It's a balmy late summer night, and you respond to lovely, pastoral Decubitus Manor Convalescent Home for a patient injured in a fall. Upon your arrival, you find a charming and alert elderly male complaining of neck pain. He fell 24 hours before, went to the local ED that night and had staples put in his scalp. Skull and C-spine x-rays revealed no obvious fractures, and patient was discharged back to the nursing home.

He complained of neck pain throughout the day today, and finally the doctor ordered him sent back to the ED for a CT scan of the cervical spine. The gentleman had been back at the nursing home today until 9:00 pm, when the radiologist finally interpreted the CT scan. The unofficial, verbal interpretation relayed to the rad tech was "odontoid fracture, and comminuted fracture of C-1."

Our charming little old man is neurologically intact, and has been doddering around the nursing home for 24 hours with no ill effects. The nursing home doc wants him to go somewhere with an on-staff neurosurgeon, which the local ED says is a facility 70 miles away. They call an ambulance to make the transport.

Enter your intrepid hero, Ambulance Driver.

Now here's the conundrum. This is a neurologically intact patient, 24 hours post-injury, with a history significant for osteoporosis, severe arthritis, and anxiety. He is alert and able to follow commands appropriately, and participate in his exam. He has no parasthesias or weakness in his extremities, but does have point tenderness to his posterior cervical spine. He does not have kyphosis to any appreciable degree.

My protocols are pretty clear on this issue: Gramps gets the full spinal package. Not only is he over 65 with an "injury above the clavicles" (two of our sillier criteria, based on the Canadian C-spine rules), but he has the cervical spine tenderness, not to mention the friggin' CT scan that reveals a potentially unstable high C-spine fracture.

Now, an 80+ minute trip strapped to a spine board isn't the cruelest thing I can think of doing to this man, but the other two possibilities involve nipple clamps and a live ferret. He weighs less than his age, and his chart already includes orders for a Fentanyl patch PRN and gel seat pads for his wheelchair. I don't like the idea of boarding him if I can help it.

But we're not talking about what I would do. What would you do?

Do you shrug your shoulders and say, "Protocols are protocols," and tell him to suck it up for the 80+ minute trip to the hospital with neurosurgery, or do you explore other options? If so, what are those options? You tell me what you'd do in my place, and I'll post what I actually did in a few days.

You make the call.

You old hands have probably used this trick a few times, but I'll bet most of the newbies have never heard of it. I know my partners usually look at me like I've grown a second head whenever I have them help me do it…

"We want EMS to pay attention to the assessment of the actual patient, rather than the assessment of the possible cost of repair of the vehicle."

Word to your mutha, RM. In fact, I'm stealing that line. Next time one of my co-workers makes a silly decision based solely on what the vehicle looked like, I'm going to ask him, "Are you an EMT, or an auto insurance adjuster?"

I've opined before on the irrational degree of faith EMS places in mechanism of injury criteria. For some, it's a belief system bordering on culthood. MOI criteria were developed as a conceptual tool to give us an idea of where and what to assess, and a rough means of predicting what injuries may be present.

It is not the assessment itself.

The proper use of MOI is to guide assessment, not to dictate treatment and transport decisions.

Further in, Rogue Medic points out:

Why do we treat STEMIs (ST segment Elevation Myocardial Infarctions) with the opposite approach?

The dichotomy is that with trauma triage, we accept a 1,000% to 2,000% overtriage rate, while with STEMI triage, we consider a 5% overtriage rate to be unacceptably high.

The reason is because we're activating trauma centers based on what the car looked like, and we're doing STEMI alerts based on what the patient looked like.

While their pack/day cigarette habit, the number of cheeseburgers they routinely scarf down, and whether their daddy died of a heart attack may be pertinent history, we're activating the cath lab based on presentation.

We should be using the same approach to triage our trauma patients.

**********

Okay, so maybe that wasn’t exactly how it happened, but since that’s the way most EMS war stories begin, why break with tradition?

TOTWTYTR and I left EMS Today 2011 after the exhibit hall closed Saturday, and pointed ourselves north to Philly to meet some blogger friends for dinner. After a superb meal and a couple hours of riotously funny conversation, we continued on our way, stopping overnight in Edison, NJ.

Sunday morning, before continuing our trek to Massachusetts, we stopped at a local diner for breakfast. Since my vow to change my eating habits for the better, breakfast for me has usually been a cereal bar and a piece of fruit. This morning, however, I decided that man cannot live on twigs and berries alone, so I indulged myself with scrambled eggs and bacon, with the substitution of Egg Beaters being my only concession to healthy eating.

