Pride-Ego-Humble-Patient Centered Care

[NomadicMedic]

I get a funny book sometimes when I ask patients, “would you like to go to the hospital with us?“ I think they believe that that’s the only option. If it’s really non-acute, I’ll say, “we have some options. You can go with me, you can have someone drive you to urgent care, you could have someone drive you to the emergency department, you can make an appointment with your primary care physician… It’s entirely up to you.“

...and I do want to clarify, this is for entirely non-acute patients. This is the patient that has had back pain for three weeks and they haven’t been able to make an appointment. Somebody who’s had a cold for two days. Honestly, the kind of stuff that would best be seen at an urgent care or fast track.

It should never be, “why did you call an ambulance for this?” I’ll treat everybody appropriately and give them options. That’s how you function as a patient advocate and not as a jerk.

 

[VentMonkey]

I get a funny book sometimes when I ask patients, “would you like to go to the hospital with us?“ I think they believe that that’s the only option...

Is it chock full of funny one liners? Maybe some awesome dad jokes?

Seriously though, I agree and am the same these days. Was I always? If I’m being honest, no.

I will say there is something to be said for those who continue to get pummeled to the ground in high call volume, “dynamic” systems. With that, there is a reason the better providers typically move on, and/ or venture out.

I think it’s all too easy to become apathetic without even realizing it.

The same could be said for the provider who was once in that fish bowl, but now judges easily from the outside of it.

 

[NomadicMedic]

Gotta love the autocorrect that I didn't notice.

We're in this strange place, where salty, uncaring providers are celebrated on social media and the "burnt out EMS meme" reigns supreme.

Social media is ruining us.

 

[StCEMT]

I like what some of the cities are doing with mental health teams, intox vans like Denver, community paramedicine, nurse lines etc. But yeah, I feel your pain coming from high volume system that had the same issues.

I really wish we had stuff like this, intox vans alone would be huge. Right now the slack just falls on the 911 system for all of those things. I'd love to see this be something we have on our 3 year timeline. There are plenty of times that it isn't that I don't empathize with, but I am less than a mile from the hospital, the system is NUA, and I have to get all the pertinent info in that time and get back out.

 

[VentMonkey]

Social media is ruining us.

Agreed one thousand times over. So many personal feels hurt over the frivolous things in life...like...work.

 

[Lo2w]

I really wish we had stuff like this, intox vans alone would be huge. Right now the slack just falls on the 911 system for all of those things. I'd love to see this be something we have on our 3 year timeline. There are plenty of times that it isn't that I don't empathize with, but I am less than a mile from the hospital, the system is NUA, and I have to get all the pertinent info in that time and get back out.

My previous 911 was ripe for a tiered BLS/ALS/Community Medic response. We had at least 15 hospitals of various capabilities to transport, no more than a 10-12 minute transport from any part of the city. Instead they utilized EMTs as seat fillers and drivers …

 

[SandpitMedic]

It has been a while since I started a new thread and I often tend to post on the more abstract, introspective side of medicine when I do. So without breaking tradition, here I go again. I have two points of observation here, so feel free to hit one or both.

First, I have noticed over the years as my educaction increased, as my experience lengthened, so did my conversation, my chattiness if you will. By this, I mean I take time to speak to patients. I engage them in conversations. I ask questions unrelated to their presenting condition, I give concern/regard for things in their life other than the issue in front of me. Don't get me wrong, I am not sitting on scene running the clock, however I do not rush through every little thing required. I know they need X, however I also know X can wait two more minutes if they are in thought or telling a story. I do not overtly control every little thing on scene as much as I used to. I know it will get done, I know how and when to get it done, so I have subconsciously removed the mechanical, robotic response of our scene action. My assessments can vary widely depending on the ebb and flow of whatever is transpiring in front of me, I do not systematically check off X Y Z. I will get to it. If urgent, sooner than later of course.

I bring this up mostly because it has been a verbalized trend among students, and younger/newer "peers" I have worked with. Their feedback is positive and they ask how I came to do this. I really do not have an answer for them, I usually just say years of practice and leave it at that. To my fellow experienced providers, is this common for yourself? Are you able to objectively see a shift in your patient interaction techniques through the years? Is this all just muscle memory like everything else we do repeatedly? I do enjoy keeping scenes calm, conversation flowing...is this an area we can improve upon with new students? Effective communications, psychology, etc?

