"Could you hand me the?..."

[VentMonkey]

Time and time again I hear folks remark about so and so being "dialed", always being calm, or just generally keeping their wits about them through critical calls.

I realize it's been discussed before, and I also know that EMT and paramedic schools often don't drive these points home. Fair enough, they're busy enough teaching textbook fundamentals as they should be.

I just wanted to shed some light and debunk any myths. I also wanted to share, and have others share what "tricks of the trade" they have learned over the years. Many, I'm sure are like me and have learned from some awesome mentors both directly, and indirectly.

The bottom line is this:

No one is born with that "cool", it does develop over time, but one of thee biggest things one can do, particularly when first starting out is prepare. That's it.

I'm not talking about just "acing" your class then bragging about it. I am talking about showing up early, going through any and everything that's not only used on a daily basis, but even dusting cobwebs off of items such as traction splints, KED's, or that piece of equipment seen way in the back of shelf 10 that hardly sees the light of day.

I am talking about setting up all of your airway gear to meet your needs. Making sure your ETCO2 cap is exactly and proficiently reachable. Untangling the cords to the ECG monitor that the last lazy oaf left a mess. Putting stickers back on the 4 and 12-lead cables because, again, it was too much trouble for said lazy oaf, and their gomer partner. Changing the house tank at the beginning of the shift even if it's teetering your company's "bare minimum standards" (I was able to show this invaluable lesson to a trainee a month or so ago when we did then had two arrests in one shift).

So what's say we all share our tidbits so that all is not lost on the newer generations and providers out there wondering the "tricks" to making things flow consistently*?

*There are no real tricks to consistent competence, only hard word, and well, consistency. Failing to prepare is preparing to fail, as the old adage goes.

 

[mgr22]

I agree with the importance of preparation, a big part of which, unfortunately, is taking care of things others should have done. That's why I carried my own "15-minute bag" wherever I was allowed to do so. I had almost everything I'd need to treat a patient for that long (notable exceptions were EKG/defib and O2). There was no wondering about whether used or expired items had been restocked; that was up to me alone. And I knew where everything was.

 

[VentMonkey]

Right, and if complacency and consistency were two people they would not play well together. In fact, they often are and often don't.

I think now I can SMH about it, but the noob who picks up bad habits from these types then turns around, and wonders why the person wanting to have things set a certain way is the way they are is worth bringing up.

Sure, you can "prep" people before each call or shift, but how do you know how they'll react under real stress? You don't, no one does.

That's why I advocate for each provider to find their groove so to speak and put things exactly where they need them in order of priority. I was notoriously hard on all of my trainees this way for this exact reason. I regret nothing.

Since we work in such an impressionable field I happen to think sharing why (specifically) the stronger providers are generally very uniform when it comes to preparing. I've had EMT's snicker at the little things I make the biggest fuss over. I ignore them, press on, and generally stay away from their shifts from there on out.

Attention to detail will save your hide every flippin time, period.

 

[SpecialK]

Do you blokes not do a check at the beginning of every shift? As for getting your e.g. airway gear set up, do you not have a checklist for that?

Full vehicle check at every shift change and if for example the night crew comes onto station while the day crew are out and Control calls to respond in the spare ambulance, that ambulance is not turning a wheel until the minimum "critical" check is done. This is a one minute to ninety-second check of the bare basics (oxygen, suction, response pack, medicines module, radio, lights), even if the job is a cardiac arrest, the ambulance doesn't leave until a critical check is done.

 

[NomadicMedic]

Do you blokes not do a check at the beginning of every shift? As for getting your e.g. airway gear set up, do you not have a checklist for that?

Full vehicle check at every shift change and if for example the night crew comes onto station while the day crew are out and Control calls to respond in the spare ambulance, that ambulance is not turning a wheel until the minimum "critical" check is done. This is a one minute to ninety-second check of the bare basics (oxygen, suction, response pack, medicines module, radio, lights), even if the job is a cardiac arrest, the ambulance doesn't leave until a critical check is done.

All too often the check is only "is it present?" not for function or usability.

There's always the stuff you need on the truck, but if it's set up the way you want or not… That's the difference between fumbling around to having a smooth flow. For example, I always make sure there's a start kit and several flashes in the IO kit. That's not required at my service, but it makes my life easier when everything is in one place.

