Frustrated with IFT

Rin

Rin

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I'm so frustrated with IFT lately. It's so slow trying to gain any experience...I'll run into something new, break out the necessary equipment, then kick myself for not being expertly smooth with it. "I've been working here X amount of time already, I should be good at skill Y by now!" ...and yet it'll be the first time I needed skill Y in all that time. I guess I need to force myself to think in terms of experience instead of time.

My other MAJOR frustration with it is that I struggle with knowing when I should divert to an ER. If my patient presents with any issues, and we're heading toward their nursing home, I don't know what the nursing home is capable of handling. They have nurses and doctors on staff, and yet they send patients out for everything, call EMS to start IV's for them...What exactly do they do again?

So a patient with an elevated B/P and known hypertension...or a patient not fully A/O with known dementia etc...is this their baseline? Are they normally better? Is this an 'episode' for them? Have they even had their medication? The majority of the time there's no one who can answer these questions for me.

Yet if I diverted to the ER with every patient with an issue, I'd be diverting almost EVERY patient. Once in a while, I hear about other coworkers diverting, but I don't know how common it is or how much of that is them trotting out their "best" stories. For extra helpfulness, our protocols are written from a 911 standpoint (just "transport") with no guidance on what facilities are appropriate for what.
 
Ultimately despite the fact that IFT and 911 get the same training and use the same toys, they are different fields. It's true that you're not going to learn EMS medicine nearly as fast working IFT as you will working primary response, and you're not going to have the same fluidity with the skills, but what IFT does is give you a much more nuanced understanding of medicine. Assuming that you have the time and take the opportunity to read through the H+Ps and MARs, you'll learn the way various disease processes interact in patient presentation (and the way that various medications alter that presentation), as opposed to in 911 where (especially when you're new) your best course of action is to pick out the primary symptoms and make a single field diagnosis then treat accordingly. Don't be discouraged that you aren't learning what you think you ought to be learning, recognize what you actually are learning.

As far as the issue of diversions go, they're incredibly rare in IFT, they do happen but well under 1 percent of the calls should be or are diverted (to be fair, often when a pt goes bad enough to need a diversion, it's on an increased level of care transport, where the hospital you should be diverting to is the one you're going to anyhow.).

The VERY quick and dirty rule of thumb I would recommend is to ask yourself if this patient's issue either is or will become a life threat in the next 10 minutes, if yes, go ahead and divert it. Other than that, when you get to the nursing home, report your concerns to the nurse that's accepting, they'll say one of three things:

A) "Oh, that's normal for her."

2) "WTF, Mate? I'm not accepting this patient, he's not stable enough. Send him back."

iii) "Oh, I don't know if that's normal for them, I've never had this patient before, I'll look into it." (This last one is sadly REALLY common, even more so amoung nurses sending patients out of nursing homes. It leaves me to wonder if there's some computer program in the admin's office who's whole purpose in life is to make sure that nurses are never assigned to the same patients twice.)

The last big tool in the box for you doing IFT is to never accept a bad report, don't be afraid to pin a nurse down and make them answer any and all questions you have about the patient. There's no way those same nurses would accept a patient from me with a report like, "The patient is in 2204, they're going to Don't-Care-If-Grandma-Lives nursing home, they're ready to go.". You should know enough to write a relatively comprehensive HPI before you ever see the patient. Also, asking for their last set of vitals to use as a baseline is very helpful. If any vitals are off, or if you meet and greet and the patient's mental status is altered, ask the nurse if it's baseline.
 
Use it to learn relationships of medical history, symptoms, medications, and do a decent assessment. Lung sounds, heart murmurs, skin tenting, edema, fever, wounds, bleeding fistulas (but dont be annoying if it is an everyday thing for them)

You are stuck with a patient for 20 minutes, that might be the most focused medical attention they see in a year.

