Multitasking

I would say one of the hardest, and definitely most underestimated aspects of being a good paramedic is the ability to multitask.  I have seen the work of a bunch of paramedics and the inner-workings of many calls over the past year and a half, and in order for a scene to appear to be running smoothly, the entire crew on scene, including police, fire and--of course--EMS providers must work together.  But how does everyone on a scene know exactly what to do and when?  Well, the paramedic tells them. 

According to the majority of text books written on the practice of paramedicine, the paramedic's job on scene is to stand back and make sure that all appropriate interventions are initiated by personnel on scene.  However, in real life, the paramedic is an active member of the team, providing patient care while also instructing other members on what to do, how to do it and when to do it.

As an EMT, it is often difficult to recognize exactly how hard it is to "run the scene"...until you've done it.

Let me give you some examples.

1)  You are the paramedic.  Your partner is a brand new EMT, and today is his/her second day on the job.  They have never had a job like this before, working on an ambulance.  You are dispatched to a cardiac arrest, along with fire and police.  Upon arrival on scene, you find your patient is, in fact, in cardiac arrest.  The fire crew who shows up does not have that much experience when it comes to medicine because their passion is fire, not EMS.  So now, you are the only one who really knows how things need to be done; meaning, not only do you as the paramedic have to accomplish all of the paramedic level interventions, but also, you have to provide instruction to everyone else on scene.  Following is a list of things that typically must be accomplished during the above situation.  * indicates a paramedic level skill that a paramedic may delegate to someone else on scene.  ** indicates a paramedic skill that the paramedic must perform.

- Check ABC's (Is the airway open?  Is the patient breathing, and if so, is it adequate?  Does the patient have a pulse?)
- Begin CPR
- Begin oxygen therapy and positive pressure ventilation
- Attach the patient to the cardiac monitor
- Obtain IV access
- Interpret cardiac rhythm**
- Treat rhythm appropriately* (medication administration*, defibrillation**)
- Establish definitive airway (endotracheal intubation)**
- Package patient for extrication and transport

That doesn't appear to be so hard, based solely upon the words.  However, put yourself in the position of paramedic.  YOU are running the scene.  You are asking everyone to do different tasks while, of course, making sure you do not insult anyone, and that you appear appreciative of their efforts.

As you, your partner and the fire crew approach the patient with all of your equipment, you can tell the patient is not breathing.  Family is running around the house, freaking out, yelling at you to bring him/her back to life.  You bend down assess the patient's ABCs.  The patient is not breathing and has no pulse.  You turn around to relay the information to your team, and no one knows what to do.  So you need to tell them.  You ask one of the firefighters to being CPR, while you take your place at the head of the patient.  You ask another firefighter to please take out the monitor defibrillator pads and begin attaching them, while opening your jump bag to pull out the Ambu bag.  You begin ventilating your patient at the appropriate rate, reminding the firefighter who is just standing around to swap with the firefighter performing CPR after roughly 5 cycles of CPR.  Then you realize that your partner isn't doing anything.  You ask your partner to start an IV, and you hook the Ambu bag to high flow oxygen.  Everything seems to be running smoothly, right?  Well, now the monitor is attached to the patient, and you ask the firefighter to turn it on.  Upon turning on the monitor, you interpret the rhythm.  During all this time, it is your responsibility to speak to the family about the patient's medical history.  So...recap...you're currently ventilating a patient, keeping track of when to squeeze the bag, you're telling multiple members of your team what to do, making sure that everyone is able to complete their task, and now, you have to consider the patient's medical history to begin considering a possible explanation (perhaps one that is treatable) for why this patient is now in cardiac arrest.  Additionally, you are responsible to keeping track of time so that you know exactly when to ask your partner to give appropriate medications, or when to give the medication yourself.  Not only that, but you are the one who has to intubate the patient.  So on top of everything else, you need to either set up your equipment on your own while monitoring the whole scene, or you need to ask someone to set up your equipment yourself.  Then, you have to consider an extrication plan.  Let's say the patient is in the back bedroom on the second floor of a house that has very, very narrow hallways and a very steep and narrow staircase.  Once you have spent a reasonable amount of time on scene, you have to begin the extrication, making sure to reassess your patient.  Now you have to load the patient into the ambulance and continue the process while your brand new EMT partner drives incredibly fast to the hospital, throwing around you and the firefighters who opted to ride in to the hospital to help you continue patient care.

Now, the above situation might not sound so difficult, but consider doing it while knowing the whole time that if you or any of your team mess up...there's potential for you to get sued or lose your license.

