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

- Rogue Medic

Toxicology Conundrum #022 – Life in the Fast Lane

Life in the Fast Lane is a blog by a bunch of Australian doctors. They give an interesting rationale for creating their blog –

Life in the Fast Lane was born out of an intense desire to procrastinate..

Our team was born out of passionate (and usually unresolved) debate pertaining to the elements of eLearning; medical education; medical history; political ambiguity; information sharing; the open source era and the ethos of web 2.0.

How can you not love that approach? They do an excellent job of providing clear useful information. One of the more difficult areas to teach is toxicology, but it is presented very well here. One example is Toxicology Conundrum #022

With the increase in the use of somewhat selective neurotransmitter reuptake inhibitors (Prozac, Paxil, Effexor, . . . ), I have not seen a TCA OD (TriCyclic Antidepressant OverDose) in a long time. I remember when they were common. TCAs were the overdose most likely to be fatal. They are still around, but used much less often, and now seem to be often used for things other than depression. It is always good to review this information and TCA OD is handled very well.

Give it a read and wander around the site. I know that I need to read a lot more of their stuff.


An Apt Metaphor

At Life under the Lights there is a very nice example of a difference between teaching methods. On the one hand, and it turns out to be a dirty hand in this metaphor, is training. Training is all that the supporters of cross-training think EMS needs.

On the other hand is education. Education is something that prepares you to understand metaphor.

Education vs Training: The “Professional Ambulance Cleaner”

Imagine if you will this hypothetical scenario:

As I stated – very nice.


EMS 2.0: Critical Thinking in Prehospital Training

Also posted over at Paramedicine 101. Go check out the rest of what is there.

Even though EMS 2.0 may not be any more successful at changing EMS than previous efforts at improving patient care, it does seem to be getting more attention. One place is EMS1.com. The names do not share etymology beyond the letters EMS, although both have been wise enough to get Kelly Grayson to contribute. Kelly is also the author behind A Day In the Life of An Ambulance Driver.

Kelly wrote an article called EMS 2.0: Critical Thinking in Prehospital Training. In the article, he does make reference to my blog, but that is not the reason for this post. Although, he does summarize many of my points very nicely.

He also mentions a debate on paramedic-initiated refusals. A debate that I have not commented on, because I have not been able to sit down and read through enough comments to get caught up to the current comments. This is a debate that has also taken place many times before.

Here is an example of the commentary –

“We’ve got 12-lead EKGs and capnography, and if we had I-Stats to do point-of-care labs, think of how many unnecessary transports we could avoid!” they gushed.

And that statement exposes the gaping hole in their logic while simultaneously demonstrating the flaws in the EMS mindset:

We focus on the things we can do, rather than what we know.

This is the essence of the problem. Too many people still believe that the right technology will produce a foolproofTM paramedic/nurse/doctor/et cetera.

Too many people still believe that the right technology will produce a foolproofTM human.

This completely ignores the Law of Unintended Consequences.TM This law is far too important and entertaining to ignore.

In another article on EMS1.com, Stop Talking, Dan White suggests that providing continuous transmissions of all of the information we are looking at in the ambulance – ECG, SpO2, EtCO2, BP, et cetera – will lead to more concise communication with the ED. While he means well, I think that he is overlooking the probability that the Unintended Consequence gremlins are just waiting to pounce. As Kelly writes –

All the fancy diagnostic tools in the world are wasted without the education and critical thinking skills to make effective use of those tools.

Many places have made pulse oximetry a BLS skill. How many of them use it appropriately? Nursing homes regularly send patients to the ED because of a low sat.

The fancy equipment does not lead to better care. It often only leads to toggle switch care. Sat of X or less = emergency. Sat of more than X = no problem. There is nothing in between. Everything is either an emergency, or does not meet treatment criteria.

Less than 8 – intubate. More than 8 – procrastinate.

Or should our patients receive airway management from someone who has an understanding of airway managment that goes beyond a nursery school rhyme?

