The Sealed Envelope

The last post on interfacility transfers sparked quite a number of comments, including several on the “sealed envelope” which plagues us. For those not in EMS, the sealed envelope is what the nurse hands you containing the patient’s medical records.

Sometimes “Confidential” is written on it. Sometimes they hand you the sealed envelope “for the hospital” and an unsealed demographic sheet “for you.” The demographics are the patient date of birth, address and billing information. Sometimes when you start to open the sealed envelope, the nurse or administrator scolds you — that’s confidential.

The sealed envelope can come in other forms. Sometimes it is a medical binder that the patient’s aide (when the patient is a ward of the state) won’t let you carry — she insists on keeping it in the car in which she is following. Sometimes the binder is taped shut with confidential written on it.

Sometimes the sealed envelope is just a doctor or a nurse saying — they have her records at the hospital, I’ve called them already. They don’t want to tell us anything because they see as as ambulance drivers, not professionals.

In any form, the sealed envelope is a silent slap in our faces.

What do we do when confronted with the sealed envelope? Here are some of my stories.

When I was a new paramedic, around seven in the morning I was sent to do a transfer out of the ED. I think it was a pschyiatric patient who had an IV in. All I remmber is the nurse handed me a envelope with confidential written on it, and when I started to open it, she told me I couldn’t. I told her I was going to open it. She told me I couldn’t open — at least not in front of her. It was a new policy — the information was confidential. I’m going to open it, I said. Right now. I need to know what’s on it. You can’t, she said. It’s not allowed. Then I’m not taking the patient. What I didn’t know was she has had a really long shift, and was just doing what some nurse manager who had been riding the staff all night had told her. Are you going to tell me everything that’s on it? I said. You can’t f–ing open it here, she said, then turned her back and walked away. I opened it there. She didn’t look back.

When I complained to the ED doctor who was our medical control about it later, he said, she had a bad night, you could have just taken it and opened it a minute later when you were out of her sight. But….I said.

The but… is the crux of it.

But I’m a professional — apart of the health care system — a crucial link in the chain.

I can’t tell you how many times this sealed envelope situation occurs. In just about every situation all you have to do is smile, nod and then go ahead and open it later.

But…

There could always been information you need to know, although there usually isn’t.

But…

I’m somebody.

Maybe a better man can take it. It seems almost everytime I insist on opening it. Am I insecure? Do I need to prove that I am a professional on a par or greater than my tormentor?

I need to read those papers, I insist. I need to know what’s going on with the patient. That book stays with the patient, and the patient is with me. Your phone call to the ED is a scrawl on a scrap of paper in a pile by the tirage desk that no one is going to read, I need the story. I’m responsibile for the patient. I will not eat your shit.

I hate conflict. I don’t like anyone to be angry or ruffled, but the sealed envelope pushes my buttons.

Obviously sometimes — like with the alert and oriented psych patients, as one commenter stated, you might not really need to read their whole case history — and I admit on long transfers I enjoy reading as much as I can about a patient’s history — the story of their lives — how they came to this mental state, how they were treated as children, did their families love them or abandon them, how f—ed up are they? Maybe I am invading their privacy the deeper I go into the binder.

But when it is medical — I absolutely need to know. I will sit there and interview the obstiniate nurse for a half hour asking every question I can think of if she won’t turn over the medical records. I will do a full body assessment, vitals, hook the patient up to the monitor, and put in an IV right there, instead of waiting to do it in the ambulance. Look at me I’m an F—ing paramedic.

Is it about the patient or is it about me and my need for respect? Maybe its both.

I’ve had doctors refuse to tell me their medical history — he’s just dehydrated — only to find at the hospital the patient has AIDS. If a patient is a psych, I’d like to know if he’s violent — am I transporting Hannibal Lector? I want to know what drugs a patient has just been given? Is the patient allergic to Latex? Do they have a cardiac history? Is that why their left shoulder and arm hurts. Are they a diabetic? Maybe that’s why they are acting so wierd today — their sugar is 800 plus.