I also keep all the bits and pieces in one place for CPAP with nebulizer medication. I also keep an end tidal nasal capnography set with those goodies as well.

 

[NysEms2117]

first- background on me. Fairly new EMT (<1 year of actual experience) Theres a few things that i do.
1. LISTEN, if your partner has more experience, or even just has tips that seem logical... Listen to them, theres really no substitute for REAL WORLD experience. Sure EMT class says LE will control the scene, EMS does XYZ, one of the biggest things to understand in life is Murphys law. Whatever can go wrong, will go wrong most commonly at the most inopportune time.
2. As Ventmonkey said, preparing will really save your butt. There really is no substitute for knowing where the equipment is, when to use it, and to anticipate its use. Keep in mind, in most cases(on this forum anyway) your being PAID to know where that equipment is.
3. Keep yourself calm. Even if your going nuts on the inside, if your external appearance is calm cool and collected, the patient and the patients family/friends will be as well. If they see the person whom they called for help freaking out, not knowing where anything is, what will they do? Your the trained professional here.
4. Understand what your partner wants/needs. Understand your partners strengths and weaknesses. Remember... YOUR A TEAM. I've been lucky to have 1 constant partner for 90% of my EMS shifts. I know that he is not the most physically demanding in appearance, and his voice/ tone is relatively soft. So i know if we arrive early on scene, before the nice folks that do crowd control, I must do that because he won't. I also know that he is a LEFTY, so he likes his equipment on the other side of him. Rather then having him stop doing what he's doing to move his bag of tricks to the other side. I just bring it out and place it there. It's little things like this that can save a ton of time, and make calls run smoother.
5. Finally, I learned this in my law enforcement training. KEEP PEOPLE UPDATED. Not everybody is on scene, let the right people know what the hell is going on. If you need more LE, let them know. If you need to activate a trauma team at the hospital, you need to take a step back and realize "oh **** i never told them"
Thats me, and what i think. I'm a rather new EMT though.

 

[mgr22]

Do you blokes not do a check at the beginning of every shift? As for getting your e.g. airway gear set up, do you not have a checklist for that?

Full vehicle check at every shift change and if for example the night crew comes onto station while the day crew are out and Control calls to respond in the spare ambulance, that ambulance is not turning a wheel until the minimum "critical" check is done. This is a one minute to ninety-second check of the bare basics (oxygen, suction, response pack, medicines module, radio, lights), even if the job is a cardiac arrest, the ambulance doesn't leave until a critical check is done.

That would be nice, but I have not worked for an agency that did those things consistently. It depends on who is working and what else is going on.

 

[Summit]

Building on ventmonkey's be prepared post:

On ambulance I used to do case study after case study during downtime, mentally run myself through everything I could... that way I was less excitable when it actually happened and that is how helped eliminate my worst newbie jitters.

Thinking of nursing things that transfer over to EMS:

• Have a plan for the worst case and for the most likely complication with each patient, mentally rehearse.
• Make psychomotor tasks second nature so you could think through problems while doing tasks.

Crit Care things:

• If you have multiple IV lines, untangle your IV lines and label at both ends, the pump module, and all Ys (with colored tape and or written labels) so you know what line you are accessing plus what you can Y or push into what line.
• Programming your pump should only require pausing to verify rates, volumes, meds etc.
• Adjusting and troubleshooting your patient monitoring equipment/pressure lines should be automatic processes.
• Ensure alarm settings give you the best chance of having actionable alarms and never continuously monitor any parameter that isn't meaningful.
• Know your what your IABP and vent sound like when they are working and when they headed towards a problem
• Know what to do with your pacer in an emergency (and know for each pacer if you have TVP and/or dual chamber in addition to TCP)

Oh, and you won't catch me without at least one pair of gloves in my pocket if patient care is at hand.

 

[StCEMT]

Check my equipment every day. The last two shifts I have caught things supply missed. Hasn't turned out to be hugely important, but I noticed it regardless.

Keep my equipment where I like it and know where it's at. I am still learning some of the smaller things here, but it's made my life easier before, especially on vent calls.

If it's an ICU type transfer (universal idea though), keep things clean and organized. EKG wires are a pain in the *** on their own. Throw in multiple venous access lines, vent tubing, EtCO2, an art line, etc and things get messy. I don't like messy. Be organized.

If things do go south, have a systematic approach to figure out what's causing it and how to fix it.

