Burnout is a terrible thing that we all learn about in paramedic school. It's usually discussed in the first couple of chapters of the paramedic book, but never again, really. Burnout sucks. When you get to the point that showing up at work makes you cringe and you start developing creative excuses for calling out or going home early, you're getting there. When you lose focus and forget about why we do what we do, and allow that to change the way you do things, speak to people and think, you've probably gotten there.
Recently, I hit what others have told me was my "first burnout". A burnout that, thankfully, is easy to overcome. I've been asked by other paramedics, many of them newer than me, how I stay focused, appear calm, and always try to do what is best for my patients...basically, how am I not burned out. My answer is usually that appearances are deceiving. I've learned over the year to develop the paramedic version of a poker face. That is, I don't show my emotion. I don't allow my patients, their family members or my crew to see the stress in my head. I keep it in my head.
As to how I strive to deliver par or above par patient care, the answer is simple. Our patients, whether homeless, smelly, mean, nice, poor, wealthy, or what have you, are someone's family member. They are a brother, sister, father, mother, aunt, uncle, cousin to someone. They are someone to someone. And we have been put on this earth, for at least this moment, to care for them. So how do I stay focused, appear calm and attempt to do what is best for my patient? I put myself in their shoes, or, better yet, I put a friend, or my parents, siblings, cousins, family members, in their shoes and remember that I have to respect my patients the exact same way I'd expect...and demand...a paramedic treat my family member.
But, I also explain that it is our responsibility to do what is best of the patient because that is our job. We were not hired, nor did we attend school and ultimately get licensed to practice as paramedics and EMTs to sit on our asses and do nothing while our patients writhe in pain, wretch from nausea, cry due to depression, clutch their chests because of chest pain, or struggle to breath as a result of COPD; we got hired to act upon our callings to save lives and treat people in their time of need. We come to work every day (for many of us, just three days a week...THREE out of seven), to be compassionate, to speak to our patients, to listen to our patients when they speak to us, and to treat our patients when they need us.
The practice of medicine is taking an interesting turn. We've seen medicine all over the place (especially in the United States) move away from patient-focused medicine to finance-focused medicine. Medicine has shifted away from a practice to a field in which we can be sued for making human errors. From a field where good judgment, clinical gut, hands-on-diagnostics to a field where every test must be employed to cover ourselves from legal liability. Ultimately, however, medicine is still and always will be about the patient. If we fail to focus on our patients, on what they tell us, on their signs and symptoms, the minutia we find, what they feel like, sound like, smell like or look like, we will fail at providing patient-focused medicine.
Again, we went to school to learn how to interact with other humans, to be humans who are capable of helping other humans when the need arises. We went to school to do this, so, why not do this? Why not give it your all, for three days a week? Why become bothered and frustrated when someone makes you have a bad day. For all intents and purposes, they called 911, so by definition, they're having a bad day! That's why they made your day worse; why they're being rude or short with you. They're sick!
So how do I try to continue to treat patients to the best of my ability even if I don't feel like it? Because not feeling like it is not a legitimate excuse; it is an excuse that simply represents laziness, the inability to convey compassion.
Wednesday, May 21, 2014
Sometimes We Miss Things...and Have to Start All Over Again
A wise paramedic once told the young paramedic student me "I can stop you from killing someone ten times faster than you can kill them". At the time, it didn't really mean anything to me. I thought how could he read my mind and know what I'm going to do before I do it. Now, I understand exactly what he meant. It is my responsibility as a preceptor and field training officer to be ten steps ahead of whomever I am precepting. Further, it is my responsibility to pay attention to my students, partners or new employees at all times, even when I am or appear to be doing something else. By paying close attention and thinking way ahead of their game, I can stop my students, partners or new employees from killing someone ten times faster than they can actually kill someone.
But, when a preceptor doesn't follow behind a new employee's or student's assessments, it's impossible to be ten steps ahead of them; in fact, the preceptor will likely be ten steps behind, if even that close.
The call that taught me this lesson was about two months after I finished paramedic school. My partner at the time - a phenomenal EMT, and now an excellent paramedic - was in paramedic school. I trusted him. We worked together for a few months at that point, and I was confident in his abilities as an EMT and a paramedic-to-be. I guess I should add that I still trusted him after this call because what he showed me, I otherwise might not have learned and he certainly learned from his error.