Kelly continues with –

EMS education in its current form is only barely adequate to prepare us to use the tools already in our arsenal.

Adding to the EMS scope of practice presumes that we are already good at what is in our scope of practice. The debate about paramedic-initiated refusals is an example of this. How many paramedic schools spend any time on education about which patients do not need to go to the ED? It is not really something we receive training to do, so it is no surprise that when we arrogantly do what we are not trained to do, we provide many examples of incompetence.

At one place where I used to work, they kept track of what happened to patients who refused or were triaged to BLS after being assessed by paramedics. Their main criterion was whether the patient ended up in the ICU. Unless something changes dramatically in the patient presentation, none of these patients should end up in the ICU. Yes, some stubborn refusals will, but the chart should reflect that the paramedic saw the potential for significant complications and did not just say, OK. Sign here.

I have seen refusals, where the full narrative is – Medical command consents to refusal. Patient signed AMA form. Available at XX:xx. Indicating a total scene time – leaving the vehicle, assessing the patient, contacting medical comand, getting a signature from the patient, and notifyinging dispatch that the medic is available – of less than 5 minutes. The medic is only surpassed by the medical director in lack of attention to the problem.

Some of you may argue that things aren’t that bad. You may know of EMS educational programs that excel at turning out capable EMTs.

There are excellent programs. These excellent programs exist in spite of the National Registry’s No Paramedic Left Behind dog and pony show.

The National Registry does not just share responsibility with the bad EMS programs for the pathetic state of EMS education, the National Registry pushes the envelope to the point where stupid, dangerous, and irresponsible all begin to sound like compliments.

But for the most part, those medics are as good as they are in spite of their EMS education and not because of it, and it’s not those superior medics that we should use as measure of the effectiveness of EMS education. They are, by definition, outliers.

Sad, but true.

It’s when the rank-and-file, average medic in an EMS system can make those decisions and get those tubes that we’ll know that EMS education is where it should be. And likely as not, when we get there, those medics are going to know enough to realize that they need to do very little for most of their patients.

There are many, who suggest that all we need to do is to require more education to improve EMS. All it takes is a degree to make EMS a respectable profession. As long as we keep doing things the same way, does it matter if we require 3 months of misinformation?

What if we require 6 months of misinformation?

What if we require 1 year of misinformation?

What if we require an Associate’s degree in Misinformation?

What if we require a Bachelor’s degree in Misinformation?

What if we require a Master’s degree in Misinformation?

Should we just pile it higher and deeper?

Until we get rid of the misinformation in EMS education, it does not matter how much time we spend making students memorize misinformation – we are not providing a useful education. We are not protecting patients.

There are schools that do a good job. We need to find out what they are doing well. We should not be telling everyone that more of the same is the solution to bad education.

For some other perspectives on this, Unconventional Thoughts On Emergency Services by Steve Whitehead at The EMT Spot. Not really an education post, but all of his posts are education posts. Nice clear posts that get us to look at things differently.

And I’m Hangin’ Up My AHA Spurs by Buckman at Gomerville. Great writing and he tells a story as well as Kelly does, which is no small achievement.

^ TM Unintended Consequence
Like Murphy’s law, again a humorous expression rather than an actual law of nature, this law is a warning against the hubristic belief that humans can fully control the world around them.

Possible causes of unintended consequences include the world’s inherent complexity (parts of a system responding to changes in the environment), perverse incentives, human stupidity, self-deception, failure to account for human nature or other cognitive or emotional biases. As a sub-component of complexity (in the scientific sense), the chaotic nature of the universe – and especially its quality of having small, apparently insignificant changes with far-reaching effects (e.g., the Butterfly effect) – applies.

