Pride goeth before the ambulance...
Original Post Date: 5/4/08
Pride is the double edged sword of any subculture. And, make no mistake, paramedicine is clearly a subculture. There is the pride that drives one to step forward for a difficult assignment because he knows he can handle it and can prove it. This is the William Wallace brand of pride. Then there is the darker side of pride; the kind that goeth before the fall. This pride tricks the tragic characters in our lives into stepping up for the tough job without the skills and without disclosure because they think they can do it and WANT to prove it. Sadly, the latter brand is far more common.
Paramedics are very proud of what they've done and where they've done it. So proud, in fact, that they often find themselves in over their heads because someone trusted them with a patient they've no business caring for and too ashamed to ask for help. Then who pays?
The patient.
I borrow a line from ER (the show) here: It is never about us! Our patients deserve the best care – they demand it, and they don't care who it comes from. And, this is the part that sticks in everyone's craw: we shouldn't care either. If we, anyone, cannot handle what we've been given then it is up to us, everyone, to say so. I find this especially important when charged with caring for patients between medical facilities. On scene, we skillfully bring our patients from no medical care into our charge and off to the hospital. In the case of a transfer; however, we purposefully remove them from a medical facility with the express purpose of delivering them to another one in as good or better shape as when we left. The worst possible action is for an incompetent technician to take this patient knowing they cannot care for them and not say so.
The long view of the solution is education. Learning really is power. But the solution at the bedside is to step back and let someone else take over. What stops us from doing that? You guessed it….pride's ugly, villainous twin.
To err is human; to err on purpose is negligence.
But what of the good pride? The kind that gets you to work 15 minutes early. Or, the kind that helps you find the time to press your shirt the night before your shift. Or, even better, the brand of pride in yourself and your career that drives you to get more than the minimum amount of con-ed and look really hard to find good education even if it means you have to pay for it yourself. And maybe, just maybe, if you cannot afford to pay for quality training you should reread paragraph 3 and study on the pride that keeps you comfortably living within your means, but that is an entry for another day.
Recently, I attended a paramedic graduation at a local community college, and I was surprised to see that the paramedic students were graduating alongside other program participants who had made a much lesser commitment in terms of length and intensity. The college seemed perfectly comfortable putting paramedic students behind graduates of programs that were less than one tenth as long. Paramedic school is fourteen moths full of lectures, labs and hundreds of hours of clinical skills rotations; yet this institution made them feel as though their accomplishment was no different than that of someone that had completed six weeks of school and a few hours of OJT.
How do we honestly expect to grow pride at the grassroots if there is none coming down from the top?
If we choose to treat ourselves with no respect as a matter of policy, we should expect no more from our colleagues in medicine as a matter of course.
Showing posts with label paramedic. Show all posts
Showing posts with label paramedic. Show all posts
How important can it be?
Original Post Date: 5/4/08
No, they don't stop bagging. Well, they rarely do it themselves. But the point is that they see that it is continued. Why is that, anyway? Does it have something to do with the proven need for artificial respiration in the non-breathing, or does it have more to do with an accepted level of competency among EMS personnel? Simply put, it's hard to screw up a bag valve mask, and it is hard to miss the indications for positive pressure ventilation, so the assumption that paramedics can bag a patient that clearly needs it is pretty well supported. But what if the treatment is CPAP, or vasopressors, or antihypertensives? Then how important can it be, really? Or, how likely is it that the paramedic really knows what he's doing at all? Evidence and perception would say not very. Facing facts, the common holding behind the ER doors is that paramedics know how to bag, compress and drive. So, by extension, there is no need to continue any treatment beyond those three things if the EMS crew started it.
Take CPAP, for example. CPAP is still in its infancy when it comes to EMS and thus is largely scoffed by the hospital. Some physicians actually feel we do these patients a disservice by precluding the need for intubation. I would be more inclined to believe we're cheating doctors out of skills, but I digress. This sort of poison-pen attitude spills over into the nursing staff, promoting the notion that this treatment, on which some patients are DEPENDANT when they present is unnecessary and not worth continuing. To complete the vicious circle, when the patient decompensates after treatment is stopped, whatever EMS did must be to blame.
Part of this, I agree, is about personalities. Personalities are largely born from experiences, and many of the nurse's first experiences with EMS were long ago when EMT's did little more than drive and CPR. And, they listen to paramedics talk, unfortunately supporting the idea that they aren't terribly bright. I'm not sure I would listen to a doctor who told me a patient was FUBAR, so I don't think I can blame them for feeling the same way. Perhaps the most damning piece of evidence is the frequent incidence of EMS patient mismanagement, or at least perceived mismanagement.
A bigger component, perhaps the biggest, is a system wide educational failure. Everybody: physicians, nurses, respiratory therapists, paramedics and EMTs just stop learning. Professionals who are taxed so heavily at work rarely feel inclined to study or read after hours. This leaves them believing that whatever they learned in school is still current, no matter how long ago that was. Enter a handful of current, cracker-jack providers who read and study and review new information almost daily, brining that knowledge to the bedside. Imagine the audacity—challenging 20 year-old ideas and outdated theory with newly PROVEN interventions. How Dare They! What better way to deal with unfamiliar knowledge but to ignore it?? Paging the emperor: Your new clothes are ready!
A paramedic friend of mine transported a patient the other day with a bifasicular block on 12 lead. He reported this with the proper gravity to the receiving facility and they said "What's that?" Imagine, education that (should be/is)part of initial paramedic training is a complete mystery to an experienced nurse. Is that necessarily the individual's fault? Not completely; maybe you could argue (I'm sure the nurse would) that the facility should teach them better. Most likely though they would say it's not important for them to know because it's not written on the ER Flow sheet. What the fact is; however, is that everyone is responsible for their own education and, by extension, the lack thereof.