Anyways, for the disappointing part of this post, see below (And you QA/QI guys will maybe enjoy this and have a takeaway for your own crews).

I happened to be on scene in my small town as a volunteer responder backing up the paid Paramedics from a town over. We had a sweet, 70ish y/o female feeling unwell and weak. I have been to her before, she is usually rapid A-fib. Sure enough, once the Paramedics arrived with their monitors, they confirmed she was tachy around 140-150 and their desire was to give metoprolol per standing order. To do this, they needed IV access. This crew does not know me personally, and their assumption was I am maybe a basic if that. I stood in the truck and watched as the first medic blew a 22g twice in her left arm. Then the second member (an advanced EMT), said I got this. So he boldly took a 20g and went for the right AC. This lady had spider veins, his medic just blew two 22gs...why go for a 20? She needs medication, not fluids...end result, he blew the 20g in her right AC.

I then politely suggested, why not just drop a 24g in her hand? It is enough to get the medicine on board and address the issue without further sticking this lady. The medic looked at me and for brief second his eyes flashed like it was the greatest idea and then his face changed and he said "I cant wheel her into the ER with a 24! No one uses a 24g".

To which I said "access is access and you are doing the right thing for the patient". Anyways, he then told his partner to do a slow Code 3 to the ER and they were departing, he would attempt again en route. I do not know what the outcome of the patient or his care decision was....and I do not care to hear bashing on this particular medic. My point of this is...when did we become so proud that we base our competency on the size of needle utilized as opposed to bragging that we used an appropriate sized needle to deliver the appropriate care to a patient in an appropriate time???

Had the service I responded with been licensed above a BLS level (its a rural FD FYI), I then could have done some medic stuff and absolutely would have completed all this prior to their arrival, however this is not the situation. Anyways, back to the topic...where did we "go wrong" in our training and education where we instill this line of thinking?

I have always been an outgoing guy. I'm a people person. Lucky for me, medicine is not a medical business, nor is EMS a transport business... Rather, they are both facets of being in the people business. I have always enjoyed developing rapport with patients, and as other have stated you stand to gain a lot during your history if you just listen to people.

What you have described sounds like the evolution of most every paramedic. When you are young, fresh, and driven by adrenaline these are the things that happen, you rush things and you do not want to look incompetent. Especially when you add a level of discomfort of not being confident in your skills when you are newer. As you become more confident and experienced you slow down. As a by-product you begin to see that you are indeed in the people business. Throw in a tall side order of ego and that evolution takes longer, and of course some people never grow out of it. Another portion become considerably burned out, downright crispy, and it affects their performance. Those folks would benefit from a break or moving to a different service or out of medicine completely. (Having suffered from this burnout and moral injury myself, despite loving being a paramedic, I understand it is a dynamic that needs to be studied and addressed further).

Additionally, everyone has their ideal version of EMS being a certain way... such as ALS only going on true-emergencies, police transporting their own drunks, etc etc. Taking it out on patients is not the answer. There are indications that burn-out has a lot to do with that also. Many of the providers in high-volume areas are likely to be highly opinionated on this.

I guess in the end, being new and being burnt out are conditions that impede ones ability to communicate effectively with patients, and prevent one from seeing them as more than a challenge, a puzzle, a job, or an inconvenience.

In my PA training we have had many lessons and lectures on communication. Motivational interviewing, meta-cognition, and listening to understand versus listening to respond were included in our training. Not interrupting patients was a huge, huge thing during our simulations and clinical clerkships. There was a study done which showed that on average doctors interrupted their patients 11 seconds into them speaking. Listening and understanding are parts of communication as well as compassionate care.

 

[SandpitMedic]

Oh, and any access is better than no access if needed.

 

[Tigger]

In my PA training we have had many lessons and lectures on communication. Motivational interviewing, meta-cognition, and listening to understand versus listening to respond were included in our training. Not interrupting patients was a huge, huge thing during our simulations and clinical clerkships. There was a study done which showed that on average doctors interrupted their patients 11 seconds into them speaking. Listening and understanding are parts of communication as well as compassionate care.

