A Dinosaur's Position, Part I

[firetender]

My experience, after 12 years EMS, at the start of the profession, has been, in the headlong rush to get to ALS many of us lose touch with the “Head, Hands and Heart” approach that we so depended on in BLS.

My personal opinion is a medic should spend a good year or more doing nothing but BLS before doing ALS in the field. Being able to work with yourself and others -- and getting that down as rock-solid as the A-B-C's of life-support, is as important as anything else we learn in the field.

A large part of this is based on the fact that EMS is a people profession. The subtleties of dealing with people in crisis (not forgetting the subtleties of learning how to deal with ourselves amidst this bizarre world!) are immense, and critical.

Here’s a common example: Who amongst us has not found that a person in our care is circling the drain in a pool of fear and anxiety? In the short time we’re with them (and most often without even realizing it) what we end up doing is applying most of our effort to getting the person on an even keel emotionally or mentally – noting that when we get them calm, even their vitals conform, giving us more to work with, making our lives (and therapies) easier and setting the scene for their recovery.

And then, almost as soon as we get them through the ER doors, some idiot RN, Doc or Whomever finds those special words to say or insensitive actions to take that undo everything we’ve done. The patient spirals into deep fear and you know, you just know the poor ******* may end up spending 90% of his or her resources struggling just to get back to the place you established in your first few minutes with them. And that’s BEFORE they can even begin to recover. And, yes, that's assuming that they're able to survive the ordeal at all!

“Setting the scene for their recovery” is, to me, one of the most important things that we do in the back of a rig. Please take a moment to consider that what we are is, literally, “Agents of Life-Change.” We very often are an integral part of the most important moments of a human being’s life. We know from our own experience as human beings that once you get into a downward spiral, especially at a critical time, it’s hell to pay to get back to Square One.

And that’s what we do; we are key in helping individuals to gather and rally their own resources to recover. That’s not about a 20-minute block of time from dispatch to the ER that we happen to be present for. That’s about our being part of a lifetime so affected that it sets the scene for that person’s relationship with themselves and others, rippling out to hundreds of people for years to come.

How does this sit with you, Bunkies?

 

[VentMedic]

My experience, after 12 years EMS, at the start of the profession, has been, in the headlong rush to get to ALS many of us lose touch with the “Head, Hands and Heart” approach that we so depended on in BLS.

My personal opinion is a medic should spend a good year or more doing nothing but BLS before doing ALS in the field. Being able to work with yourself and others -- and getting that down as rock-solid as the A-B-C's of life-support, is as important as anything else we learn in the field.

Total agreement. Communication in terms of active listening and appropriate expression are skills.

Here’s a common example: Who amongst us has not found that a person in our care is circling the drain in a pool of fear and anxiety? In the short time we’re with them (and most often without even realizing it) what we end up doing is applying most of our effort to getting the person on an even keel emotionally or mentally – noting that when we get them calm, even their vitals conform, giving us more to work with, making our lives (and therapies) easier and setting the scene for their recovery.

And then, almost as soon as we get them through the ER doors, some idiot RN, Doc or Whomever finds those special words to say or insensitive actions to take that undo everything we’ve done. The patient spirals into deep fear and you know, you just know the poor ******* may end up spending 90% of his or her resources struggling just to get back to the place you established in your first few minutes with them. And that’s BEFORE they can even begin to recover. And, yes, that's assuming that they're able to survive the ordeal at all!

There are reasons for the actions in the ER no matter how vulgar they may appear sometimes. The decisions must be made and the information that must be gathered is vital to the transgression of events that will also affect the patient's outcome and life changes. If the patient is "circling the drain"; who to contact and does the patient want all out life support in the event of eminent demise? A ventilator could become a permanent accessory with little or no quality of life and isolated from whatever support group the patient may have. Organ donation; this is a difficult but necessary question for patient and family. Information will have to given to the patient about risks of surgery, procedures and medications. There is still a legal issue to everything we do. As cold as that may seem, it is a reality. The first few minutes in the ER are very important. I hear you on the emotional comfort, but I have seen the consequences of what can happen if someone else makes decisions that may not be in the best interest of the patient. Whenever we still have a conscious patient that can express important data to us, we're "delighted".

When I was still in EMS, I learned early on to prepare the patient for what was going to happen to them when they entered the ER doors. I would tell them that they may have to answer some tough questions and make some big decisions quickly. I tell them how there will be people coming at them from all sides wanting a piece of them, sometimes literally taking a piece of them. I try to put a positive spin on those care givers. I explain that they are there for the patient and will work quickly to get results happening.