TOTWTYTR, being the supportive friend that he is, had the friggin’ French toast, liberally smothered in powdered sugar and maple syrup.

So, as I morosely pushed my imitation eggs around my plate and wished a four-vessel bypass on my friend, we heard a commotion behind us.

“Call 911!” came an urgent voice, echoed shortly thereafter by a more authoritative one, this time with the force of command, “CALL 911.”

“Sounds like they could use some help,” TOTWTYTR observed laconically.

“Sounds like it,” I replied coolly. “Shall we?”

Because you know, it’s important to be laconic and cool when you’re a pair of trauma fighting superheroes.

So, following EMS Axiom #4 (paramedics do not run), we moseyed over to the booth in question. Well, I moseyed. TOTWTYTR, being the senior medic in the room, chose to swagger.

As we shouldered our way through the knot of waitresses and onlookers, we identified ourselves as off-duty paramedics. “Thank God,” one of them breathed, and the crowd parted to reveal an elderly woman slumped over in the booth, eyes open and unfocused, breathing agonally.

TOTWTYTR, not one to mince words, suggested, “Let’s get her out of the booth and onto the floor where we can manage her airway.”

As we did just that, I noticed an elderly gentleman sitting in an adjacent booth, watching us fearfully, tears welling in his eyes. Her husband.

A waitress stood behind him, fluttering hands gently placed on his shoulders in a comforting gesture, but her eyes had more tears in them than his.

I slid my fingers up the sleeve of her coat, feeling for a radial pulse. Finding none, I glanced up at TOTWTYTR, who was also searching in vain for a carotid pulse.

“Got anything down there?” he asked hopefully, and I shook my head. “Okay, time to start compressions.”

It occurred to me then that, for the 10+ years we’ve been friends, this was the first time TOTWTYTR and I had ever worked a call together. Despite that, we were already completing each other’s thoughts.

As I started compressions, grimacing at that initial crunch of rib cartilage separating in an elderly person, he said, “No pocket mask… let’s just do compression-only CPR until help gets here.”

I interrupted my mental compression count to reply, “I’ll call for a switch after 200, and we’ll swap positions. Just keep monitoring her airway.”

As I was nearing my 100th compression, I felt an urgent tug at my left elbow. A voice asked, ”What compression are you on?”

By way of reply, I started counting aloud, “Ninety-four, ninety-five, ninety-six…”

“Stop!” the voice blurted, and I turned my head to see an attractive woman in her mid-thirties, kneeling on the opposite seat of the booth. “You’re only supposed to do thirty compressions at a time!” she admonished.

Rather than explain the differences between dual-rescuer CPR for healthcare providers and compression-only CPR for laypersons, I simply smiled reassuringly and replied, “It’s okay, we’re both paramedics and CPR instructors.”

Apparently, that wasn’t adequate explanation.

She drew herself up haughtily, and retorted, “I took CPR just six months ago, and I know you’re supposed to give 30 compressions and 2 ventilations.”

So I retorted, just as haughtily, “Do you know who you’re talking to? DO YOU?? You’re talking to Ambulance Driver and muhfuckin’ Too Old To Work, beeyotch!”

Okay, so maybe I didn’t say exactly that. Instead, forcing myself to remain polite, I kept the confident smile on my face and used my Paramedic Voice. “Thanks for your assistance, Ma’am, but the standards changed only four months ago. You can rest assured that the paramedic CPR instructors know how to do CPR.”

TOTWTYTR suppressed a chuckle, and said, “That’s two minutes. Ready to switch?”

As I slid into position at the woman’s head, both of us noticed that her eyes had begun to focus, and that her breathing had improved enough to notice visible chest rise.

I don’t think I’ll ever get used to seeing that.

They teach you in CPR class that breathing becomes agonal within seconds following the onset of ventricular fibrillation, and truly that describes this woman’s respiratory effort. Her rate, however, was 12, perhaps 14 breaths per minute.

That’s within normal range for an adult.

I’ve seen healthcare providers mistake the onset of VF for a seizure, as the patient arched their back and spasmodically jerked. Only checking a pulse clued the nurses in to the fact that we were dealing with a lethal arrhythmia and not a seizure.

I’ve also done CPR on witnessed arrests where our compressions provided enough brain perfusion to allow the victim to open his eyes, look at you when his name was called, and nod his head in answer to questions. The moment you stopped, however, those eyes lost their focus, and the patient quickly lost consciousness.