Be able to communicate when things need to happen. Maybe not full on conversation, but at least keep tabs on each other and share findings.

Now I have plenty of times I forget little things, happens all the time. It's never really anything huge, just an "aw shoot, pass the computer" moment. The times I have had sick people though, some variation/combination of the above has usually kept things going pretty good.

 

[VentMonkey]

Do you blokes not do a check at the beginning of every shift? As for getting your e.g. airway gear set up, do you not have a checklist for that?

Yes, us "blokes" on this forum, and most likely thread do. My point is to convey this universally. I highly doubt complacency does not transcend cities, states, countries, counties, provinces, or even continents.

All too often the check is only "is it present?" not for function or usability.
There's always the stuff you need on the truck, but if it's set up the way you want or not… That's the difference between fumbling around to having a smooth flow.

This is what the thread title is making reference to. Saying it's checked knowing it isn't has burned me plenty of times from partners I did not know all too well. Now, I double check even what they say, or do out of both habit, and because I hardly trust anyone else's work. Plus, it all falls back on me anyways, right? Accountability.

Crit Care things:

• If you have multiple IV lines, untangle your IV lines and label at both ends, the pump module, and all Ys (with colored tape and or written labels) so you know what line you are accessing plus what you can Y or push into what line.
• Programming your pump should only require pausing to verify rates, volumes, meds etc.
• Adjusting and troubleshooting your patient monitoring equipment/pressure lines should be automatic processes.
• Ensure alarm settings give you the best chance of having actionable alarms and never continuously monitor any parameter that isn't meaningful.
• Know your what your IABP and vent sound like when they are working and when they headed towards a problem
• Know what to do with your pacer in an emergency (and know for each pacer if you have TVP and/or dual chamber in addition to TCP)

Oh, and you won't catch me without at least one pair of gloves in my pocket if patient care is at hand.

All good stuff for a newer critical care provider such as myself, and yes always have a pair of spare gloves. Mazel, @Summit.

If it's an ICU type transfer (universal idea though), keep things clean and organized. EKG wires are a pain in the *** on their own. Throw in multiple venous access lines, vent tubing, EtCO2, an art line, etc and things get messy. I don't like messy. Be organized.

Absolutely. I typically follow my nurses lead so as not to get too much in their way, but make it as smooth of a call, and transfer from bedside to bedside, and hospital to hospital each and every time. It really does help to have any, and all wires untangled whenever realistically, and practically possible; even if this means taking a few extra minutes on the front end, because it will save those minutes in the end.

 

[StCEMT]

Tape is helpful with those. I'll loop up all the slack and tape it to their arms.

 

[Flying]

All too often the check is only "is it present?" not for function or usability.

I encountered this within the first month of working as an EMT. It really sucks when only one other person in the service bothers to test the AED regularly and keep track of pad and battery expiry. Not to mention all of the yellow gauze I threw out.

 

[SpecialK]

Yes, us "blokes" on this forum, and most likely thread do. My point is to convey this universally. I highly doubt complacency does not transcend cities, states, countries, counties, provinces, or even continents.

In the past, yes, I've heard of people going to cardiac arrests without a working defibrillator etc.

At the beginning of every single crew change the vehicle is checked against a checklist, both Officers have to acknowledge on the checklist that it was done and done as required. They are filed and audited. If something were to happen, the checklist would be pulled and if it was signed but whatever wasn't there or something then you'd best get the union rep to pay you a visit quick smart ...

The "critical check" is done before the full vehicle check which is a check of basic response readiness; oxygen, suction, defibrillator, response pack, medicine module, lights etc. This is done before any ambulance can leave station to attend a call if the crew have not previously done it, even if it is a cardiac arrest.

Under no circumstances does a vehicle leave station if it has not been checked, and checked properly. This is not only a requirement of employment, it is a requirement of the Ministry of Health who pays for the ambulance service. As I said, when the audits come, they can and do randomly check to make sure it is being done. Again, a check wasn't done or wasn't filled in as being done by both personnel, then that's a serious problem. It is also a legal requirement under the Code of Patients Rights, they have the right to services of an appropriate standard, which includes properly functioning equipment, so, should something happen and the vehicle or equipment wasn't checked properly then the personnel involved and the ambulance service can be found in breach of the Code of Patient Rights and punished accordingly. With registration looming, failure to ensure this could lead to a referral to the regulator for disciplinary action against your practising certificate. it could also potentially be in violation of the Health and Safety At Work Act depending on what is missing or not working or not correct; for example if it were a high visibility vest or some piece of protective equipment like goggles or something and somebody was injured or nearly injured or something then again, the personnel involved and the ambulance service could be fined, and those fines do not come cheap, I've heard they are in the tens of thousands of dollars.