We were called to a person down at an intersection approximately 15-20 minutes from the closest hospital (which is a fairly far transport for us). Of course, en route to the call, I was both nervous and excited. But I also wasn't really sure how to feel because we had been dispatched to this type of call at this type of location so many times before and found nothing. So, part of me tried to convince my (new paramedic) self that no one would be there, but the other part of me wanted nothing more than to feel prepared for whatever I might find.
Although, even as a paramedic, I knew that no amount of classroom training could adequately prepare me for the real people I would treat and the real situations I would encounter as a paramedic. I knew that I would have to learn through real patient contacts, through treating real people. Feeling real pulses and listening to real breath sounds. Touching the skin of a real ill person to assess their temperature and condition. Looking into the real eyes of a patient in distress.
Anyway, we arrived on the scene to find an elderly gentleman sitting in a wheelchair. The man appeared completely out of it and he was being held up by bystanders. My partner excitedly asked if he could lead the call. How could I say no? He did a great initial assessment, ABCs intact. The patient had an altered mental status and had a contusion to the back of his head indicating some type of trauma. We quickly immobilized the patient and left the scene. Even though my partner lead the call on scene, as the paramedic, it was still my responsibility to ride in the back with the patient.
We loaded the patient into the ambulance, and, well, that's when I started to panic a little bit. You see, as a new medic, I thought it was my job to figure out why my patient had an altered level of consciousness, so I started sweating. I knew my partner had checked ABCs, pupils, c-spine, lung sounds...what was I missing?! I didn't know. I couldn't think. I wasn't sure what I was missing, but I just couldn't move forward with my assessment. In my head, I was panicked. My heart was racing, and the beads of sweat poured down my forehead. I felt my brain trying to work, but the wheels weren't turning the way they were supposed to.
I stuck to the basics. Oxygen, supplemental ventilations as needed, IV fluids, cardiac monitor, EKG, vital signs...over and over again.
Still, no clue. So what did I do? I started over.
Wiping the sweat out of my eyes, I looked at my patient and asked "sir, what is your name". With slurred speech, the patient answered. Okay, I thought, airway intact, the patient is obviously breathing, and has a pulse. I made a mental note of the slightly garbled words and continued. I assessed the patient's breathing: in...out...okay...breathing intact, but slow. Okay, my patient is breathing slowly, has altered mental status...could it be drugs? Pupils! What do the pupils look like? Pinpoint. I called out to my partner..."hey man, did you notice that the patient's pupils are pinpoint?". His response: "oh yea, I forgot to tell you". Oops. By the way, pulses were equal, regular and strong, so circulation was intact.
Now that I recognized the patient's respiratory effort was depressed, and the patient had constricted pupils, I had an idea regarding how to fix it. Narcan! I gave the patient narcan and while my patient's breathing improved, his mental status did not.
Okay...what else am I missing. At that point, with a patient so severely altered, my next step was to expose the patient to assess for further trauma. No injuries found, but I found a necklace indicating my patient has diabetes. But his blood glucose level was 130...so, I thought to myself: could that still be the issue.
And then I remembered a time when I was working with my previous partner and we had a completely obtunded diabetic patient, profusely diaphoretic, as is classic with a hypoglycemic episode, and a stable blood sugar also in the 130 range. We administered IV dextrose and the patient awoke. My partner at that time explained that normal blood glucose levels vary depending on the patient's compliance with medication, diet, etc.
So, I gave this altered elderly male patient some IV dextrose. He awoke, and explained to me that he has chronic back pain and takes opiate pain medication for relief. Whew...problem solved.
After this call, and many other similar calls, patients with altered levels of consciousness became one of my favorite calls to tackle. As I explain to my students and new hires...and whoever else will listen, part of our jobs as paramedics is to be like detectives. We may run into a scenario with which we are unfamiliar, but we need to search for clues, follow all leads and rely on experience and gut to forge our path toward developing some sort of explanation. That explanation can dictate our treatment plan, and potentially save our patient's life. So, when at first the scenario is perplexing, sometimes, starting from square one is the way to go.
But, when a preceptor doesn't follow behind a new employee's or student's assessments, it's impossible to be ten steps ahead of them; in fact, the preceptor will likely be ten steps behind, if even that close.
