Discussion
Background Statement
In this scenario, several serious problems are unacceptable for the professional clinical practice of the ambulance team. In short, as paramedics, Roy and Robert were unable to provide proper care for two patients who were in a critical situation, which resulted in the death of one of them. Although Robert attempted to resuscitate patients while Roy was driving, a fatal mistake was made when both men ignored the rules of responsible hospital selection, which resulted in multiple delays. Apparently, if the men had been more attentive to their work responsibilities, it would have saved a girl’s life.
The Key Points Needed to Understand
Of primary importance in this example is understanding the gaps that Robert and Roy committed during the work schedule. According to Erbay (2016), the fundamental ethical principles of the Emergency Medical Services (EMS) are fairness, harmlessness, non-stigmatization, and no patient triage. In addition to this ethics, the crew’s work is limited by the EMTALA law, adopted for signing in 1986 (Silverman, 2015; Plaster, 2015). The law imposes restrictions on the permissiveness of paramedics’ choice, forcing them to work with absolutely all categories of citizens, including those who do not have a Medicare insurance policy. According to EMTALA, EMSs are obliged to provide the patient with safe and quality care from the place of accident to the hospital of destination and to provide all necessary medical services that have the potential to help patients.
Script Summary
Tired of a busy schedule in the office, Robert and Roy went to the streets to provide EMSs. Due to professional stress and lack of rest, as well as low organizational culture, workers did not check the divert status board of unactive ED hospitals. In turn, this factor led to a fatal mistake while working with the first two patients who were victims of a car accident: a father and a daughter. While Roy was driving the vehicle to deliver critically injured patients, Robert provided first aid. Thus, stress also had an impact on the paramedics’ judgment and sobriety, and therefore, they were wrong while choosing a hospital to transport patients since the facility was in ED diversion status (“What is ED Diversion,” n.d.). After that, the men went to another clinical organization, but there was also a delay caused by a verbal conflict between paramedics and doctors. Although the second hospital agreed to help the patients, it was too late, and the girl died of cardiac arrest.
Main and Secondary Problems
The central problem of this scenario is the low organizational culture prevalent among EMS paramedics. With great confidence, it can be argued that this issue is not caused by the low qualifications of the two employees, Robert and Roy, but rather by serious management problems at the emergency department level. In the example, at least five consecutive troubles should be noted, which in general could have been inhibited if the quality of organizational management had been higher. The range of such problems includes (i) the lack of obligation to look through the divert status board, (ii) unequal distribution of the schedule, the lack of notification of the hospital about both (iii) the critical condition of patients and (iv) the route of the car, (v) the priority of communicating with doctors over the provision of real care. Discussing the primary nature of these factors, it should be recognized that the refusal of notifications — for various reasons — along with violation of working hours is a critical problem of EMS. Meanwhile, secondary factors may be the refusal to view the ED-board and the prioritization of actions, since each of these issues could have been solved if the paramedics had contacted the hospital in advance. Although, in most cases, secondary risks may become primary, this does not seem logical for this scenario.
Cause and Effect Analysis
In the analysis of the cause and effect mechanisms underlying the death of a girl due to cardiac arrest, four major conditions were identified:
- If Robert and Roy had a full rest, they would feel less stress at work prepared by the organization.
- If the paramedics had looked at the bulletin board in advance, they would have chosen the right hospital.
- If Roy or Robert had contacted the hospital on the way, they would have found out that it is in ED status.
- If the paramedics did not argue with the hospital, the girl would have a chance to be rescued.
Justification of Role
Clearly, the solution to this problem should be implemented at the organization’s management level but not in cooperation with two employees. Although Robert and Roy have made a severe mistake in their working practices, this could have been avoided if the overall corporate culture had been higher: fair schedules and staff training. As an external consultant invited to inhibit a problem, the author will seek to restore or reinvent a culture where employees feel less professional stress and pressure. The author is convinced that this approach will show positive results on clinical indicators. Indeed, an external consultant may not be aware of the work nuances, which is a weakness of this role. However, it is independence and impartiality that can be crucial to create a quality and healthy work environment.