Robert K. Merton listed five possible causes of unanticipated consequences:[8]
Ignorance (It is impossible to anticipate everything, thereby leading to incomplete analysis)
Error (Incorrect analysis of the problem or following habits that worked in the past but may not apply to the current situation)
Immediate interest, which may override long-term interests
Basic values may require or prohibit certain actions even if the long-term result might be unfavorable (these long-term consequences may eventually cause changes in basic values)
Self-defeating prophecy (Fear of some consequence drives people to find solutions before the problem occurs, thus the non-occurrence of the problem is unanticipated)

The Relevance paradox where decision makers think they know the areas of ignorance about an issue, and go and obtain the necessary information to fill the ignorance, but neglect certain other areas of ignorance, because, due to not having the information, its relevance is not obvious, is also cited as a cause.


Changing Standards in Education – from other things amanzi

I am often critical of the way EMS keeps trying to make it easier to keep up a steady flow of brand spanking new paramedics. Not because we produce a high quality product (new medics), but because the public is too ignorant to notice.

The main tool is the National Registry of EMTs exam, but other exams aren’t noticeably better. Dr. Bongi, from other things amanzi, has a post up at Better Health by the name of When Incompetence Kills.

Basically the powers that be are not-so-gradually degrading the degree. To them somehow it seems like a good idea.

It becomes difficult to have half a dozen, or more, medics show up for every emergency call, when we have standards. Do we decide that one competent medic is enough, or do we hit them with a double dose of barber shop quartets – in the hope that all the patient really needs is a lot of company, and maybe a song?

Of course, we choose the high quantity, low quality route.

The image is from the Wikipedia Project Triangle article.

Now not all that long ago, to miss free air on an X-ray even as a student was a mistake that would fail you. These days you can easily get through medical school without worrying about trivialities like free air on X-rays. Also, to have perforated bowel causes intense almost unbearable pain. Even a street sweeper would be able to pick this up in the patient.

Seems as if EMS is not alone in the just push them out the door with a card kind of standards.

Yet the doctor at the referring hospital did not miss this easy clinical diagnosis only on one day or two days or three days, but on four days.

About 9 years ago, I stopped teaching paramedic school, because I could not continue to contribute to this farce. I was forbidden from doing anything outside of the limited classroom time. There were 2 people in the class holding everyone else back, but nothing was to be done about them, because they have not failed the ridiculously low criteria to remain in the course. It’s up to their preceptors to pass, or fail, them. According to the program director. I was forbidden from getting rid of the dangerous students future paramedics.

So not only did his treating doctors totally miss a very obvious diagnosis that any 4th year medical student should be able to make and thereby neglect to treat him appropriately, but the one necessary thing they tried to do, because they didn’t know how to do it properly, caused further damage to the poor man.

One student was considered a troublemaker. One reason was that he would ask questions about things that would not be on the test. It was OK to have to essentailly repeat a lecture, because 2 people want to have paramedic cards, but don’t let on that they haven’t grasped the most basic points, the points from the first 5 minutes of the class. Everyone knows that the real evil is to ask a question about something that will not be on the test.

I cast my mind back to when I was still in academic circles. I remember the professors complaining about pressure from the powers that be to pass students even when they felt the students were not suitably prepared.

I guess I was just imagining things, because that would never happen in paramedic school. Dr. Bongi’s description is of medical school.

I myself was asked to examine a student in a practical exam. I failed her because she was simply a danger to any person unlucky enough to become her patient. And yet the powers that be had so changed the system from when I was a pregrad that she could not be failed and was released into the community.

When you cannot change the system from within, the only choice left is to leave or to force them to throw you out. I have taken advantage of both exit strategies.

We are killing them with kindness.

Killing the patients with kindness to the students. But the NR validates everything they do, and they are the experts. And you can’t go wrong buying a house when everyone else is, too. We’ll give you one mortgage on the house and another on the downpayment.

Don’t worry about the interest rate.

Debts like these never come due . . .

except in the real world.

The mortgage sellers and the NR don’t have to deal with their mistakes. They are making money selling their sub-prime product. The patients pay.

Dr. Bongi, you have my sympathies. It is too bad that more people do not understand.


Taking Notes in Paramedic Class

Also posted over at Paramedicine 101. Go check out the rest of what is there.