Apparently, that was the case with this woman, because as we vainly searched for a pulse, her breathing quickly declined and her eyes rolled back once again.

Muttering under his breath, TOTWTYTR resumed compressions, and I maintained a head-tilt, chin-lift in hopes that a little passive oxygenation might be possible with the changes in intrathoracic pressure brought about by chest compressions.

Shortly after beginning our second cycle of compressions, a set of AED pads appeared in my field of vision, held by a police officer whose hands were shaking so badly that he could barely pull the backing paper off the pads. TOTWTYTR looked at the shaking hands, followed them up to the officer’s face, and made his judgment.

“It’s okay,” he said gently, “we’ve got it.” Taking the pads from the grateful officer, he quickly lifted the woman’s blouse and applied them. As the AED analyzed the rhythm, he rocked back on his haunches to rest.

“Shock advised,” purred the AED in its telephone operator’s voice. “Stand clear. Push the SHOCK button.”

“Everybody clear!” called TOTWTYTR, waving his hand over the patient.

Nothing happened.

I looked up to see the cop standing three feet away, the SHOCK button on the AED flashing an insistent red.

“I think he’s waiting on you to do it,” I said softly, nodding at the cop. TOTWTYTR twisted around to look at the abandoned AED, then up at the cop. Shrugging, he pressed the button, the woman’s back arched in spasm, and we were already shifting positions before her torso relaxed onto the floor once again.

TOTWTYTR resumed compressions, waving off my offer to switch places. “I’m good,” he grunted. “I had just started when we stopped to shock, anyway. See if the cop has a BVM.”

The cop, overhearing him, unzipped a side pocket of his BLS bag, ripped the BVM out of its plastic wrapper, and thrust it at me.

Naturally, the mask was not attached to the bag. Story of my life.

I got up, stepped behind TOTWTYTR and fished the mask out of the BVM wrapper. I settled in at the woman’s head, tilted her head back, and nodded at my partner.

“Go ahead,” he grunted, hands poised just above the woman’s chest. I delivered two breaths, and as soon as the second one was in, he resumed compressions, counting aloud this time.

See what I mean about completing each other’s thoughts? It couldn’t have been a more seamless transition into two-rescuer CPR, with barely a word exchanged between us.

I wish my BVM technique had been as flawless, because I was missing a few breaths now and then. I dropped the BVM briefly to reposition her head, and resumed ventilations the next time the count reached 30.

Only got the first one in, damn it.

“Someone hand my partner an OPA if you’ve got one,” TOTWTYTR ordered, and presently a medium adult Berman-type OPA was handed to me. The arm that held it was clad in turnout gear.

I looked up at the firefighter holding the OPA. “If you’ll hand me your tubing, I’ll hook you up to oxygen,” he offered. Gratefully, I handed him the BVM’s oxygen connector, and he opened the flow meter to 15 liters.

Unfortunately, inserting the OPA proved more difficult, because our patient was trismic. I managed to wedge the OPA briefly between her molars, but since I wasn’t wearing gloves, I was somewhat reluctant to stick my thumb in her mouth to perform and tongue-jaw lift.

Besides, adding a severed thumb to the mix would only complicate her airway issues. So, I carefully repositioned her head and resumed ventilations, sans OPA. With a little more attention to detail, I was able to ventilate her more effectively.

As the AED counted down, “Analyzing in 5, 4, 3, 2, 1… stop compressions… do not touch the patient…” I looked up to see more professional rescuers in the room, including several not wearing turnout gear.

Problem was, they were all on the wrong side of a knot of onlookers, and were having little success in making their way to the patient, doing it the polite way.

As TOTWTYTR pushed the SHOCK button a second time, I maneuvered into place to resume compressions. We had given several sets of compressions and ventilations when I heard that familiar voice at my left elbow, “Here, put these under her neck.”

I looked up to see our helpful bystander, the CPR critic, thrusting a six-inch stack of wet napkins at me. Resisting the urge to tell her to go boil some water, I instead thanked her for her help and laid the soggy napkins on the woman’s chest. “We’ll get right to that on the next compressor switch,” I lied.

The next time the AED started its analysis sequence, a calmer voice said, “Thanks guys, we’ll take it from here.” TOTWTYTR and I looked up to see that the BLS rescue squad had managed to maneuver their way to the patient’s side. One was already kneeling beside the AED, finger poised over the SHOCK button. A third was standing behind TOTWTYTR.