I once found a femur fx in a paraplegic from a nursing home on a random ift
 
Like bear said. I learned most of my EMT skills by IFT work. What does a fib feel like, what does copd or pneumonia sound like. How does a chronic but stable patient with xyz disease look like? I learned what ais "normal" for diseases, now I can better identify abnormal in the same patient.

Also if you have a toy in you box that you rarely use. Make sure you pull it out and play with it before you need it.

911 I find to be easy (as a basic). They are sick. Figure out what's wrong, and transport and report what you find.
 
I feel like you guys are giving too much credit to IFT, or indirectly to experience. You are gonna see both things in IFT and 911. The great thing about IFT is that you are gonna have a diagnosis, and you are gonna have a chart with a review of systems that elaborates on how they came up with that diagnosis. There is gonna be a lot of fluff or extra information in that chart that is gonna make it difficult to associate things with a certain disease especially if the patient has multiple diseases/conditions, which many IFT patients do. The same is true for medications, the patient usually has a bunch of medications that are gonna make difficult to associate it with a certain disease or condition unless you specifically ask what the medication is for or it's listed with the MAR (medication administration record). I think the issue with skills is the fact that few patients will only have one problem where it will be easy to associate a sign, symptom, or medication with that one problem so it will be difficult to make this association even with experience or visually seeing it.

As far skills, you aren't gonna perform a lot of skills in both IFT or 911 as an EMT because an EMT doesn't have that many skills. The primary one you are gonna do on both are vital signs. In 911, you will probably do more backboarding, splinting, bandaging, and electing to start oxygen administration versus IFT, but lets face it, those are easy skills that you either don't need practice on (administering oxygen) and will probably be inappropriate even though it's tradition/protocols (backboarding and oxygen administrating) and you can easily practice the rest (bandaging, backboard, splinting) during your free time.

There is one thing I really like about IFT over 911 although I don't have a lot of 911 experience other than observation (I have been exclusively been doing IFT for several years, no 911) and that is working on a dedicated critical care transport (CCT) unit with either a CCT-Paramedic or a CCT-RN. I wouldn't say I learned that much more things clinically, but did learn more about equipment commonly used on those calls: ventilators and IV pumps. Both equipment as a paramedic (if you become one and one is allowed to be used in your area) are gonna be equipment/service dependent so you may learn how to use it in one area, but another area or company is gonna use something different. Although I cannot do much other than prepare the ventilator or IV pump for the CCT-P or CCT-RN, which is minimal (you input numbers, plug in some tubing, but you don't actually switch it over or anything like that... the CCT-P and CCT-RN have to make sure all the numbers are correct/sane and switch it over themselves), I did get to learn what each mode and setting means (ie AC vs SIMV vs CPAP + PS, volume control vs pressure control, what is pressure support, what is PEEP, what is FiO2, etc) and have been exposed to medications that CCT-P or CCT-RN can administer in addition to the standard drugs that paramedics can give (we have a much bigger drug box although still very limited compare to the rest of the US). So that I definitely really do like about IFT CCT vs 911 ALS, and I will be sad that one day I might be a paramedic, but the extra drugs I know (the basics) about I won't be allowed to administer or transport with unless I become a CCT-P or CCT-RN. Paramedics in my area also don't use IV pumps or ventilators so we cannot set that up on a 911 call or do that for IFT calls either unfortunately. :[

I am gonna say that you should do what others recommend. Read the chart particularly the review of systems part (it's the part where they break up everything by system when describing the signs and symptoms). Check out the MAR and look up the drugs using a PDR (physician desk reference). Continue to do your own assessment on a patient when appropriate and take vital signs. Don't be afraid to learn outside of your scope when you get a chance (eg if the patient has an IV, don't be afraid to learn how to tell IV gauge size, how to describe the location of the IV, what's infusing, and what rate... transporting a patient with infusion of basic isotonics is actually allowed in a lot of places for EMTs even though a lot of EMTs don't realize it, or another example is working on CCT and learning what a drug is that was administer or infusion, learning what each thing on a ventilator, IV pump, etc. means).

