# Systematic Approach



## ZootownMedic (Jun 29, 2012)

Hey guys....so I am nearing the end of my first phase of Internship and I am doing really well. I never worked for a very long time as an EMT but am starting to find my rhythm and put it all together. My pathophysiology, interactions with FD(they respond on almost all our calls), pt interactions, differentials, and treatment plans are solid. I am however really struggling with my systematic approach. 

I don't have the experience yet to have a 'system' worked out for assessing the patient AND for treating them in the back. Our transports times are short and I am having a hard time getting everything done in the back of the ambulance. Part of this is because I don't have a lot of experience working int he back of a rig(I am actually getting pretty quick considering this) and I also don't have an organized way of getting things done. I feel like I have wasted movements. My preceptor told me that this is the biggest thing I need to work on and I am doing well otherwise. 

Just was wondering what some of you with more experience do(or even others in the same spot as me) to have an organized approach. I do always start by introducing myself and partners, determining if they are critical or not(sick or not sick), getting a set or having my EMT or a FF get a set of vitals, and go from there. Sometimes I just get lost in the chaos though. Another thing is that I have a hard time 'stepping back'. My preceptor told me that as a Paramedic you shouldn't even touch the patient unless you have to(or just want to). This lets you stand back and get the whole picture. I have been working on that as well. Any advice would help. Thanks!


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## CANMAN (Jun 29, 2012)

Well first off I disagree with your preceptor's thought of "you should never touch a patient unless you have to."

Background on my system: Single ALS provider system with one EMT-B partner. No other resources unless you call for manpower, at which time you get whatever volunteer shows up (most of the time with no medical training). 
With that being said obviously you have to multi-task and utilize your time wisely. 

So here's how I roll on calls. Depending on the call will depend on what I bring in. Bag configurations vary so I will not elaborate on this. I talk with the patient and do the interview, and hands on assessment, depending on what the call is for. EVERYONE gets a set of vitals at the patient's side and my partner takes care of that. While I talk and assess I will also write stuff down, If I don't write it down I will forget name, DOB, etc. I can remember history etc. Based on inital presentation (sick vs. not sick) and the assessment we will either remove to the unit and start treatment there, or start treatment inside the home and call for additional manpower. 

Obviously there are variations to this but thats the standard. Working in the home for sick patients gives me the advantage to normally have everything done by the time my manpower shows up. Then all we have to do is load and go. If the patient is not that sick and time isn't a huge concern, then don't feel bad for loading and then taking your time until your comfortable. Speed comes with skill, skill comes with time IMO. 

As far as telling you what order to perform your interventions, thats obviously going to be call dependent. If I am working someone up ALS then normally its O2 of some form (NC, NRM, CPAP, etc) monitor with cont. Spo2 and NIBP, then a line. If I am working with a squared away partner then normally all I have to do is a line and meds. If you work with a regular partner get in a groove and train with them. You can also delegate. If I get info enroute to a call say a cardiac arrest, I will say for example: I am going to grab the O2 bag and monitor, how bout you get a board and the ALS bag.

Hope that helps.


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## ZootownMedic (Jul 1, 2012)

Thanks man. I ran a call with another preceptor yesterday and things went way differently. Why my preceptor wants to rush to the ambulance and then try to get EVERYTHING done with a 5 minute transport time with a non-critical patient is beyond me. Yesterday I didn't feel rushed and did things like 12-leads, IV's, blood sugars, etc on scene for several patients. When I got in the back I just reassessed and continued my physical exam and focused htx. Things went way smoother. I think he is trying to push me to my limit and make me good but at the same time whats the point of rushing when you don't have to? Speed is not a substitute for quality medicine especially when time is not of the esscence. Part of learning I guess and working with different preceptors. 

As a side note...I noticed something yesterday that just occured to me. The 3 critical patients that I have had with this preceptor have all been stay and plays. We waited until we had bilateral large bores, 12 leads, etc until transporting and these were some of our longer transport times on more critical patients. Then on non-critical patients he is rushing out the door and making me bust my *** to get things done in the back. Just an interesting and strange realization I had....Thanks for your advice though man.


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## Doczilla (Jul 1, 2012)

If you're the senior medical person there, (either not a student anymore or assuming that role under the supervision of the preceptor) your job is to delegate. That dosent mean to stand there and do paperwork. In EMS, most assessment steps are done simultaneously. That means that while you are performing your ALS assessment, others are performing BLS level tasks while you perform ALS level tasks, assuming it is needed. Utilize the people that are there. 

This also depends on if the F.D is ALS or not. If they are, and your system has the certificate of need (meaning you're the transporting agency), you should still be calling the shots. Let's say they arrived first and established the first line interventions. Did they get the medication list? Which facility do they need, or want to go to? Has next of Kin been notified if they are not present? Do you need a rider in the back to help? How long should you stay there? 

Or, if you arrived the same time, delegate first line stuff while you prepare breathing treatments, 12 leads, setting up intubatjon equipment , draw up meds, etc. No one should be standing around if there is something next on the list. This is how you cut down on scene times while also developing your leadership skills. You can have someone treated, packaged, and questioned all at the same time.


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## Veneficus (Jul 1, 2012)

Speed does not build accuracy.

Accuracy builds speed.

First of all, you are new. So you will have wasted movements. You will forget things and come back to them. Some you will forget entirely. 

You need to go slow, work on getting everything done properly. Once you have mastered proper technique, then you will start to refine your technique. 

Do you think a surgeon is perfect the day he becomes a surgeon?

How many years of basic practice does it take before a classical dancer is even ready to get on a stage?

The same with a virtuoso musician.

Medicine is not a sprint, it is a marathon. Pace yourself. Do it slow, do it right.

Speed and refinement will come. 