[“Setting the scene for their recovery” is, to me, one of the most important things that we do in the back of a rig. Please take a moment to consider that what we are is, literally, “Agents of Life-Change.” We very often are an integral part of the most important moments of a human being’s life. We know from our own experience as human beings that once you get into a downward spiral, especially at a critical time, it’s hell to pay to get back to Square One.

False hope or words like "It's going to be okay" "You'll be as good as new soon" may send mixed messages to the patient. They may know they are pretty messed up and your words may sound like "you're screwed" to them. Honesty without making any big time diagnoses or predictions to the patient while preparing them for the battle at hand and those "idiot RN, Doc or Whomever" in the ER. Those healthcare workers also will see the reality of those first few minutes in the ER. Many of those workers will follow the patient throughout their entire path in the hospital to rehab if that is what is in the cards.

Hospitals are more in touch with the spiritual side of care now. Chaplains and alternative care practitioners are more readily available. Healthcare workers are also given a chance to utilize these services. Those "idiot RN, Doc or Whomever" may see as many as 5 codes in their ER in one day, day after day. As mechanical and cold as it may seem, straight facts are necessary. These are not people that don't care. They have difficult questions to ask and under the pressure of system constraints and protocols.

 

[firetender]

Good catch!~

"When I was still in EMS, I learned early on to prepare the patient for what was going to happen to them when they entered the ER doors. I would tell them that they may have to answer some tough questions and make some big decisions quickly. I tell them how there will be people coming at them from all sides wanting a piece of them, sometimes literally taking a piece of them. I try to put a positive spin on those care givers. I explain that they are there for the patient and will work quickly to get results happening. "

I really appreciate your chiming in with these responses.

It is true, since I've been out of the field for so long, I have lost touch with the day-to-day assault that everyone in EMS experiences, but what I'm trying to offer are concepts that help medics (ALL medics) broaden their experience of themselves in relation to their professions. Part of that is to open discussion about how they can be more effective, and in the process, more supportive and supported, on a human level.

Bringing up the point to "prepare the patient" for the next phase is such an integral part of being an agent of change! I forgot that one, didn't I?

In Hawaii, we say Mahalo! That means Thank You!

 

[VentMedic]

You do have a good thread started here. The only thing that ruffled me a bit was the comment about the ER personnel. Another lesson I have learned is either to educate, walk away or stay closer to the patient when there are people around who are presenting negativity. Showing respectfulness can be disarming to those who want to bring on an "attitude" toward any situation.

My rules of survival:

1. Show respect for myself and anyone around me (no matter how little it is appreciated by others).

2. Honesty with myself first. This includes personal and professional matters.

3. Honesty with others (my patients) as much as the laws, ethics and common sense allows.

4. I try not to use my life examples to connect with the patient. I draw from my experiences for sincerity, but let the patient have the spotlight. "Nobody really knows how another person feels".

5. Respecting any human form no matter how lifeless it appears. (dead person, intoxicated or nursing home patient in a catatonic state)

6. Stepping out of my zone of comfort and experiencing something different. Take a class with a friend or loved one, attend an alternative medicine class, take a weekend seminar on Massage Therapy or Healing/Therapeutic Touch (depends on where you take the class or the philosophy behind the class), explore the arts or take an art class.

7. Knowing when reality is for real.

Besides my degrees/licenses in the health sciences, I am a licensed Massage Therapist (20 years, started in Infant Massage with preemies on ventilators) and a Reiki II practitioner. These disciplines have taught me about grounding one's self and not take on the negativity of those and situations around me.

I have survived the medical profession for 30 years and will probably have to last a few more. I'm still young.

 

[Guardian]

My experience, after 12 years EMS, at the start of the profession, has been, in the headlong rush to get to ALS many of us lose touch with the “Head, Hands and Heart” approach that we so depended on in BLS.

My personal opinion is a medic should spend a good year or more doing nothing but BLS before doing ALS in the field. Being able to work with yourself and others -- and getting that down as rock-solid as the A-B-C's of life-support, is as important as anything else we learn in the field.

A large part of this is based on the fact that EMS is a people profession. The subtleties of dealing with people in crisis (not forgetting the subtleties of learning how to deal with ourselves amidst this bizarre world!) are immense, and critical.

