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.
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