury to determine what level of trauma response will be needed at the hospital (Category 1, Alpha, or whatever their terminology is) and whether blood should be brought to the trauma bay.
- For stroke, the current symptoms and LAST TIME KNOWN WELL are paramount to determine if the stroke team needs to be mobilized.
- For STEMI, EKG findings, age, and vitals are important. If the patient has a cardiologist, knowing who this is may be important if the hospital has more than one cardiology group that takes ER patients.
- Report to online medical control physician, usually to obtain advice or permission to execute some part of the protocol or deviate from protocol.
- This usually requires a more detailed report to paint the picture. Make sure you know who you are talking to before you launch into this report. It won’t do for you to give a detailed report to to the person that picks up the phone only to repeat the whole thing when the physician gets on the line.
- Start with your BLUF (bottom line up front) and tell them what you are asking for. If you need an order for something, say so. “Doc, I need an order to repeat the ketamine dose in this patient. 45 yo M in a rollover MVC…” “Doc, I have a patient here that wants to refuse transport and I don’t think that’s in her best interest. This 65 yo F was found today…”
- Handoff to another provider such as another EMS provider, nurse or physician at the receiving hospital.
- This report should be detailed, including all treatments rendered and the patient’s response. Concerning findings or clues of the patient’s history are conveyed then.
- If it is a time critical situation such as a trauma, you probably have only 30-60 seconds to deliver this info. Don’t rush through it but give a concise history and summary of injuries and last vitals. Summarize any medications given especially pain medications, sedatives, or paralytics.
- You can always give the summary report to the resuscitation team, then fill in the details with the nurse who is the “recorder” documenting the resuscitation.
- For handoff to another prehospital provider, it is good practice for that provider to read back the summary report to you to make sure everything was understood.
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