It is also a courtesy to the on-coming crew that you leave the ambulance fully re-stocked and ready to be checked off without needing to have anything replaced or some mess cleaned up, just as the off-going crew did for you when you arrived. Obviously, if you're out and are late returning then you just make it up and leave and the on-coming crew can respond in the spare vehicle or whatever.

I'm really not sure how this can even be a problem? You guys must have similar?

 

[StCEMT]

I'm really not sure how this can even be a problem? You guys must have similar?

For me, all our stuff is in small containers that are sealed, which makes checking the truck easy. I count the boxes and make sure the seals are good. From there it's just battery checks and make sure what the power system is working and all our stuff like the pump and batter charger are actually charging. I don't have to restock anything. All I have had to do is go back to supply because they missed something or double stocked a wrong box and replaced the wrong number, and that isn't often a big issue. However it is expected that every single truck be checked in the morning and they are.

 

[VentMonkey]

@SpecialK I think we are worlds apart, both literally, and figuratively. In the United States there is a hodgepodge of different types of services, many of which don't (for various reasons) yield consistently productive, and effective providers. Individualism, at least here, has no guarantees.

Back to things I've learned:

Put the tube tamer behind the patients head before endotracheal intubation. By dressing it around their neck so to speak I find this saves so much heartache when trying not to dislodge or move the tube.

I tie my IV tourniquets on the hand rail in front of me for IV's. I always make sure both glucometers are where I need them, and what I need them at. My list of "must checks" are most certainly airway, cardiac monitor supplies, gas, O2, and a plethora of IV stock.

I also like putting the BP cuff on the OUTSIDE of the sleeve tucked behind the screen/ cover for the monitor, and neatly rolling the SPO2 probe up. I guarantee every time I check where we keep our different sized BP cuffs it's a mess so I will put them back neatly.

All these seemingly trivial things make such a huge difference it is remarkable. Sadly, most people don't believe it until they see it...firsthand. What's worse is that many providers never learn from their mistakes.

 

[Tigger]

There is a lot to be said about thinking through how you want the call to run. It's not enough to set up your IV stuff if you don't actually put it where you're going to do it. Think about where you put your electrodes, will they be in the way later? Can you even find them later?

If I'm going to have to carry someone who is minimally responsive but I want them on the monitor, I'll put combo pads on them. Tough to pull those suckers off.

 

[planetmike]

This is what the thread title is making reference to. Saying it's checked knowing it isn't has burned me plenty of times from partners I did not know all too well. Now, I double check even what they say, or do out of both habit, and because I hardly trust anyone else's work. Plus, it all falls back on me anyways, right? Accountability.

One negative side effect of never trusting anyone else's work is that they learn "why bother checking it? You're going to do it yourself anyways." One provider I work with regularly does his own checks after I've just done the check, but he does it with an attitude which reinforces the notion that I don't know what the heck I'm doing.

 

[VentMonkey]

One negative side effect of never trusting anyone else's work is that they learn "why bother checking it? You're going to do it yourself anyways." One provider I work with regularly does his own checks after I've just done the check, but he does it with an attitude which reinforces the notion that I don't know what the heck I'm doing.

Eh, I'll hedge my bets. I work as a ground paramedic part-time so I never have a "consistent" partner/ EMT. I do tend to pick up shifts with those that are more tenured, who I don't have to worry about second guessing, and who I can generally trust a bit more overall.

It sounds like that particular partner has been burned before, and perhaps a tad burned out themselves. It's sad that universally we all do not employ the same work ethic, however, this is nothing new nor will it hardly ever change.

Just this morning it took us an extra 20 minutes to get on the road because this unit was left like a pile of hot mess. So yeah, I'll do it my way and worry about it falling back on me instead of trusting someone to be offended only to fall back on the "why should I even bother" mantra.

That's an excellent work ethic BTW, and shows they're truly learning from their partners example. I do agree that approach and attitude do play their parts.