As we stood up and massaged the kinks from our lower backs, the local EMTs delivered a third shock and resumed compressions, with little wasted motion.

As we stepped back and watched the CPR ballet, for once as spectators and not participants, my buddy said laconically, “Our work here is done. Shall we wash our hands before finishing our breakfast?”

Remember how I said it was important to be cool and laconic when you’re a lifesaving superhero? Y’all make a note of that.

“Good idea,” I chuckled, and followed him to the men’s room.

As we made our way back to our table, I noticed our patient still lying there, and no one doing compressions or ventilations. I elbowed TOTWTYR.

“Check it out,” I snorted. “We do uninterrupted chest compressions right up until the professional EMTs get here, and now everyone’s busy doing anything but what they’re supposed to be…”

… and then I noticed the woman breathing, and doing a pretty fair job of it, in fact. One EMT was feeling for a carotid pulse, a triumphant grin on his face, while another was filling the reservoir on a non re-breather mask.

“Okay, well maybe they had good reason to stop compressions,” I admitted sheepishly. “Looks like they got her back.”

“Hope so,” TOTWTYTR agreed. “Witnessed arrest, CPR started immediately… maybe she’s got a fighting chance.”

When we got back to our table, the busboy had already cleared our plates. Damn it, and I was looking forward to those home fries. It seemed the fates were conspiring to keep me honest.

Our waitress, however, appeared immediately, topping off TOTWTYTR’s coffee and refilling my water glass. She was still crying, and her hands were shaking like a leaf.

“Hey,” I said softly, nodding toward the EMTs. “Look over there.”

The ALS ambulance had arrived, and they were busy packaging the patient for transport. From fifteen feet away, we could see the steady rise and fall of the woman’s chest. The waitress stared for a moment, and turned her eyes back to us.

“They got her back,” I told her. “Wouldn’t have happened if someone hadn’t had the good sense to call 911 right away.” TOTWTYTR nodded in agreement.

As we gathered our things and made our way to the cashier, it seems everyone wanted to thank us.

The cops shook our hands gratefully.

So did the firemen.

Ditto for the EMTs.

The medic from Robert Wood Johnson made it a point to duck back into the diner and give us an attaboy before she transported.

The manager of the diner refused our money, saying our breakfast was on the house. Diner patrons tugged at my sleeve, wanting to shake my hand before I left.

To be honest, it felt a little weird. And one thing I noticed; no one bothered to heap such praise and gratitude on the people in uniform who were working on her, too. There’s something wrong with that.

But something also tells me the cops, firefighters, EMTs and paramedics don’t much mind. They know that resuscitation is a team sport, and saves are a team victory.

After all, they’re professionals.

I agree with his assessment. My impressions of EMS 2.0 run along the same lines, misgivings I outlined in my wet blanket posts on the movement. None of the ideas espoused in EMS 2.0 are substantially different than the 16-year-old EMS Agenda For the Future.

I can remember 12 years ago, when I was Chris Kaiser or Justin Schorr, and TOTWTYTR was the guy tempering my idealism with a hard dose of reality and perspective.

What is different this time is the social media revolution.

EMS bloggers like Justin Schorr, Chris Kaiser, and others, filmmakers like Ted Setla, and EMS podcasters like Jamie Davis, Chris Montera, Greg Friese, and Ron Davis have recognized the power of social media, and they’ve harnessed it to empower the rank-and-file EMS provider in the process.

The days when the professional committee members could shape EMS policy without input from street providers are becoming a thing of the past. We have a voice now, and its a powerful one.

Now we just need to figure out what we want to say, but that subject is weighty enough to deserve its own blog post.

Other observations on the EMS Today exhibit hall:

• Therapeutic hypothermia is taking off in a big way. Three or four years ago, when we realized how effective a prehospital treatment CPAP couldbe, we saw an explosion in the number of product offerings to fit the demand. Now, it’s therapeutic hypothermia for post-ROSC patients. I saw at least a dozen more cooling systems than were offered even last year.
• We’re still taking the wrong approach to airway management, but it’s getting better. Yes, there is an ever-widening array of suproglottic airways, but there is also an ever-widening array of toys, gee-gaws, doodads and expensive video laryngoscopes that supposedly make endotracheal intubation easier…
• … ignoring, of course, the fact that the problem isn’t so much lack of tools as it is lack of education and practice, and ever-decreasing proof of benefit. And that’s not likely to change as long as we continue to view ourselves as a patch and a skill set.
• Ambulance design continues to evolve. After EMS Expo, I posted a look at some of those changes. Later this week, I’ll revisit the subject with some of the new stuff I saw at EMS Today 2011.