If your preceptor doesn't agree, he is a moron because he does not know how to develop new people. Does he really expect you to reach his level of proficency during your internship? If that is the case, he couldn't be very good because it probably took him years to attain the level he is at. If you could do it in a couple of months what does that say?


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## xrsm002 (Jul 1, 2012)

SmokeMedic don't feel bad. I'm in my last semester of paramedic school doing my truck time, my preceptors make me use my critical thinking skills, I haven't worked on a 911 ambulance since 2005, I did transfers but never had critical calls with that. I still get confused cuz my classroom instructor says bls before Als however we had a diabetic whose blood sugars was below 40 and they alert and oriented and I was gonna give oral glucose. I was told to do d50 IV instead. My first code I ran in the field I was so nervous I took out a NRB abd hooked it up to tank, instead of a bvm. It all comes down to experience. My instructors who have had 5+ yrs in EMS still get calls that make them "pucker"


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## xrsm002 (Jul 1, 2012)

Oh and as far as those fast bls calls the patients are possibly frequent flyers or know patents that call in for bs calls. My I try and give everyone equal care if I can, treat them as I would want my family treated.  I know some people where I'm at do the same stuff. I hope I don't fall into that bad habit


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## Melclin (Jul 3, 2012)

I hear what you're saying. I hate feeling rushed. 

I like what vene said about accuracy building speed. I was going to equate it to playing the guitar. When I was learning to play, I always found it easier to play a piece properly, but much slower than I was supposed to and then to speed up as I got more comfortable. Trying to play at the required speed and then increase accuracy over time never worked for me. I felt flustered and frustrated and rushed. I'm still rubbish though, so perhaps this isn't the best example.

I found the same was true as a student. I took my time and did everything properly and over time simply got faster. 

Roughly speaking (of course everything is case dependant) I run most jobs this way.

-Introductions.

-The story (hx of current complaint)(also do a quick pulse check at this stage. Fast or slow, extremity temperature. Good info to have early.
-Exact current symptoms.
-Pertinent negatives. 
(_during this time, my partner will generally fetch the meds, get a little hx from bystanders/family and set up gear for me as needed, Pulse ox, BSL, Temp, monitor_)

-Brief medical hx + meds (add to it later with more detail in the case of non-transports).
-Physical exam.

-Read back (summarise for the pt what pt has told me and ask them for corrections or additions).
-Form working diagnosis, inform patient and discuss a treatment plan.
-Begin treatment/lay down care plan. 
(_partner will organise egress/take equipment out to truck_).

In the case of a transport:
-Reassess vitals/continue treatment (get moving after BP and chest exam).
-I get the pt to go back through the whole story from start to finish, this time with my notepad in had and I form a handover/ re-evaluate my treatment. Its interesting to note how much more comes to out the second time around. 
-Detailed medical hx.

-Repeat treatments/vitals as needed. 


As I say, obviously some jobs will go a little differently but this is how the majority of my jobs go. The only common difference is that in sicker patients a targeted physical will happen simultaneously with hx taking, usually with the rest to follow on the way in. I hate it when I don't complete this process. Pulling up at the hospital trying hard even to get the basics down with a difficult historian and what not.

Also having a little list of dot points that have to be covered with each common kind of job may help. For an elderly fall for example it might be, GCS, establish exact mechanism, head strike, LOC, neck and neuro, +/-pain relief, +/-spinal, explore causes. I still do everything at some stage but if things get messy (poor historians, very short transport time, 14 hrs into a night shift) I know exactly what I need to have done at a minimum and it helps me target the info I need early on even if I have plenty of time.


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## ZootownMedic (Jul 3, 2012)

Thanks for all the advice guys. The other thing that sucks about my current preceptor(2 shifts left) is that his EMT tries to act as a second preceptor. I didn't mind at first because he is very knowledgeable and has 5 years of constant street experience. He is a great EMT. He has a good knowledge base of ALS interventions, assessments, and meds as well. After 10 shifts though it starts to get a little old with having two people constantly judging, crtiticizing, commenting, and giving homework. He often repeats himself over and over and even comments on how I am being graded. So while I have felt I have been doing well in my first phase I have this EMT constantly telling me that I need to do this better or this faster etc. Its just stressful(as it should be). Done with phase one in a week though and on to a new preceptor. I have enjoyed this one as he is very knowledgeable but I am ready for a new one that will let me set the pace a little more to my style of medicine. I don't know what kind of medic I will be but I know that I will not be in a rush unless it is needed. Thanks again for all the kind replies and advice.


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## Sublime (Jul 4, 2012)

SmokeMedic said:


> Thanks for all the advice guys. The other thing that sucks about my current preceptor(2 shifts left) is that his EMT tries to act as a second preceptor. I didn't mind at first because he is very knowledgeable and has 5 years of constant street experience. He is a great EMT. He has a good knowledge base of ALS interventions, assessments, and meds as well. After 10 shifts though it starts to get a little old with having two people constantly judging, crtiticizing, commenting, and giving homework. He often repeats himself over and over and even comments on how I am being graded. So while I have felt I have been doing well in my first phase I have this EMT constantly telling me that I need to do this better or this faster etc. Its just stressful(as it should be). Done with phase one in a week though and on to a new preceptor. I have enjoyed this one as he is very knowledgeable but I am ready for a new one that will let me set the pace a little more to my style of medicine. I don't know what kind of medic I will be but I know that I will not be in a rush unless it is needed. Thanks again for all the kind replies and advice.



I feel you man, I think sometimes preceptors can forget what it was like to be a student, or that they ever were one. I had a lot of different preceptors throughout paramedic school, and everyone has their own style. A few of them did me little good other than reinforce what kind of medic I didn't want to turn out like.


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