Here’s a common example: Who amongst us has not found that a person in our care is circling the drain in a pool of fear and anxiety? In the short time we’re with them (and most often without even realizing it) what we end up doing is applying most of our effort to getting the person on an even keel emotionally or mentally – noting that when we get them calm, even their vitals conform, giving us more to work with, making our lives (and therapies) easier and setting the scene for their recovery.

And then, almost as soon as we get them through the ER doors, some idiot RN, Doc or Whomever finds those special words to say or insensitive actions to take that undo everything we’ve done. The patient spirals into deep fear and you know, you just know the poor ******* may end up spending 90% of his or her resources struggling just to get back to the place you established in your first few minutes with them. And that’s BEFORE they can even begin to recover. And, yes, that's assuming that they're able to survive the ordeal at all!

“Setting the scene for their recovery” is, to me, one of the most important things that we do in the back of a rig. Please take a moment to consider that what we are is, literally, “Agents of Life-Change.” We very often are an integral part of the most important moments of a human being’s life. We know from our own experience as human beings that once you get into a downward spiral, especially at a critical time, it’s hell to pay to get back to Square One.

And that’s what we do; we are key in helping individuals to gather and rally their own resources to recover. That’s not about a 20-minute block of time from dispatch to the ER that we happen to be present for. That’s about our being part of a lifetime so affected that it sets the scene for that person’s relationship with themselves and others, rippling out to hundreds of people for years to come.

How does this sit with you, Bunkies?

12 years isn't that long, I wouldn't call you a dinosaur. After 12 years, I would call you competent (hopefully). Now, we are lucky enough to have a some dinosaurs on this site and I guess thats why I keep coming back.

My communication skills were good enough that I didn't need a year at the basic level. If you do fine, but it's not for everyone. Especially since a good paramedic program should ensure communication skills are up to par before graduating someone and should give the students plenty of time to practice.

I haven't really seen a big problem with the way EDs communicate with pts (how they talk to us is a different story). It's good to calm and inform pts but not necessary to treat them like children. I'd like some specific examples of what a doctor or nurse said to one of your pts that caused them such grief or health crisis. Based on my experience, I just don't see it happening.

Anyway, thanks for sharing and I hope you keep on posting

 

[firetender]

Well, considering the 12 years started in 1973, I'd say for the profession, that's Neanderthal, anyway.

I hear and applaud the general tone of support for ED personnel that is being expressed here. Overall, my experience was good, but I'd estimate it'd be fair to say that for each hospital I've worked with, there's been at least one incident of potentially harmful insensitivity come through one of its personnel.

I'd love to hear that such incidents are rare today!

 

[firetender]

In response to VentMedic

(having trouble getting my post to follow the post I'm responding to!)

Everything that you shared speaks to some of the most challenging personal decisions that EMS personnel must deal with. How do we want to be as technicians AND as human beings in relationship to our charges?

What I most appreciate is that you clearly have taken the time to define who and how you wish to be. Such matters are, as a whole, things we're blindsided by, finding ourselves having to suddenly make a choice based on the circumstances of a call, and not being too sure if and how we're going against our own values at the time. Only later does the realization set in.

My guess is everything you mentioned was not copied from a book and came through trial and error. Thank you for modeling the conscious definition of a personal policy that works for you!

I wonder how many paramedic courses anticipate such questions and prepare their students to deal with them?

 

[VentMedic]

Actually my post is nothing more than common sense and good values.

Treat co-workers and pts with coutesy and respect to gain respect.

Find an outlet when feeling frustrated or burnt out.

Knowing when you can not change the outcome no matter how hard you try.

Remarks from ER personnel, like I mentioned in my first post, may be construed as insensitive to some, but also serve a purpose.

What I find insensitve sometimes is when we talk over the patient giving report like the patient doesn't exist. Then, when the patient tries to correct a fact, we ignore them.

But again, iit all comes down to just good manners.

Finding fault or criticizing other healthcare providers just fuels the fires of negativity. Bashing other healthcare providers (nurses, doctors) may make you feel better for the moment, but it may send mixed messages about team work in the healthcare system as a whole to a new team member (medic, nurse or whomever). EMTs and Paramedics may not feel "appreciated" when they drop off their patient in the hospital for their efforts. Most of us in healthcare don't feel appreciated. But, we know our jobs are important to the patient. If we're creative, we can find ways to stroke our own egos.

And yes, I could give many examples of bad behavior by people in all medical disciplines (nurses and paramedics included) that could be disturbing to the patient. In my current position and in the years in EMS, I can educate (usually with just a "don't go there" look to get their attention), act as a buffer for the pt or walk away.