Motivational interviewing is possibly the best soft skill I've ever been taught. I was fortunate to get some education when I was doing a lot of work on a mental health response unit, it's use knows no bounds.

 

[NomadicMedic]

I took a 4 hour introductory course on Motivational Interviewing and it made me a MUCH better provider.

 

[FiremanMike]

"It's about them, not about us."

This is what I've been trying to preach for the past month or so during our mostly informal trainings. We are not practicing medicine to make ourselves feel better and lately for whatever reason I've seen a lot of folks providing a lot of ego driven care. Looking for Trosseau's sign of latent tetany is not going to alter your decision making for a syncope patient that you're going to transport to the hospital, though it will hurt the patient. Dropping EJs on patients that already have large bore peripheral access is for your ego, not the patient's care. Talking down to patients with non-emergent complaints and trying to talk them out of an ambulance ride because you believe "ambulances are for emergencies" makes you an *******, not a good paramedic.

Certainly there is something to be said for experience giving you the ability to better interact with your patients as well. I can run most of my calls in my sleep realistically. It is not difficult to rule out badness, gain access, and medicate someone in pain, which is high proportion of my "ALS." When I didn't have that routine down as well, it was harder to multitask. Not so much the case anymore, and I think my patients appreciate that.

Taking the time to get to know your patients matters. Even if you don't really like people, I keep seeing all this research about how affect correlates to fewer lawsuits. Maybe do it for that? I dunno.

As for IV size, someone once told me that the size of the IV catheter isn't printed on the death certificate. Do your best to get the best access you can get. I don't give up easy, but I know my limitations in an ambulance and what I'm realistically using access for.

Incidentally I started a 24 in an adult patient for the first time in six years on an adult patient last night. My string of luck of getting 22s in strange and difficult places finally ran out I guess. Stage 4 cancer patient who fell and needed some fent. 24 worked just fine for that. We had a nice talk on the way to the hospital, so nice in fact that I think I actually shed a tear when she talked about where she wanted her ashes spread. Can't do that if you're obsessing over your ego...

I make an effort to tell our new folks during onboarding that every run is a chance to make a difference in someones life.. Even if they're not really sick, it's a chance to just be nice to people..

When I see folks after a run or in the station I always ask "did you make a difference in someone's life today?"

I hope that I'm planting seeds..

 

[FiremanMike]

I took a 4 hour introductory course on Motivational Interviewing and it made me a MUCH better provider.

Can you point me in the direction of the course you took?

Thanks!

 

[NomadicMedic]

I will find the link when I get back to the station. It was designed for social workers and addiction counselors, but there is a lot of value in it for what we do. If you just search for motivational interviewing free course, you’ll probably find the link.

 

[DrParasite]

@FiremanMike this is what I would recommend: https://tinyurl.com/tjg4o4e

 

[Tigger]

@FiremanMike this is what I would recommend: https://tinyurl.com/tjg4o4e

I'm sure google will be able to tell FiremanMike just what MI course NomadicMedic took and had a good experience with. Thanks for contributing to the mission of this site.

Here's the last time I'll say it in 2019. This community is (among other things) about letting providers share their experiences and what has worked for them. We try to promote a culture that allows for this. Telling someone to go google it is not helpful and will not be tolerated.

 

[FiremanMike]

@FiremanMike this is what I would recommend: https://tinyurl.com/tjg4o4e

Googling this turns up many responses. Nomadic had a good experience with his. Rather than just pick and hope, I'd prefer to go with a program that is actually worth my time.

 

[NomadicMedic]

Googling this turns up many responses. Nomadic had a good experience with his. Rather than just pick and hope, I'd prefer to go with a program that is actually worth my time.

Sorry. This was the one. Requires a free registration.

HealtheKnowledge: Log in to the site

healtheknowledge.org

 

[FiremanMike]

Awesome! I’ll crank that out this week, thanks a bunch

 

[ghost02]

Thanks for the reference, I'll get it done this week.

 

[chriscemt]

Social media is ruining us.

Indeed.