The call that taught me this lesson was about two months after I finished paramedic school. My partner at the time - a phenomenal EMT, and now an excellent paramedic - was in paramedic school. I trusted him. We worked together for a few months at that point, and I was confident in his abilities as an EMT and a paramedic-to-be. I guess I should add that I still trusted him after this call because what he showed me, I otherwise might not have learned and he certainly learned from his error.
We were called to a person down at an intersection approximately 15-20 minutes from the closest hospital (which is a fairly far transport for us). Of course, en route to the call, I was both nervous and excited. But I also wasn't really sure how to feel because we had been dispatched to this type of call at this type of location so many times before and found nothing. So, part of me tried to convince my (new paramedic) self that no one would be there, but the other part of me wanted nothing more than to feel prepared for whatever I might find.
Although, even as a paramedic, I knew that no amount of classroom training could adequately prepare me for the real people I would treat and the real situations I would encounter as a paramedic. I knew that I would have to learn through real patient contacts, through treating real people. Feeling real pulses and listening to real breath sounds. Touching the skin of a real ill person to assess their temperature and condition. Looking into the real eyes of a patient in distress.
Anyway, we arrived on the scene to find an elderly gentleman sitting in a wheelchair. The man appeared completely out of it and he was being held up by bystanders. My partner excitedly asked if he could lead the call. How could I say no? He did a great initial assessment, ABCs intact. The patient had an altered mental status and had a contusion to the back of his head indicating some type of trauma. We quickly immobilized the patient and left the scene. Even though my partner lead the call on scene, as the paramedic, it was still my responsibility to ride in the back with the patient.
We loaded the patient into the ambulance, and, well, that's when I started to panic a little bit. You see, as a new medic, I thought it was my job to figure out why my patient had an altered level of consciousness, so I started sweating. I knew my partner had checked ABCs, pupils, c-spine, lung sounds...what was I missing?! I didn't know. I couldn't think. I wasn't sure what I was missing, but I just couldn't move forward with my assessment. In my head, I was panicked. My heart was racing, and the beads of sweat poured down my forehead. I felt my brain trying to work, but the wheels weren't turning the way they were supposed to.
I stuck to the basics. Oxygen, supplemental ventilations as needed, IV fluids, cardiac monitor, EKG, vital signs...over and over again.
Still, no clue. So what did I do? I started over.
Wiping the sweat out of my eyes, I looked at my patient and asked "sir, what is your name". With slurred speech, the patient answered. Okay, I thought, airway intact, the patient is obviously breathing, and has a pulse. I made a mental note of the slightly garbled words and continued. I assessed the patient's breathing: in...out...okay...breathing intact, but slow. Okay, my patient is breathing slowly, has altered mental status...could it be drugs? Pupils! What do the pupils look like? Pinpoint. I called out to my partner..."hey man, did you notice that the patient's pupils are pinpoint?". His response: "oh yea, I forgot to tell you". Oops. By the way, pulses were equal, regular and strong, so circulation was intact.
Now that I recognized the patient's respiratory effort was depressed, and the patient had constricted pupils, I had an idea regarding how to fix it. Narcan! I gave the patient narcan and while my patient's breathing improved, his mental status did not.
Okay...what else am I missing. At that point, with a patient so severely altered, my next step was to expose the patient to assess for further trauma. No injuries found, but I found a necklace indicating my patient has diabetes. But his blood glucose level was 130...so, I thought to myself: could that still be the issue.
And then I remembered a time when I was working with my previous partner and we had a completely obtunded diabetic patient, profusely diaphoretic, as is classic with a hypoglycemic episode, and a stable blood sugar also in the 130 range. We administered IV dextrose and the patient awoke. My partner at that time explained that normal blood glucose levels vary depending on the patient's compliance with medication, diet, etc.
So, I gave this altered elderly male patient some IV dextrose. He awoke, and explained to me that he has chronic back pain and takes opiate pain medication for relief. Whew...problem solved.
After this call, and many other similar calls, patients with altered levels of consciousness became one of my favorite calls to tackle. As I explain to my students and new hires...and whoever else will listen, part of our jobs as paramedics is to be like detectives. We may run into a scenario with which we are unfamiliar, but we need to search for clues, follow all leads and rely on experience and gut to forge our path toward developing some sort of explanation. That explanation can dictate our treatment plan, and potentially save our patient's life. So, when at first the scenario is perplexing, sometimes, starting from square one is the way to go.