The larger medical community believes we, EMS, don't have the capacity to manage these complex treatments. Medics should know that we can't afford to be without it.
Next: PRIDE
Original Post Date: 5/4/08
No, they don't stop bagging. Well, they rarely do it themselves. But the point is that they see that it is continued. Why is that, anyway? Does it have something to do with the proven need for artificial respiration in the non-breathing, or does it have more to do with an accepted level of competency among EMS personnel? Simply put, it's hard to screw up a bag valve mask, and it is hard to miss the indications for positive pressure ventilation, so the assumption that paramedics can bag a patient that clearly needs it is pretty well supported. But what if the treatment is CPAP, or vasopressors, or antihypertensives? Then how important can it be, really? Or, how likely is it that the paramedic really knows what he's doing at all? Evidence and perception would say not very. Facing facts, the common holding behind the ER doors is that paramedics know how to bag, compress and drive. So, by extension, there is no need to continue any treatment beyond those three things if the EMS crew started it.
Take CPAP, for example. CPAP is still in its infancy when it comes to EMS and thus is largely scoffed by the hospital. Some physicians actually feel we do these patients a disservice by precluding the need for intubation. I would be more inclined to believe we're cheating doctors out of skills, but I digress. This sort of poison-pen attitude spills over into the nursing staff, promoting the notion that this treatment, on which some patients are DEPENDANT when they present is unnecessary and not worth continuing. To complete the vicious circle, when the patient decompensates after treatment is stopped, whatever EMS did must be to blame.
Part of this, I agree, is about personalities. Personalities are largely born from experiences, and many of the nurse's first experiences with EMS were long ago when EMT's did little more than drive and CPR. And, they listen to paramedics talk, unfortunately supporting the idea that they aren't terribly bright. I'm not sure I would listen to a doctor who told me a patient was FUBAR, so I don't think I can blame them for feeling the same way. Perhaps the most damning piece of evidence is the frequent incidence of EMS patient mismanagement, or at least perceived mismanagement.
A bigger component, perhaps the biggest, is a system wide educational failure. Everybody: physicians, nurses, respiratory therapists, paramedics and EMTs just stop learning. Professionals who are taxed so heavily at work rarely feel inclined to study or read after hours. This leaves them believing that whatever they learned in school is still current, no matter how long ago that was. Enter a handful of current, cracker-jack providers who read and study and review new information almost daily, brining that knowledge to the bedside. Imagine the audacity—challenging 20 year-old ideas and outdated theory with newly PROVEN interventions. How Dare They! What better way to deal with unfamiliar knowledge but to ignore it?? Paging the emperor: Your new clothes are ready!
A paramedic friend of mine transported a patient the other day with a bifasicular block on 12 lead. He reported this with the proper gravity to the receiving facility and they said "What's that?" Imagine, education that (should be/is)part of initial paramedic training is a complete mystery to an experienced nurse. Is that necessarily the individual's fault? Not completely; maybe you could argue (I'm sure the nurse would) that the facility should teach them better. Most likely though they would say it's not important for them to know because it's not written on the ER Flow sheet. What the fact is; however, is that everyone is responsible for their own education and, by extension, the lack thereof.
The larger medical community believes we, EMS, don't have the capacity to manage these complex treatments. Medics should know that we can't afford to be without it.
Next: PRIDE
That Dog Don't Hunt.
Original Post Date: 4/20/08
Like any service, one that I know has bumps in the road; obstacles. Like many, a chief problem with this one is the local hospital. If it isn't C Spine it's IV's, if it's not IV's it IO…always something and nearly always something manageable.
Well, when this week's "something" came up I asked one of the bosses at this service about it, and he agreed that his field personnel were right and that they should approach hospital administration about a policy change on their end. Then, he said something that brought all my delusions of adequacy crashing down.
"With the personalities over there, I don' think anything will change." Wow.
So, and stop me if I got this wrong, if a policy is suggested, adopted by management and put into practice, it can all be negated by "personalities" in the Emergency Department?
Just so we're clear, this isn't an IV KVO. What we're talking about is a treatment that is started in the field and must be actively continued in the hospital to remain effective. Yet, for whatever reason, the hospital staff takes the call from EMS but will not arrange for the treatment to be waiting upon the patient's arrival. Then, they act surprised when either EMS stays in the ER to maintain care or the patient gets worse when the treatment is abruptly stopped. How is this anything but a continuity of care issue? Since when must patients foot the bill in suffering for the wages of pride?
Next time: They don't stop bagging, do they?
Original Post Date: 4/20/08
Like any service, one that I know has bumps in the road; obstacles. Like many, a chief problem with this one is the local hospital. If it isn't C Spine it's IV's, if it's not IV's it IO…always something and nearly always something manageable.
Well, when this week's "something" came up I asked one of the bosses at this service about it, and he agreed that his field personnel were right and that they should approach hospital administration about a policy change on their end. Then, he said something that brought all my delusions of adequacy crashing down.
"With the personalities over there, I don' think anything will change." Wow.
So, and stop me if I got this wrong, if a policy is suggested, adopted by management and put into practice, it can all be negated by "personalities" in the Emergency Department?
Just so we're clear, this isn't an IV KVO. What we're talking about is a treatment that is started in the field and must be actively continued in the hospital to remain effective. Yet, for whatever reason, the hospital staff takes the call from EMS but will not arrange for the treatment to be waiting upon the patient's arrival. Then, they act surprised when either EMS stays in the ER to maintain care or the patient gets worse when the treatment is abruptly stopped. How is this anything but a continuity of care issue? Since when must patients foot the bill in suffering for the wages of pride?
Next time: They don't stop bagging, do they?
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