The myth of the uncontrolled environment

How many times have you heard someone say “you guys work in an uncontrolled environment” as a justification for some deviation from the standard of care? If you work in EMS or the emergency department, i’m guessing quite a few. The ED and prehospital settings are notoriously viewed by others as the Wild West, where we have to do everything as quickly as possible to “save lives”. I’ve seen this mindset throughout my career and it has always bothered me. Why should your “environment” determine the level of care a patient gets? Obviously if a patient cannot be accessed or is physically blocked from an intervention this will dictate care for some period of time. But the vast majority of patients are cared for in open, purposefully designed spaces such as the back of an ambulance or a resuscitation bay. So if the actual space is not the issue, what makes an environment “uncontrolled”?


I’d suggest that the only thing that makes an environment seem “uncontrolled” is the providers and care team in it. A critically ill patient is the same whether they are in the field, the ED, or the ICU, aside from potentially differing stages of the disease process. The key is how providers prepare for and address issues in their own unique environments. We must be in the mindset that no matter how chaotic or seemingly “uncontrolled” things may be, we cannot degrade the level of care being delivered. Team leaders must be able to ensure the environment remains controlled and things are done properly, no matter the acuity of the patient.

A common example is procedures. Shortcuts are often taken in the emergency setting and there is rarely a reason to do so. We are doing our patients a disservice by knowingly degrading their level of care and putting them at an increased risk of complications. Examples of this include not taking sterile precautions when necessary, not optimizing patients before intubation, and generally rushing procedures due to a perceived time limitation. Many providers have the “faster is better” mentality. But does this actually benefit most patients if the actual procedure is done poorly? I don’t think so.

The corollary is that interventions are often not performed because of the perceived chaos and lack of time. Instead, providers may decide to “let them take care of it later”. This is a common occurrence with prehospital providers delaying treatments and assuming the ED will perform them. And the ED commonly delays treatments assuming the ICU will perform them. These delays can and do impact the quality of patient care.

Recently, I read a comment from a paramedic on an article regarding proper positioning for intubation. The comment suggested it is often impossible to properly position a patient for intubation while in a house, before moving to the ambulance. However, many providers use this as an excuse to not properly position the patient but still perform the intubation. But, the right thing to do, is to not intubate at all until you can properly optimize the patient. As we know, most patients can be managed with basic airway maneuvers until intubation can be performed properly.

Patients should receive the same quality medical care no matter the environment they present. A cardiac arrest patient should receive the same care by paramedics that they would receive if they arrested in the ED, and the patient in the ED should be resuscitated the same as they would be in the ICU. It is our job as emergency and critical care providers to implement processes, perform training, and organize to ensure the sickest patients receive the best care possible.


Please contact me with any questions, concerns, or comments

The myth of the uncontrolled environment