Wednesday, May 7, 2014
It's Been a WHILE
Well, it's been a little over three years since I last posted on this blog. I guess I got so wrapped up in being a new paramedic that I completely forgot to record my experiences here. So, to catch you up, I am still a paramedic but also function in the role of a field training officer. Field training officers are the first point of contact for new employees once they've been released from the classroom portion of their new hire onboarding process. The new employees do third-rides and one-on-one rides with us for a minimum of four weeks.
Anyway, as you can imagine, a lot has happened over the last three years and I will do my best to include past and present experiences in the blog posts to come. For now, I'll summarize the last three years of my career.
Since I became a paramedic, I have run nearly 4000 calls, about 25 of them have been cardiac arrests or obvious deaths, almost 200 calls for legitimate respiratory distress, 120 chest pain/cardiac-related calls, and 80 major traumas, including shootings, stabbings, assaults, and car wrecks.
Thankfully, through those calls, whether serious or not serious, medically necessary or not medically necessary, I can say I have learned a lot. When training a new employee, one of the most important points I like to make is that as paramedics and EMTs, we can learn from everyone and everything. We can learn from the patient who isn't breathing, the patient who's bleeding out, the patient who has threatened to kill us, the patient who has actually kicked, punched, slapped, spit at or tried to wrestle us. We can learn from the patient who's complaining of toe pain, or the one who doesn't really have a complaint and just needs a warm place to sleep for the night. We can learn from the patient with chest pain and an abnormal EKG, or the one's who have extremely diminished lung sounds, or none at all. We can learn from the bodies left behind at the scene of an accident, or the patients who survived the accident. We can learn from everyone and everything!
Often, my new employees chuckle when I mention that they can learn from those patients with lower acuity complaints, but there really isn't anything funny about it. I can honestly say I've learned from those patients. Whether I've learned some aspect of patient care, or something about documentation, or how I, as a human, relate to other humans, I've learned something. And, when I, or any other EMS provider feels they've learned all there is to learn, it's time to leave the profession.
In fact, one of the things that has kept me in EMS is the knowing that every single day can present a learning opportunity. I'm thankful that I have not yet, and hopeful that I will not in the future take for granted this wonderful aspect of my journey through prehospital medicine.
Well, this post is long enough for now. Next time I will write about some interesting cases I have been confronted with since I became a paramedic.
Anyway, as you can imagine, a lot has happened over the last three years and I will do my best to include past and present experiences in the blog posts to come. For now, I'll summarize the last three years of my career.
Since I became a paramedic, I have run nearly 4000 calls, about 25 of them have been cardiac arrests or obvious deaths, almost 200 calls for legitimate respiratory distress, 120 chest pain/cardiac-related calls, and 80 major traumas, including shootings, stabbings, assaults, and car wrecks.
Thankfully, through those calls, whether serious or not serious, medically necessary or not medically necessary, I can say I have learned a lot. When training a new employee, one of the most important points I like to make is that as paramedics and EMTs, we can learn from everyone and everything. We can learn from the patient who isn't breathing, the patient who's bleeding out, the patient who has threatened to kill us, the patient who has actually kicked, punched, slapped, spit at or tried to wrestle us. We can learn from the patient who's complaining of toe pain, or the one who doesn't really have a complaint and just needs a warm place to sleep for the night. We can learn from the patient with chest pain and an abnormal EKG, or the one's who have extremely diminished lung sounds, or none at all. We can learn from the bodies left behind at the scene of an accident, or the patients who survived the accident. We can learn from everyone and everything!
Often, my new employees chuckle when I mention that they can learn from those patients with lower acuity complaints, but there really isn't anything funny about it. I can honestly say I've learned from those patients. Whether I've learned some aspect of patient care, or something about documentation, or how I, as a human, relate to other humans, I've learned something. And, when I, or any other EMS provider feels they've learned all there is to learn, it's time to leave the profession.
In fact, one of the things that has kept me in EMS is the knowing that every single day can present a learning opportunity. I'm thankful that I have not yet, and hopeful that I will not in the future take for granted this wonderful aspect of my journey through prehospital medicine.
Well, this post is long enough for now. Next time I will write about some interesting cases I have been confronted with since I became a paramedic.
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