Yes it would be nice if the EMT and Paramedic programs could properly prepare students for difficult questions about things other than the procedure itself. But the training is limited in time and still has PDQ schools to push student through quickly.

My Respiratory Therapy program was 4 years. I was required to take classes that might be considered as "BS" to some but were actually the most helpful later. Books by Richard Kalish and Elizabeth Kubler-Ross were required reading. The principles in their books could be applied to death and dying and also to life and living. One could apply Kalish's "The horse on the dining room table" analogy to many situations in life. Luckily I was in RT school while I was a medic. What I learned there I was able to utilize on the street. Again, I was careful not to offer advice that crossed boundaries of good sense or my scope.

For some, if you didn't get good values and manners from your parents to where it just happens naturally, then developing a good bedside presence may take a little more effort. Hopefully there will be a good mentor for you where you work.

 

[Stevo]

a very good opening post Firetender, good enough for Jems or any other trade related periodical in fact

~S~

 

[firetender]

Thanks, Stevo!

As I read what you wrote it became clear to me that I'm not doing this to be published, I'm doing this to begin the dialogue, right here, right now.

I'm thankful that y'all are contributing in the ways you are. It gives all of us something to work with to broaden our capabilities!

 

[Stevo]

i have long considered ems as the eye of the storm for those whom we serve firetender

they say that we only make a difference in a small % of runs

i guess in the technical respect that may be true

but i'd like to think that in the human respect , you've made a spot on assessment of the good we can do out there

~S~

 

[Margaritaville]

If you have a decent amount of time in the field, you get to know the ED personnel. Most of the time you know what to expect from them and they know how you handle things. The ED staff works as hard as we do and some of our opinions may differ, however, I believe they are as passionate about their jobs as we are about ours. I also believe that we should do our job appropriately and whatever happens after we have transferred care is neither my concern or problem. My job stops when I transfer care. If I wanted long term contact I would be a floor nurse.

 

[mdymes]

A dinosaur's position

Many good thoughts here. I agree that in a perfect world we should require all personnel to function at the basic level for a minimum of one year. But unfortunately this world of ours isn't perfect so we make due with what we have. The responsibility must fall on the training the medic receives. First they must receive a good basic knowledge and understanding of the patient as a whole from the person with feelings to the body as a piece of machinery. This training starts in the classroom but must be continued in the field. Too many times a potentially good medic is turned loose to the field trainers that have no business teaching due to attitude, experience and most commonly no training in teaching skills. These medic/students receive bad field training and habits that they will carry on for the life of their career. Management needs to make the commitment to the training and adhere to the minimum years or hours required as well as train the field trainers to be good instructors. As far as the other medical professionals referred to here we should try to remember that we are all part of a team that is much larger that the individual components that make it up. We should always try to understand their perspective and respect them. If in doubt about a tactic or line of questioning ask that person about it, who knows you may learn something new or even make that person look at themselves and realize that they could do it better! As far a making a difference you should try to remember that we always make a difference even when the outcome is not what we had hoped for. That difference could be to the patient or the surviving family and/or friends. Put people first and that outcome will usually be a positive one. Mike

 

[medic417]

I agree being a basic makes you use your senses so it is good to develope them. As ALS it is easy to start getting side tracked with all our toys. But this happens even when someone is a basic for many years. Experience is what gets you past this and back to the basic senses before jumping to the toys.

 

[Ridryder911]

If medics were properly educated instead of trained, then they would completely understand the "toys" are just adjuncts in making a diagnosis, not to be constrained nor replace good assessment and clinical experience. Again, there is no real differential in BLS versus ALS in true patient care in a medical care, rather a start and progression in treatment. EMS is one of the few areas that continuum is divided.

No other medical profession requires "prior" experience before entering a formal program. Even physicians can go from no experience to intern. So yes, experience would be beneficial but not essential, even then we need to consider the experience of being a first responder then as many described a title only, if this even worthwhile?

We receive many Paramedics that have never worked in the field, and like everyone else obtain experience as they go. Hopefully, the service will monitor and place with field training officers for guidance and as well obtain experience. As the shortage of Paramedics, not EMT's become more prominent, we will see more and more non-experienced Paramedics. There is only so many EMT positions available, and services such as mine that do not employ basics have become more prominent it is harder for the basic level to obtain experience and a job.

R/r 911

 

[mdymes]

Dinosaur's Position

Very well put R/r 911!! The key is that every Paramedic receive solid field training that starts with basic assessment then leads to the decision making and follow through with treatment. Now if only we could teach "common sense"!! Mike