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How I became the 'stand back, big picture, non-interventional' paramedic

Sometimes the mark of a great medic is in the things that aren't done

One thing I've noticed as I progressed in my career is that the more my knowledge base and experience expand, the less likely I am to use my skills. It seems counterintuitive at first that the frequency of providing a skill changes as an inverse function of your ability to provide it expertly.

But once you realize that it takes experience and expanded knowledge to develop that one essential skill that most programs fail miserably in teaching — critical thinking —  it makes sense.

It takes time to develop restraint as a medic. It seems that most paramedic programs turn out two types of students: those who have very little confidence in their skills, and those who have entirely too much. Rarely have I met a new medic who strikes a balance between the two.

I was the second type. In the early years of my career, I considered it a badge of honor to be known as an aggressive paramedic. I measured my worth as a provider by how deeply I was able to get into a protocol or a treatment algorithm. My motto was "Over treat many, under treat none."

But implicit in that statement is the presumption that all those treatments I was providing actually helped the patient. Now, I know better. In fact, many of them may have done harm. It took me a full five years for my skills to catch up with my ego — and that's a reflection of how large my ego was, not how meager my skills were — and a full five years beyond that to learn that just because I can do something to a patient, doesn't mean I should.

An example

Take a patient I treated earlier this week, for example. She had a sudden onset of dyspnea, exaggerated air hunger, orthopnea and diaphoresis. She was tachycardic, BP through the roof, with a room-air oxygen saturation of barely 60%, and CO2 steadily rising. Lung apexes sounded like a coffee percolator, bases had no air movement at all.

To a seasoned medic, that presentation just screams "ACUTE PULMONARY EDEMA" in big, flashing red letters. To a newbie, it screams, "Wow, she's really having problems breathing! I wonder if I should intubate her?"

Twenty years ago, I'd have intubated that patient while wide awake, and I'd have gotten that tube.

With my eyes closed. Standing on one foot. While composing a sonnet.

And if I did anything else, like maybe start an IV or give her some Nitro or Lasix, it would have been an afterthought. And I'd have strutted a bit, dead certain that I was an airway samurai. I'd done the hard part, leaving the easy stuff for the nurses.

15 years ago, I'd have applied CPAP, maybe some Nitro and definitely Lasix. And I'd have had to improvise the CPAP, using one of these. And if she had given me the slightest inkling that she was about to crump, I'd have intubated her without hesitation. I had the skill to do it. I'd have had my airway kit laid out to one side, and every so often I'd have gazed at it longingly, silently hoping that perhaps she would crump, and give me another opportunity to demonstrate what an intubation stud I was.

And ten years ago, I'd have been fogging the Nitro to her in doses that would have been unthinkable to me early in my career, and using one of the new whiz-bang CPAP devices on the market, confident in the knowledge that I could tube her if she deteriorated, but hoping that we could avoid that step if necessary. My intubation skills were better than they had ever been, but I had learned restraint in applying them. If transport time allowed, I might have administered some Lasix.

And seven years ago, I'd have probably added the Lasix to the list of interventions I'd rather avoid, like intubation. I'd have read enough of the research to know that relatively few of our APE patients are actually in volume overload, and that many of the patients treated with Lasix are relatively hypovolemic afterward.

And last week, I was happy that the CPAP and Nitro worked, and that I had successfully avoided intubating someone.

I had finally become what my good friend Gary Saffer describes as a "stand-back, big-picture, non-interventional paramedic."

What I learned

It's not that I had become less aggressive. I simply had learned when and where to be aggressive, and that most of those instances involved BLS skills. The interventions that proved most beneficial to the patient were largely things that my EMT partner could perform. My partner became not just someone who could hand me equipment and do menial tasks, but an integral part of the team whose role on scene was every bit as important as mine. They became the hands to my brain.

That also made me a lot more popular with the EMT's I worked with. Imagine working with a medic who not only doesn't consider himself too good to perform BLS, but actually trusts the EMT to perform his job without micromanaging every aspect of it. Even better, a medic that makes it plain that the kid with the white patch is just as important to patient care, if not more so, as the grizzled old guy with a sparkly gold patch.

When I graduated from paramedic school, I was skilled at endotracheal intubation. After ten years, I was even more skilled, but I took greater pride in my knowledge of airway management.

When I was a new medic, the ACLS algorithms were my Bible. I could recite them verbatim, and spit out even obscure drug doses at will. I was skilled at rhythm recognition, and knew how to cardiovert, pace, and defibrillate. I ran codes like a drill sergeant. I spent a great deal of time in ACLS and PALS classes teaching my students to memorize that same trivia.

Ten years later, I realized that algorithms are reference tools, and that it made no sense to waste class time memorizing something that was written down in a pocket guide precisely to make memorizing it unnecessary. I also learned that the really useful knowledge was nowhere to be found in the algorithms, and that in some respects, the AHA was as full of crap as a septic tank.

I went from being highly proficient in ACLS skills to being very effective at managing a resuscitation. And believe me, they are two different skill sets.

When I was a new medic, I taught close to 200 PALS courses in three years. I directed our state's EMSC program. In the field, I was our service's designated Pediatric Expert and Kid Sticker. I knew a dozen tricks at inserting IV catheters into tiny little veins, without unduly traumatizing the tiny little patients.

Ten years later, I still had those skills. I also started far fewer IV's in children in the last fifteen years than I did in the first five, because I came to realize that if a child really needed a vascular access in the field, it probably was more effective to do an IO. If my only justification in sticking a child is to keep the ED nurses happy, I don't do it. I take more pride in transporting a child and showing them that ambulances and paramedics aren't really all that scary.

I'm also a lot more likely to allow that child's mother to ride in the back, because I know I'm not going to be fumbling around doing painful and dubiously beneficial things to her kid, and if ALS really is needed, I'm confident in my ability to provide it and manage her fears at the same time.

It took me ten years to realize that the better I do my job, the less exciting it is. I don't have very exciting, life-and-death war stories these days. The best stories now focus on the bizarre and humorous aspects of my job, and the simple human interaction I am privileged to experience every shift. More than ever, I am realizing that my most effective coping mechanism is a highly developed sense of whimsy.

When you're a new medic, or you're a grizzled medic precepting a new one, keep that in mind. It takes experience to develop a sense of restraint, and it takes time to understand that the things that make a medic great aren't what he can do with his hands.

They're what he can do with his head and his heart.

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