I have been listening to some of the old episodes of the EMS EduCast. There has been a bit of discussion of note taking, even criticism of the inadequate methods of taking notes.

Why are you in a class room?

To learn.

How do you learn?

Everybody learns a little bit differently There are several different ways of learning, but if the paramedic class is designed to teach you how to take notes, then note taking is important. If the paramedic class is designed to teach you how to understand how to be a paramedic, then note taking is only important, if that is the method that works to help you understand.

The purpose of the class is to have an understanding of the material. Writing, while the teacher is talking, does not help me to understand the point the teacher is trying to make. Note taking is to help reinforce later, what was learned in the class room.

Too many times I have had questions from students, who copied down what was said, but had absolutely no idea what it meant, because they were busy writing, rather than listening.

If I am talking to someone, and the person is sitting there writing, should I assume that the person is listening to me?

If I am talking to a boss, and the person is sitting there writing, should I assume that the boss is paying close attention to what I am saying, because what I am saying is so important that he/she needs to write it down?

No. I would assume that the boss, writing something down, is doing something else. Writing and listening are not all that compatible.

Note taking should probably only take place after the concept is understood.

Note taking is to reinforce understanding.

Note taking is not a substitute for understanding.

If we spend a lot of time on note taking, are we making sure that they understand, first? Too often, we do not, in my opinion.


Badly Written Questions – I

Also posted over at Paramedicine 101. Go check out the rest of what is there.

Since there seems to be a desire to focus more on the basics, I thought I would address test taking in the various EMS classes.

According to some instructors, there are no badly written questions. There is always one best, right answer to these questions.

There is one right response to that statement and it is not very polite. OK. There are many possible responses. They are not all impolite, but they should all disagree with the statement.

The people who defend badly written questions, even just disputed questions, are the people who are destroying EMS education.

First, we need to admit that there are badly written questions. Not only are they badly written, but they reteach the material, and they do it in a way that is misleading.

Are badly written questions useless?

Not at all. Badly written questions can be very useful. They are a great opportunity to have a discussion, whether with the entire class, a part of the class, or just an individual, about what is wrong with the question and why.

This is an opportunity to improve the understanding of the students, and maybe the instructor. Passing up this opportunity and defending the question is abandoning our students, just as we might abandon a patient.

Disputed questions may be written intentionally to stir up debate, but they are only useful on a quiz, when you can devote a part of class, or an entire class, to the discussion.

Most of these badly written questions seem to be multiple choice questions. Many are on course completion exams. There will be no further classes, unless the student retakes the class.

Determining whether someone passes a course, based upon a multiple choice exam, is one of the more idiotic things we do in EMS.

The ability to recognize the correct answer – correct according to the person who wrote the test – is not even close to being the same as understanding the material.

The ability to recognize that same correct answer, has nothing top do with competence.


National Registry of EMTs – Is it really that bad?

In the comments to Zero Tolerance III – Star of Life Law second comment, was a comment by Greg Friese,

Rogue medic, eliminating the NREMT (NR, or National Registry of EMTs) is a bold and radical suggestion. How can we assure some minimal knowledge and competency across all providers in all areas?

The way you write that, one might think that the NR had some way to assure some minimal knowledge and competency across all providers in all areas. The NR does not assure any level of competence. The NR claims to, but the NR fails.

Wouldn’t it be nice, if they did assure some level of competence? Wouldn’t it be even better, if it were actually a useful level of competence?

JCAHO (TJC, The Joint Commission, or the Joint Commission for Accrediting Healthcare Organizations) is just as dangerous to patients in the hospital. They are both about enforcing checklists rather than improving patient care. There are good uses of checklists. CRM (Crew Resource Management training) is something we need. CRM does not seem to be encouraged by JCAHO or NR, but JCAHO and NR love their irrelevant check off sheets.

If your instructors know enough to teach EMS well, they should know enough to evaluate the knowledge of candidates for a license/certification. The NR has become so focused on the avoidance of the appearance of discrimination, that they have made even the appearance of the actual evaluation of competence secondary to the avoidance of discrimination. The NR seems to be headed toward the complete automation of their testing system.