Strengths and Weaknesses of the Organization
For ease of perception of information and to show a more general picture, the author decided to provide the organization’s weaknesses and strengths in the form of a composite matrix below:
Alternative Solutions
Then, the modeled simulated matrix clearly reflects the fact that by now, the organization has more weaknesses than strengths. In other words, referring to the author as an external management consultant is a justified measure dictated by the current circumstances. In this case, it is appropriate to offer two solutions that can show not only the consultant’s competence, but also help EMS in the initial stages.
First and foremost, the organization is offered to change the set of ambulance crews to solve two problems at once, namely the lack of proper rest and the creation of a more diverse team. The right strategy would be to hire additional staff or sign an agreement with a local clinic to periodically invite doctors to work in ambulances (Schuppen, 2017). Such an experience would seem useful since it would make the team’s skills more valuable and improve communication between doctors and paramedics. It should be admitted that the choice of this path will stimulate the expansion of jobs, which means that already working employees will have additional time to rest. On the other hand, training is required to help employees, such as Robert and Roy, join the corporate culture. Systemic education and training, along with available manuals, should remind paramedics to follow the company’s central rules. At the same time, this strategy increases staff competence if training is accompanied by professional development lessons.
Evaluation Methods
In clinical organizations, the primary indicators are health parameters: mortality, recoverability. Along with these data, the author would have previously collected information about the time that the crew takes during transportation and patient feedback. In total, before the implementation of the strategies, the author would have four criteria. Since the corporate environment changes, the consultant would assess KPIs data dynamics to determine the program’s effectiveness. The potential scenarios for change are presented in the matrix below.
References
Erbay, H. (2016). Some ethical issues in prehospital emergency medicine. PMC.
Plaster, M. L. (2015). Who pays the tab for unfunded care? Emergency Physicians. Web.
Schuppen, H. (2017). 10 ways to improve collaboration between your hospital and ambulance service. Dutch Resus.
Silverman, M. (2015). Keeping up with EMTALA — It’s the law, and it’s good for your patients. Emergency Physicians. Web.
What is ED Diversion? (n.d.). California ED Diversion Project. Web.
Appendix A
Robert and Roy, emergency medical technician paramedics (EMT-P) were back on the streets after a slow afternoon of handling administrative tasks in the office. Neither paramedic had checked the divert status board before heading out, so they were unaware that numerous hospitals in the city were on Emergency Department (ED) divert. After having worked 18 hours with only 3 hours off, they were hoping to settle into a quiet shift that would allow them an opportunity to get some rest. Within 30 minutes of getting to their first assigned post, the radio call came through that an adult and child were injured in an automobile accident. Robert and Roy headed to the scene to find that a father and daughter had been riding a bicycle when they were struck at high speed by an automobile. The injuries were serious, and both needed emergency treatment. The paramedics decided to take both patients to the nearby city hospital for treatment. Robert rode in the back and was in charge of caring for the patients, while Roy drove.
On the way to the facility the young girl quit breathing and required intubation to sustain her airway. Because of the time required to intubate and stabilize the patient, Robert never notified the receiving facility that they were coming with two critical emergent patients. In addition, Roy, as the driver, never contacted the facility and also never contacted dispatch to see if the facility was on divert. Upon their arrival at the city hospital, Robert and Roy found out that the hospital was on ED divert as well as pediatric trauma divert. In other words, they were not accepting any patients to the ED and they were not accepting any children. Because Robert and Roy felt that they could not support the pediatric patient any longer in the back of an ambulance, they wheeled both patients into an unprepared Emergency Department. A verbal battle ensued between the emergency room physician and the paramedics, which led to a further delay in care for the injured trauma patients. Ultimately, the hospital agreed to care for the patients, but soon realized that the young girl had gone into cardiac arrest and died. She could not be resuscitated.