In this job we can come into someone’s house — someone who is very sick or dying — and people look at us like we are the hands of their god — we can walk onto an accident scene and move men and machines with our words — or we can walk into an office or onto a ward and be treated like poop on shoes. It creates an indentity crisis. You want to say to the nonbelievers I’m not poop on shoes, I’m a hero, I’m a lifesaver, I’m the man, the MAN — I’m not an errand boy.

I’ve mellowed a little over the years. I try to be nice about opening the envelope or asking for more information. I try to do it without an attitude. I don’t need to prove anything to anyone — I am a paramedic. I’ll go find the doctor and I’ll say hate to bother you, but there’s a few things I need to know and I’ll talk the lingo. Most of the time it works.

“I just need to make certain everything’s in order,” I’ll say to a nurse, smiling, pretending to be deaf to their objections. “Make certain everything’s there we’ll need for our report. Gotta keep those CQI stats up or You know how attendings can be if you don’t have the answers ready when they ask. Or gotta keep the lawyers happy. Or those damn state regulators happy. Or it accredidation time again.”

Many times they smile and commiserate. We are comrades in the health care bureacracy. Nothing personal, just doing our jobs.

With my luck, my next call I’m going to get the sealed envelope and a battleax handing it to me.

I don’t like conflict.

I don’t like sealed envelopes.

I’ll try to handle it calmly, professionaly.

But…

6 Comments

  • Eric says:

    Yup, that HIPAA Fairy can be a real bitch. That’s what our local hospital tried to tell us when we were handed the sealed envelope for our out of town transports. Luckilly, we worked out a deal where they would copy off the intake sheet, or (my favorite), the dictated H & P from the ED doc. This was specifically done for us. We are able to get enough info to complete our charts. Most of the time, I am allowed to look at the patient’s chart to get the same info. The sealed envelope doesn’t appear so much anymore, thankfully. When it was a big deal, I’d ask the patient in front of the nurse if I could look at their paperwork. It was a sweet, albiet small, victory when the patient said yes & I ripped that puppy open right in the ED.
    You’re right, Peter, about the lack of respect and consideration from other members of the “healthcare team”. ‘Poop on a shoe’ – heh. Thanks for shining a light on these things so that we can hash them out.

  • Snoop says:

    What a bizarre situation. Surely it’s about giving the patient the appropriate care at the time he needs it? And that means opening the envelope before a situation kicks off. It’s absurd to think that you should have to start reading the paperwork once a patient has begun to have trouble. Then there’s your safety and the safety of everyone else on the road to consider.

    I ever get to be a patient, I want everyone to know what’s wrong with me to make sure I get the best care.

  • F says:

    I’m willing to bet that Nurses feel like poop on a shoe at least as often as we do. They work right alongside those who consider themselves to be of a higher order, witness to constant disrepect and misunderstandings of their capabilities. We at least get a chance to be “the man” once in a while. I’m not sure that they do. As much as it hurts, and as much as I would like it to change, I can almost understand the need to pass the buck down the line just a bit. Not that it is right, but- keep in mind how many medics treat their EMT partners. Sealed envelopes galore.

  • kingmagic says:

    The sealed envelope is an outdated throwback to the days of the “Ambulance Driver”.
    Here in the U.K. there is still the odd old fashioned nurse/sister/matron who believes that we should “doff our caps” (if we had them issued) and “tug our forelocks”.
    We are part of that patients “continuity of care” and as such should be given all the relevant info.
    Its basic stuff….we are not in the Victorian era or pre WW2, we are in the 21st. century.
    Have you noticed that these people who insist on the sealed envelope thing are the ones who know nothing about we do?
    All the best and keep ripping those envelopes apart!!
    Kingmagic of purpleplus.

  • Jen says:

    Amen! Preach on brother!

    I’ve never commented here before and actually just found your blog a short while ago. Hope you don’t mind a link.

  • PC says:

    Thanks for your comments all. On the comment about passing it down the line, that reminded me of a cartoon an EMT drew quite a number of years ago around here. I wish I had kept a copy of it. The jist of it was the way everyone viewed paramedics from patients to nurses to doctors, etc. The last one was how EMTs viewed paramedics. The paramedic was drawn as Darth Vader. It killed me.

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