If your instructors do not know enough to assess the the knowledge of medic candidates, the NR check off sheets do not make up for that deficiency.

The NR focus is on several prepared scenarios and a bunch of stations. stations with scripts. Scripts just to avoid any appearance of variation. Do your patients present this way? Mine sure don’t.

NR Medic – I’m calling to notify that we will be arriving with a number 5 in seven minutes. No, wait. Make that a number 7 in five minutes.

Incomprehensible doctor noises on the other end of the line.

Yes. I gave him the drug in the spray bottle. No. I’m too busy filling out check off boxes to look at the patient.

More doctor noises, but noticeably cranky.

You’re the doctor. You figure out what’s wrong with him.

Really high pitched doctor noises, like nails on a blackboard.

Well, he’d better still be alive. He hasn’t signed the billing sheet, yet.

Having a limited number of medical conditions to deal with is great. These order off the menu numbers make patient care so much easier. We don’t have to mess around with any of that thinking stuff. Thinking makes my head hurt. Some of those numbers can be kind of difficult to tell apart.

Ooops. gotta go. There’s a number 3 five blocks from here. Or is that a number 5 three blocks from here. Whatever! We just give them medicine off the menu. It isn’t as if there are real differences – yellow box, silver box, blue box. What difference does a color make?

I am so glad I don’t get paid to think. Being indiscriminate is the best part of the job. Well, that’s out motto, but I don’t know what it means.

This is all about preventing the possibility of having a human make a decision. How can you create a system to evaluate human decision making, but act as if human decision making is the enemy? You can’t, but that is the goal of the NR. Will they ever recognize the futility of this behavior? Who cares? They are making money off of it. That is what matters.

Teaching students to be good medics will almost always make them highly likely to pass the exam.

I agree. A good medic should pass the exam, but I have failed an excellent medic for a simple oversight, just because I was not allowed to ask what he meant. The NR rules are more important than the outcome.

The more important question is, does the NR test weed out the dangerous medics?

Absolutely not.

True, some dangerous prospective medics will fail, but passing does not correlate with competence. What independent evidence do we have that passing this test is something that correlates with the ability to work with minimal supervision and full standing orders.

Why full standing orders?

Because anything less is an indication of incompetence. If the medics are not capable of working without that mother-may-I phone call, they are not competent. Go to the best systems in the country. You will find that they have the fewest requirements to call for permission.

If OLMC (On Line Medical Command) permission requirements were correlated with quality, you would find exactly the opposite. OLMC requirements encourage incompetence – not in the medics, but in the medical director. The medical director has OLMC requirements, because of a lack of understanding of EMS oversight. The lack of understanding of EMS oversight leads to dangerous medics – unless the medics are motivated to police themselves. Of course, this attempt at responsibility by the medics can be discouraged by the medical director or management.

Teaching students how to be good test takers will increase the odds of them passing significantly.

Yes, but what does that have to do with competence?

You are starting by assuming that the NR test actually has something to do with competence. It does not. Then you are claiming that you have to teach the student how to take the test.

The result is that too much time is spent on training the medic students how to take the medic test, rather than training the medic students how to be medics. In other words, how to use critical judgment.

What are the most important skills that a medic should have?

1. Assessment.

If you do not know how to assess patients, how do you know what to treat? How do you know what protocol to apply?

2. Critical judgment.

Critical judgment helps in knowing where to go with an assessment. You won’t assess every patient the same way, but you do need to know what questions to ask and what places to look.

Having initially assessed the patient, you need to be able to decide what to do with the information you have obtained. NR does nothing to evaluate critical judgment.

But what about the critical/not critical decision in the patient assessment station?

Trust me, the patient is critical. I don’t even need to be there to know that. Or have they changed something?

NR encourages the cookbook approach to EMS, by their devotion to check off evaluations, rather than an interactive assessment of ability. If medic evaluators cannot be trusted to use judgment in assessing medic candidates, then they should not be trusted to treat patients.

