Without evidence of benefit, an intervention should not be presumed to be beneficial or safe.

- Rogue Medic

Evaluating EMS Competence and Priorities – Part II

In Part I, I wrote about EMS education and evaluation in the classroom. I do not think that these are something we do well.

Is there another part to the education process?

Yes. The education is broken down into 3 parts – classroom, hospital, and field. The classroom is where the most structured part of education happens. In the hospital, there are a variety of experiences. Unfortunately, many hospitals do not take advantage of the almost unlimited teaching opportunities available during this time. They view the student as an obligation, rather than an opportunity.

Many times the paramedic students will end up working as paramedics in a service area that transports patients to this hospital. While the medic student has been working as an EMT, the medic student may have picked up many bad habits, the hospital still has a very good chance to get the medic student to see patient care from the hospital’s point of view.

In the hospital, the medic student can see some of the problems that the ED has in handling patient transfer from EMS. Some of the problems the doctors and nurses have in managing multiple patients – something that is rare in EMS. Some of the problems in transferring a patient to another part of the hospital. If there are a bunch of patients in the ED waiting to be admitted to the ICU, that is a legitimate reason for the hospital to go on divert. We tend to complain that a certain hospital is frequently on divert, but it may not be anything the ED can control. It may not have much to do with the number of patients in the ED, but with the need to provide longer term care to ICU patients, who are still waiting for their number to be called to leave the ED.

The medic student is not there just to start IVs and draw bloods, and certainly is not there to clean rooms. Not that there is anything wrong with cleaning rooms, but this is not The Karate Kid. The medic student is there to learn. If there are no patient care experiences, then scenarios, reading the pharmacology books and other ED books are excellent opportunities. The PDR (Physician’s Desk Reference – since this is a sales catalog, free on line access is available to only those who write prescriptions – not most nurses and not medics), Goodman & Gilman’s The Pharmacological Basis of Therapeutics, Goldfrank’s Toxicologic Emergencies, Tintinalli’s Emergency Medicine, and many others. You should be familiar with the material in the books prior to giving a drug, but it really sinks in when you are the one giving the medication. Giving a single NTG to a chest pain patient with a blood pressure of 116/58 and seeing the pressure drop by twenty points can be a real attention getter. In the same shift there may be a CHF patient who initially receives 5 NTG at one time, yet his pressure increases from 220/108 to 232/112. Medications can be complex and should not be seen as all that predictable, especially if the patient is already receiving many other medications and/or we may be giving other medications.

But we can’t read reference books!

Of course we can.

We should actually learn more from the reference books, the nurses, and the doctors during your hospital time, than at any other time in medic school. We should see more patients during the hospital time, than during the field time, even though the hospital time is much shorter. We need to ask questions. A lot. Most doctors seem to enjoy teaching. That see one, do one, teach one, approach works in our favor, here. This also may give us an opportunity to get to know future medical directors we may have. The same applies to asking nurses.

At least there are no stupid questions, so we don’t have to worry about that.

There are stupid questions. Everyone will ask some. I have asked plenty of stupid questions and I will ask many more. The good thing about stupid questions is that they may allow someone to show us where our thinking went wrong. If we can learn from that, we will learn to think more systematically about what we want to know. I used to ask many different doctors the same question. Some would explain things in a way that did not help me to understand, others might explain something in a way that was not really relevant to EMS use, and some would provide an explanation that cut right to the essence of what I did not get. Another benefit of asking a bunch of doctors the same question, is that when they see a patient with something similar to what I was asking about, they can point out the similarities and differences, so that I can experience assessing it, or something like it, in a real patient.

Now, I tend to go online first, find out a bit about what I want to know, then ask a doctor.

Hospital time is almost never where a medic student is eliminated from the program. Perhaps, if you refer to your preceptor crudely as a part of her anatomy, you may be told to get out and never come back. It is hard to disagree. This might conveniently work to get rid of a future problem child. Some professionalism is important in EMS. There should be some distance, if only a hair’s breadth, between our knuckles and the ground. We don’t have to walk fully upright; not all of our syllables need to form intelligible sentences; but working through a shift without getting arrested should be considered a positive.

In the hospital, treatment may be quite different from EMS treatment. We should have an idea of what treatment will be provided in the hospital and avoid treatments that would interfere with those treatments. Shorter acting medications can be very useful for this approach.