The man behind the curtain

[Veneficus]

So today while reading a case study book, I ran into one of the doctors whom I have had the honor of being a student of last year. We have a friendly rivalry of who is the bigger philosopher going.

In between discussing the benefits of cross country skiing over meditation, we came around to our other mutual interest of doing what is right for patients, not what is easiest.

It actually revolves around being thorough. Which the American Heritage Dictionary defines as:


ADJECTIVE:

1.Exhaustively complete: a thorough search.
2.Painstakingly accurate or careful: thorough research.
3.Absolute; utter: a thorough pleasure.

But the topic transcends simple ordering of what diagnostic or treatment. Now it is fair to point out this doctor is an Internal Medicine guy. So our version of "emergent" and starting points are somewhat different.

In classic form he performs a physical and history and asks: "what is most likely?"

After my assessment, I ask "what is the worst it could be?"

But the common ground is indisputable. A detailed physical exam and history.

Now I have harped on this subject before probably adnauseum, but I wanted to explore it from a different take, from that of mentorship.

In EMS there are lots of half assed things. One of my favourites is looking for ambiguous findings. "look for something wrong." "DECAPBTLS." "Trauma vs. medical."

I have heard them all.

I have discovered many years ago that looking for specific findings yields more success. I was taught to do this by people I consider mentors.

Do you have a mentor that teaches you stuff like this?

Now granted, it is much easier when you have a very good understanding of anatomy, physiology, and pathology, but is there somebody in your organization or employ that helps you correlate what you see?

Somebody who shows you what to look for?

What is important?

Is there somebody who constantly challenges your exam and history skills to make them better?

Do you take it upon yourself to do a complete exam or history to the best of your ability at every chance you get?

Do you seek the most accurate picture?

For example, when you see edema do you just work with that or do you seek out specific cardiac abnormalities? Renal? Consider ovarian when applicable? Or the other potential underlying causes?

Why or why not?

In short, how thorough are you and do you have somebody who constantly teaches and encourages you to be more so?

 

[46Young]

I try to be thorough. My biggest opposition is a medic Lt stepping on me, interjecting during my interview and physical exam, or telling me to "just load them up and get to the bus."

Sometimes, if I'm the sole medic on the bus, I'll get a quick CC, demographics, baseline vitals, and do the rest on the way to the hospital. If I cover everything enroute, then fine. If it doesn't get done, it's because we're four minutes from the hospital, and the pt doesn't need anything other than diagnostics and maybe some O2.

 

[AnthonyM83]

No, sadly I've had to be my own mentor in the field since EMS isn't taken very seriously here. I have had some good ones in the classroom and during periods of training but not coworkers I can observe or be observed by on scene. Thus its been a really slow process... with the enthusiasm I have for the job I sometimes wonder where my skills would be if I had more help...but around here if you've been working at a private EMS company for more than 2 to 3 years you're considered an old timer... I have seen and learned from some good people, though...

Actually emtcity and emtlife, places full of people who care...THEY'VE been my mentors from the start...

 

[Melclin]

PLENTY
In the short time I've been involved in EMS I've met many people who encourage and nurture my skills and knowledge.

For example I knew a MICA paramedic at uni who saw that I hated the guideline mindset and encouraged me to 'Figure out whats wrong with the patient, then consider what you have on the truck and in your mind that can help them, instead of trying to decide whether they fit into CPG A23 or CPG A23.1". Up until I finished uni I used to have weekly visits to his office that could last hours, to discuss recent cases, articles or problems I was having.

The entire faculty is full of smart, educated people who give their time to mentor us as well as their own studies (Mostly PhD, with some MPHs thrown in).

Out on the road, I'd say about 40-50% of medics I've met were keen to teach and encouraged me to read and learn more. Of course some were tired or burnt out, but mostly medics try to set good examples for students (with some notable exceptions though it must be said) and are keen to help you if you have the right attitude.

We have a "grad year" or internship after finishing the degree, that is at least one year long, in which time you are expected to study and receive mentoring from a variety of Clinical Instructors before your final qualification panels. After that Clinical Support Officers may have a role in continuing development. The CSOs I've me have all been walking EM libraries and have never encouraged anything but ridiculously thorough assessment & the reading guides it.

Not one of the above has ever encouraged me to do anything but be more thorough in my assessment.

HOWEVER
I think its important to prioritize that thorough assessment. I remember in second year my partner was doing a full field pulmonary oedema scenario and was going through doing a physical exam looking for pedal oedema. The MICA medic assessing demolished him and asked how a finding of pedal oedema or not would change his treatment. At first I thought he was one of the anti-education types and was going to preach guidelines for an hour or so. As it turned out he was an extremely intelligent medic and in the coming years helped me to prioritize assessments and treatments. Nothing wrong with collecting information on the pt's 40 year medical history, but you need to prioritize the collection of information you need in order to make time critical treatment decisions.

You're allergic to peanuts and you just ate satay beef? You're short of breath, with obvious angioedem? Here's some adrenaline. You've ticked enough boxes to raise my index of suspicion enough to treat. The rest can come as I treat/later. The fact that you had a PE after knee surgery two years ago is important and I will illicit that information in the fullness of time, but the adrenaline has to come first. Before that MICA medic spent some time with me, all my patients were dying of old age before I finished assessing them.

ALSO
You don't need to take a supper thorough medical history to hand a band aid to someone for a cut on their finger. What baseline assessment should be mandatory in all patients and what should be reserved for specific indications?

I'm going to a music festival to do event first aid tomorrow where there will be thirty thousand drunk overheated music fans are camping, drinking, fighting and taking drugs. Not everyone I will see needs, or is going to get a full Hx and physical.