Doctor's Offices

Doing calls in doctor’s offices can be tricky. “Do you start working the patient in the office or wait till you get out to the ambulance?”

Here are the assumptions. You are a transport medic so you have the stretcher with you. The patient is not in cardiac arrest or so sick that they will crash if you don’t do something right away. At the same time, they are sick enough that you will likely have to give them an IV and medicine once you get into the ambulance. Here is a scenario I have had three times — a patient with an PSVT in the 180-220 range who has come to the doctor’s office for an emergency visit because he is feeling uncomfortable. Here is how it played out each time.

1. I am a relatively new medic. After getting a report from the doctor, I say, “Do you want me to give him some adenosine?” He says “No, wait for the ED staff to do it.” Deflated, I wait for the ED staff and the ED Doc gets mad at me for not having given it.

2. I am a more experienced medic, I keep my mouth quiet. I nod, put the patient on the stretcher, get them down in the ambulance, where I do my thing, give them the adenosine — the rhythm breaks and converts to a sinus in the 80 range, the patient feels much better, and all is good.

3. Just recently, the doctor tells me the patient is in an SVT. He already has an IV line, and has done a 12-lead. This time, it is a little different. The doctor asks “Do you have adenosine?” I say, “I do. I can give it here or out in the ambulance.” “Your choice,” he says. I think a moment, and then say, “Let’s do it here.” I give it, and it all works out great.

Let’s analyze all three situations.

Situation 1. You have a doctor who doesn’t appreciate EMS. The problem with these doctors is if you ask them in front of their patient about treatment, you run the risk of a clash of wishes. I once had a 35-year-old patient having a severe allergic reaction– hives from head to toe with crazy itching. I asked the doctor what he had done for the patient. He had given Benadryl PO. “What about epi?” I asked. “No, it is contraindicated,” he said. “She is hypertensive.” “What is her pressure?” “140/90.” Okay, so now I have boxed myself in. Once I get out in the ambulance I have to convince my patient to let me give her epi against her doctor’s wishes.* Another time I had a patient having an asthma attack, I gave the patient a breathing treatment in the doctor’s office – no issue here – but then I tried to also get an IV in the doctor’s office. When I missed my first attempt, the doctor began yelling at me for wasting time and to get the patient to the ED now. Not a comfortable situation.

It has never happened to me, but I have heard many stories of medics starting care in a doctor’s office and getting into huge fights over the direction of the care. Sometimes the medic was right and sometimes the medic was wrong. Conflict like that doesn’t serve anyone well. One of the worst cases I heard of and this one sounds unavoidable, was a cardiac arrest in a foot doctor’s office in which the doctor insisted on running the code, using his own algorithms. The medic was new and wasn’t able to seize control back. I am always uncomfortable when calls become territorial, which is why I like to get on my ground.

These experiences have all led me to the general approach of situation 2. Get the history and get into your office – the back of your ambulance. This doesn’t mean that there aren’t situations where you have to stand your ground and do what you have to do. It is just that there are some cases where it might be easier for all to just vacate the doctor’s space. Some doctors do it for you. They leave the patient in the waiting room with only the receptionist or family member to give a report. They don’t want the patient taking up an exam room. I have taken care of patients unresponsive with head bleeds slumped in their waiting room seats clutching their CAT SCAN photos.

Situation 3 is relatively rare – a doctor both knowledgeable of prehospital care, engaged in the patient’s care, and respectful of prehospital’s domain. This situation, when it presents, should be seized upon. I have only had this happen one other time in a doctor’s office – where I was encouraged to work the patient right there before the doctor. That was for a semiresponsive hypoglycemic patient. The doctor was fascinated and very complimentary as we put in an IV and gave the patient D50. He had treated diabetics in his office for years, but this was the first time he had actually witnessed a patient crash in front of him and then seen the effects of D50.

None of all of this is to say that the majority of EMS interactions are not professional and courteous. Most of the cases involve getting a report, putting the patient on the stretcher and getting on the way. I have seen doctors who did not seem competent to me and I have had doctors pick up subtle ST elevation that I might have missed that turned out to be STEMIs.

As anything in EMS, whether to start working a patient in a doctor’s office (beyond 02 and a monitor) all comes down to the great saying, “It depends.” The point of this post is just to say to newer medics to beware of some of the drawbacks to doing your thing on the doctor’s turf, and unless necessary, it may be best to just get the report, ask any pertinent history questions you might have, thank the doctor, and get on your way.

* At the time epi was in our protocols as standing orders for this, now we would withhold epi and just treat with Benadryl unless the patient developed wheezing or become unstable.

2 Comments

  • Christopher says:

    We have a doctor in our service area who will literally hand us orders, not only for us, but for the ED staff! These aren’t direct admissions either. It’s a really awkward position to be in, and I was pretty new when I first encountered it. I too was admonished by both the doctor and the ED. I learned with that doctor to get a quick report and do the rest in the truck.

    Otherwise, the vast majority of doctor’s office visits we get a report from the patient’s nurse (and some paperwork). Never had any problems with those handoffs. Even if I start a neb treatment or IV and antiemetic they don’t have a problem.

    I certainly hope never to be in a position in a doctor’s office which could compromise patient care.

  • Brandon O says:

    In Mass we have no obligation to listen to docs on scene unless they choose to formally assume responsibility for the patient, in which case we can use them like medical control. Of course being a diplomatic is good for avoiding complaints and, y’know, staying employed.

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