2) Same partner/resources set up.  This time, however, you are responding to a scene where two people are shot.  The fire service is on scene along with police, prior to your arrival.  Most likely, even if the fire department has no interest in medicine, if there is blood and guts, they will agree to play.  The first person is shot one time and laying in the back yard of the residence unable to ambulate.  The second person is shot multiple times to each leg and laying in the front yard.  Needless to say, he is not ambulatory. 

This situation is VERY different than the other one.  For this one, I will give you details of a call my partner and I ran just the other day.

We were dispatched to a call for a person shot one time to the leg.  As we arrive on scene, it is obvious based on where the majority of the firefighters are standing that our patient is sitting by the front steps to the house.  As we approach the patient, the firefighter who assumed scene command prior to our arrival informs us that we have a second patient, also shot.  No other details are provided.  I ask my partner, should I call for another unit?  She says, no, let's see what we have first.  (Sidenote: as a new paramedic, I might be anxious when finding out that I have two patients on scene, both shot.  However, as an experienced paramedic, my partner knows that prior to calling for additional resources, we have to make sure that the situation really requires a second ambulance.  Let's say that both of our patients are shot one time to the leg with a small caliber gun.  We could handle that on our own, thus not stressing an already stressed EMS system.)  My partner looks at me and says "ok, the patient up front is yours, I'll walk to the back of the house to see what's going on there."  Umm...ok...I can handle that...I think.  I get to my patient and see that he has been shot not once, but twice.  Both with a VERY large caliber weapon, and both to his legs.  The wounds were both approximately 3-4 inches in diameter with likely the same depth.  Blood is oozing from both wounds.  I have 4 firefighters, my jump bag, all of their equipment and my stretcher.  I look to the firefighters for information about the patient; information that I expected they might be able to provide, being that they have clearly been on scene for greater than 30 seconds.  Such information includes vital signs, complete count of wounds and anything else they might find pertient.  Well, at least they were able to get the bleeding on his right leg under control.  I immediately went to the head of the patient (this is a strategic location so that I can see not only the entire patient's body, but also the entire scene including available personnel and equipment in front of me.  I was able to establish that my patient was pale, cool, diaphoretic, had no radial pulses and that he was alert and oriented.  From that position I was also able to ask the fire department to and instruct them how to bandage his second wound.  I also noticed that the fire department had not put my patient on oxygen and that they had attempted to obtain IV access.  Knowing that I had a patient who was in shock and in critical condition, I needed to place my patient on high flow oxygen and begin the extrication process, even though this patient would not be transported in my ambulance. (I know he would not be transported with my because he was the more critical of the two patients and because we were the first ambulance on scene, we are the last off the scene, meaning that the more critical patient would be transported by the second unit to arrive.  Oh, by the way, my partner did emerge from the back yard to update me on the other patient and to get the update on my patient).  Even though I knew that we needed to get this patient to my ambulance so that he can get out of the cold weather, I continued with the firefighters' initial plan and asked one of them to obtain an IV.  When he was unsuccessful, I attempted.  However, because the patient was in shock, I knew the likelihood of establishing an IV was slim to none.  But, I attempted nevertheless, delaying extrication.  While in the long run, I did not delay this patient's transport to the hospital, I did not extricate him in the quick fashion that I should have.  This is a mistake I made because of how difficult it is to manage an entire scene with multiple patients and multiple members of a team on scene.

It is important as a paramedic to be able to step back and take in the entire scene, including your personnel and the patient and his/her condition.  This is something that new paramedics often struggle with.  The other difficult task this scene presents to a new paramedic is two sick patients.  A lot of new paramedics would have seen that this patient was VERY sick, and they would have left the scene with this patient, leaving the newly arriving unit to figure out what was going on with the second patient down the hill.  This practice, while unfortunately common, defies the known protocol for a multi-casualty/patient incident.

While I know I recovered from my brief brain fart that allowed my patient to stay outside in the cold weather only a very short time longer than he should have, I also know that I made a mistake and that I learned from it.  No one is perfect, but in this line of business, every little mistake a paramedic makes has the potential to come back and bite them.  The patient was rushed to surgery upon arrival at the hospital and is still alive.

In my mind, as I wrote above, multitasking is probably one of the most difficult parts of being a paramedic.  And the only way to get good at it is to experience it.

Thanks to my partner and all the awesome paramedics I have worked with who have left me in charge of many scenes (while of course making sure I don't screw up) so that when I am a paramedic, by myself without another paramedic on scene to tell me what to do, I will be able to do it...I will be able to multitask and get everything that needs to get done, done.