NR behaves as if the use of medic judgment is the worst thing that could ever happen. This is the antithesis of good EMS. Any system that takes this approach should limit itself to BLS (Basic Life Support). There is no reason to have a Procrustean EMS system.

Procrustes is from Greek myth. He had an iron bed into which he required every passerby to lie down. If the traveler was too tall, he would cut the legs down to fit the bed. If they were too short, he would stretch them on the rack until they fit the bed. Similarly, we end up harming the patients to make their assessments fit the protocols we have. Rigid protocols are not good for patients.

Instructors can do both things without teaching to the test.

There are people who need assistance with test taking skills, but why divert the whole class from paramedic education to teach basic test taking methods? Because the ritual is more important than the result.

One example of this ritual over result fascination is the intubation station. If you do not state that you see the vocal cords, do you pass intubation? It does not matter if you can place the tube in the mannequin better than the instructor, you do not pass unless you chant the chant.

What if you don’t see the tube go through the cords?

That does not matter. That is not one of the check off boxes. You really shouldn’t bring reality into this.

What about the written test?

How does asking trick questions with just a single best answer have anything to do with good EMS? How many patient care situations have just a single best answer? Almost none. Those that do are not the ones being asked on the multiple guess exam.

This multiple choice, trick question, setting requires a bunch of test preparation. This is poor testing, so we have to spend time making up for the horrible test design. I know they have a bunch of people with all sorts of classroom degrees to validate these farcical tests, but that does not seem to help them to screen out dangerous medics. They validated their test. Why doesn’t this validated test weed out the ones who do not understand?

Whenever I hear validated, I think of Inigo Montoya saying, You keep using that word. I do not think it means what you think it means. How do we end up with so many EMS invalids with such a well validated exam?

We will be talking with a NREMT rep on an upcoming episode of http://www.emseducast.com. We are working on using ustream.com to allow live listening and chatting.

I like the idea of the NR.

The execution leaves a lot to be desired. Sometimes I think that execution of those in the NR might be the solution. Just one, or two, ought to do the trick. How slow to catch on can they be?

EMS is not a computer simulation. Their validated Ivory Tower models do not apply. The ambulances are not all little boxes made of ticky tacky.

The patients are not little boxes. The patients are what EMS is all about – not the little boxes on the multiple choice test or the evaluation sheets.

As I stated, I like the idea of the NR. The problem is that the idea and reality are miles apart.

Having the ability to move, almost as if we were professionals, is a good idea. I have been a medic in several states. Getting reciprocity for each move was different. NR could assist those of us who do not manage to stay in one place. NR can have a lot of input on the way EMS is run.

NR could also facilitate reciprocity for out of state paramedic disaster assistance. The way it is now, paramedics are not really more useful than basic EMTs, once they have crossed a political boundary. Unless the receiving state has the capability to grant emergency authorization to medics in disaster situations. Many states do not have this ability. Reciprocity might take months, which is OK if the disaster is nice and patient. Even FEMA can get its act together faster than that.

From what I see, NR has a big effect on the way things are run. People look for a quick and cheap way to hand a medic card to people, but to avoid responsibility for giving medic cards to people who aren’t even good basic EMTs. NR provides that excuse.

The idiot passed NR. How bad can he be?

Sometimes the answer is very bad.

Why should a paramedic test be quick or easy or cheap?

We end up with a similar approach to medical oversight. Quick and easy and cheap.

Why should we be paying discount rates for medical directors? We have medical directors who authorize medics to treat patients, but never meet the medic. I have worked for some of them. This is the NR approach applied to medical direction.

EMS should be limited to BLS, except where there is a well compensated, well educated, aggressive medical director. A medical director who understands EMS. A medical director with appropriate support personnel depending on the size of the organization.

Medical directors who practice absentee medical direction should be locked up. There is no reason to allow patients to be subjected to that kind of abuse. BLS is safer than bad ALS (Advanced Life Support).


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.