EMS From a Distance: Doing what doesn’t come naturally

Challenge yourself to overcome clinical weaknesses


I did my first ALS rotation on a New York City ambulance in November 1994 – an exciting time for a middle-aged paramedic student in the midst of a career change. After three months of administering meds to polyurethane patients, I was primed to help humans with my newly honed practical skills.

My preceptors, two of the smartest, most constructive medics I could have hoped to draw, were doing their best to buff “good” calls just to give me more chances to play. I was hoping for “unconscious, not breathing” and pictured us saving lives with our drugs and our daring. Yes, the borough of Brooklyn would be in good hands that morning.

Then I missed my first three IVs.

Self-improvement has to compete with inertia, a natural state for EMTs and paramedics who mistake mandatory refreshers and stale CME as surrogates for new knowledge.  (Photo/USAF)
Self-improvement has to compete with inertia, a natural state for EMTs and paramedics who mistake mandatory refreshers and stale CME as surrogates for new knowledge. (Photo/USAF)

I was mortified. I didn’t want to be known as the guy who couldn’t hit veins the size of cannelloni. My first thought was to leave – not just the city, the state. I could pack a few things and take to the road in my high-mileage Saturn, hoping both of us would make it to, say, Wisconsin before breaking down. I assumed my family would learn to live without me after a few weeks of wondering why Stony Brook didn’t let students go home between classes.

Coping with failure

The last time I’d felt so feeble was as a seven-year-old afraid of loud noises. Sirens, bells and buzzers were bad, but the scariest were cap pistols – toys that imitated gunfire by detonating tiny charges on paper rolls. How could I be the next Roy Rogers if I couldn’t blast make-believe bad guys with my simulated six-shooter?

Being an industrious kid who started thinking outside the box before that expression was even invented, I figured I should do more – not less – of what frightened me. I wrapped blankets around my head to muffle sounds, then removed those layers one at a time while rapid-firing a whole roll of caps. Our living room smelled like the O.K. Corral, but by the time I’d untwisted that oversized turban of bed linens, I was cured.

Back to 1994: After that oh-for-three day, I was preoccupied with missing IVs and started shying away from most attempts. Somehow, I got enough of them to graduate, but I felt like a paramedic in name only – a secret fraud who couldn’t be counted on for one of the most routine procedures in prehospital medicine. I decided it was time to self-prescribe more of that exposure therapy from 35 years before, with angiocaths instead of blankets and caps.

Provoking proficiency

I forced myself to do as many sticks as I could, even on little spindly veins I had almost no chance of cannulating. My partners didn’t mind; they were happy to set up a bag, take a history, do an EKG – whatever else was needed. I wasn’t great at IVs during that first year in the field, but by my first refresher, I was getting about four out of five – average for the paramedics I knew.

When I changed jobs a few years later, I learned that my boss, Eric, an experienced medic whom I never saw shy away from critical care, had faced a problem like mine, but with endotracheal tubes instead of IVs. As a newbie in the early ’80s, he’d avoided intubation until he reached a decision point: either acquire the requisite confidence in necessary skills or look for another line of work. Pride rendered the latter no more of an option for him than it had been for me; he forced himself to engage and became a competent airway manager.

How about you? What part of your practice should you be better at? That’s a question posed by Inside EMS co-host Chris Cebollero during a recent podcast about clinical excellence. Citing pediatrics as a topic EMS providers often struggle with, Cebollero challenged his audience to be proactive. “If you know that’s your weakness, what are you doing to make it a strength?” he asked.

The honest answer from many of us would be “nothing.” Self-improvement has to compete with inertia, a natural state for EMTs and paramedics who mistake mandatory refreshers and stale CME as surrogates for new knowledge. Other impediments to progress are seniority and the popular notion that street smarts can’t coexist with book-learning. We think because we’ve endured more than a few years in this business, we’ve necessarily absorbed all the expertise we need.

It’s easy to rehearse what we’re already good at. New capabilities come bundled with break-in periods and doubt. It feels great, though, to conquer long-standing weaknesses and set new goals for personal bests. Just ask Eric. Or that kid with the cap gun.

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