In the end, I think working IFT is BEST for learning operations of an ambulance ie where hospitals are, door codes, capability of the hospital, policies and protocols, how to use a gurney, learning the roads, etc. The clinical things you learn from experience (whether working 911 or IFT) is probably gonna be slightly different, but come at a different rate (you might see pursed lips, accessory muscle use etc. more on 911 for example, but 911 might see a lot of things where they won't be able to associate it with something for sure because diagnostics haven't been done or no diagnosis by a physician has been done yet). The quickest way to learn clinical things will be to learn it on your own reading books, through active discussion of patient assessments, and skills will probably be infrequently used so you will have to practice them on your own or with friends at a school or during your free time at work if allowed. That way when it actually does happen in front of you, you will know what you are seeing rather than guessing (in 911) or trying to decipher a chart (in IFT).

Not at my current company, but my previous one. We used to practice CPR, backboarding, splinting, and patient assessment frequently when we were posted at the station. I felt like that benefited me way more than when I had an actual call at IFT or what I saw during my observations with 911 units. We took pride in practicing during our down time because it was a very slow station. Many 911 calls I saw were usually simple things like coryzal symptoms (gotta give a shout out to Brandon Oto from emsbasics.com and is a poster here for that word, hehe), psychiatric (just like BLS psychiatric transports we do), and minor trauma (scrapped knee, twisted ankle, etc). Your (limited) skills will deteriorate even if on 911 unless you put extra effort into practicing it or discussing it (skills like CPR, you're gonna need practice, discussion talking about things you messed up on/could have done better on, and you are gonna need to mentally prepare yourself if you are gonna be in charge of organizing things.. I mean mentally not like emotional, but ask yourself what needs to be done and run a fake scenario in your head, practice it with different amount of resources eg you can pretend to have a whole resuscitation team that's capable of everything, do a scenario where it's just you and your partner and no one else is coming, or maybe you can pretend to be a paramedic and have an EMT partner, or maybe both you and your partner are paramedics, come up with issues like you guys weren't able to get an IV successfully, the patient was a traumatic patient, or the patient wasn't in vfib/vtach - most people practice CPR as if it's only vfib/vtach only so they aren't prepared to go through the algorithm PEA/asystole or aren't prepared to think further than "this is related to cardiac ischemia" rather than think other H & Ts). This is not just limited to single patients either, think about doing fake scenarios in your head of running an MCI... are you gonna be the IC? Is it just you and your partner? What resources will you need? What kinda MCIs might you bump into or be pulled into while at work (eg if you work near an airport, will you respond to an airplane crash? I work near three large airports and three small ones). I work near a lot of chemical plants too. Maybe terrorism?

I am not gonna downplay experience. Experience is great. There are some things you are gonna see more frequently than others, and there are some things you might see only once or twice in your life and won't get another chance to be ready for it so your only way is to practice mentally and read about it/research it or practice it with others if possible.

Anyhow, I am rambling now....

In regard to diverting, what UnkiEMT said is excellent. Is the patient gonna die in 10 minutes (or is there an obvious problem pretty much)? If not, continue transporting, lol.

A lot of that information, you should be able to obtain prior to transporting.
 
Rin said:
So a patient with an elevated B/P and known hypertension...or a patient not fully A/O with known dementia etc...is this their baseline? Are they normally better? Is this an 'episode' for them? Have they even had their medication? The majority of the time there's no one who can answer these questions for me.
Click to expand...

That's why you get paid the big bucks.
 
If you're properly assessing the pt and getting an H&P and verbal report before leaving, you shouldn't be running into surprises often. If it is a hospital discharge to a SNF and there is anything suspect about the pt (generally a low grade temp or abnormal BP), I'll get the nurse to clear it with the doctor at the sending and receiving facility before moving them to my stretcher. Nursing homes don't really treat any new developments, in case you were still unsure as to what they can and can't handle.
 
While there will absolutely be times you have to divert to an ER, they normally are exceedingly rare on BLS IFT, especially if it is a hospital discharge. They should be stable before you leave the hospital. Otherwise you should not be taking them out of the hospital in the first place. A SNF is no place to be assessed and stabilized, that is why they were in the hospital. When I was an EMT, my company did 911 and IFT. I can only remember once, I had to turn around and return a patient to the ER while transporting a hospital discharge patient

Dialysis patients are another story. Dialysis is a rough procedure on the body, and treat every dialysis patient you pick up after treatment as if they may have a medical complaint because they might. While every patient must be assessed, dialysis patient's are especially important. Chest pain with actual cardiac events, respiratory problems, sometimes with fluid overload, hypertensive crisis, hypotension with associated symtoms as well as diabetic complications are just some of the conditions that can occur after treatment. I have definitely taken many dialysis patients from their treatment strait to the ER when I was doing IFTs. As a medic, dialysis centers are one of our most frequent "customers" of the 911 system in town, so you will definitely see some of the same things we see.

As far as your EMT skills, all I can say is practice. Try and get on a 911 service if you can. However you can still learn a ton on IFT. However the one main thing that 911 teaches you is how to stay cool, calm, and rational during an emergency where the scene is going south, family is yelling at you, ect. There is no substitute for that experience, but you can at least practice for it. Also, judging from your post, your heart and attitude are in the right place. That is good because many EMTs on IFT get complacent and you are not so kudos to you for that.
 
IFT get an unnessicary bad name, and everyone seems to hate it. Most of us started in an IFT company and we pretty much all do it on occasion even if we are primary 911.

I like you had many of the same feelings of frustration for a while. But I turned it around and learned from it. I gained experience on IFT I would never get 911. Even if it doesn't apply to 911, I now understand things about medicine I didn't before and it helps connect the dots.

When on IFT, put yourself out there. Ask questions, look up medications and conditions. Remember those through assessments you learned in school? Do them in transport. Listen to lung sounds, practice palpating a carotid (something most people don't do until they have a full arrest... Better know exactly where it is". Heck I even started listening to heart sounds because I love the heart. Oh this is a patient with aortic regurgitation. Mental note to listen for that. Just because I can. I worked BLS, ALS, CCT and a dedicated AMI unit. I've transported open chests, balloon pumps, and more MD teams than I can count. More than just cool stories, they are learning opportunities.

Even if you just have BLS at your service, plenty of room to learn. Its slow, but you'll get there.

As for diverting... You'll usually know. I've never diverted an IFT, but I have had situations where a BLS transfer pick up quickly became a load and go Code 3 to the ER. All of those times I've been too close to ERs to call for ALS, but you gotta do what you gotta do.
 
At the old company that I have worked at it was all IFT and dialysis. Now at the new company things have changed a bit, we pick up patients from the homes and take them to the ER. A few dialysis patients and lots of behavioral calls (Baker Acts in Florida). A few weeks ago I have rolled up on a kid that nailed by a ford explorer and sustained a femur fx. At least I know that every day brings something different.
 
IFT is also a good time to learn your medications; you have the chart that shows the meds, and medical hx; figure out which is for what. good training for Paramedic school, and/or RN, PA or Medical School.
 
johnrsemt said:
IFT is also a good time to learn your medications; you have the chart that shows the meds, and medical hx; figure out which is for what. good training for Paramedic school, and/or RN, PA or Medical School.
Click to expand...

And don't forget you can talk the patient about what they have been through, what the plan is, and what is like living with whatever they have going. Gives you a little empathy and makes it easier to talk to future patients because you have an idea of what their condition meens for them.
 
Doing 911 calls is usually more exciting, but fwiw all of my most meaningful calls in EMS have been IFT's.
 
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So...since complaining that I'm not gaining much experience, it seems that every shift since has been full of firsts. I guess I asked for it! Also, my company has finally handed down a much more comprehensive book of protocols. No more learning company policies through word of mouth, thank god.
 
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