That’s all the free ice cream I’ve got for right now, folks. Check back soon for a post where I pose the question: “What is EMS – public health, or public safety?”

OLD SAYBROOK – Police Chief Michael Spera would be facing a nearly $30,000 bill for overtime costs in the next few weeks but for officers’ generosity.

Almost every officer is training to become a certified emergency medical technician by taking 90 hours of classes for about two months after their shifts and on days off, without overtime pay.

Those who aren’t participating are already certified.

Think about it; high mobility rather than fixed locations, some degree of personal autonomy within the rank structure, strong communications and interpersonal skills, creative problem solving…

… all these things are part and parcel of EMS, and they seem to describe law enforcement far better than they do fireground operations. Even an interrogation and gathering patient history have a great deal in common.

Combined law enforcement/EMS isn’t a very common system model, but it is done in other places. Gretna, LA has had a dual role law enforcement/EMS system for many years, and I’m sure there are others.

Try as I might, the only negative thing I can say about this idea is that, at only 90 hours, their EMT training is only about half as long as it should be. The 1993 National Standard Curriculum for EMT-B was a minimum of 110 hours, and most schools did more than that. I doubt that implementation of the new National EMS Educational Standards would make the course shorter.

So what say you, readers? Does a law enforcement/EMS model make sense?

Of the various definitions found in the dictionary, the one most applicable to us would be, “an expert or specialist, such as a physician, who gives practical experience and training to a student, especially of medicine or nursing.”

That definition fits as well as any, I suppose, but the role of a preceptor cannot be distilled into a one-sentence definition. Much like the Supreme Court’s opinion on pornography, it’s hard to describe, but we know it when we see it.

When a preceptor passes on that “practical experience and training,” there are volumes of tradition, science, art, wisdom and bullshit encompassed in those four little words. The good preceptor passes on the collective wisdom – and sometimes, inadvertently, the bullshit – of our profession to the next generation, and I mean all of it; what EMS was, what EMS is, and what EMS should be.

I’d say “what EMS will be,” but so much of that depends upon how well that preceptor does his job.

If you want to know what a preceptor really does, you have to go back to the root word:

Precept: [pree-sept] -noun

1. a commandment or direction given as a rule of action or conduct.

2. an injunction as to moral conduct; maxim.

3. a procedural directive or rule, as for the performance of some technical operation.

4. a law.

All four definitions are important. All four have direct bearing on our practice as EMTs. They encompass our traditions, our attitudes, and our expectations of proper behavior. They are our professional ethos. The role of the preceptor is to be a steward of our profession, and in so doing, prepare the next generation of EMT’s to be stewards of the profession as well.

So why is it that many preceptors only pay attention to #3?

I suppose it’s only natural that, in a profession dominated by action-oriented, Type A personalities, that many of us feel uncomfortable teaching, for lack of a better word, the “soft skills.” As a long-time member of Louisiana’s training cadre for new EMS instructor candidates, I saw this firsthand.

The vast majority of new EMS instructors feel most comfortable teaching only in the psychomotor domain.

A few gregarious, creative types find themselves well-suited for teaching in the cognitive domain. A few more of the psychomotor types, after gaining confidence in their knowledge and skill set, add the cognitive domain to their repertoire.

But damned few, if any, have any clue how to teach the material most vital to preceptors: the affective domain.

EMT instructors can teach the knowledge and skills, but the preceptor instills the attitude, and we all know that, of all the traits necessary for success in a given profession, a positive attitude is one of the most important.

This is not a failing unique to EMS instructors and preceptors. Academics in all disciplines struggle with teaching attitudes and behavior, and few succeed at it. Those that do are easy to spot. Chances are, you’ve seen them yourself. If you think back on all the teachers you’ve had in your life, I’ll bet you could pick out one or two that had the most positive influence.

In your moments of greatest stress and indecision, whose advice do you crave? Who do you first think of when you want to share the elation of a professional triumph? When you feel beaten and discouraged, whose voice whispers your mental pep talk? Who plants the metaphorical foot in your ass when you need the motivation?

Right now, you’re probably smiling, thinking of just such a person.

Your mentor.

When it comes right down to it, any idiot can earn an EMT card. But there is a big difference between holding a card, and being an EMT. Regulatory agencies and all-too-many EMS systems don’t recognize the difference, but your patients and fellow providers do. Unfortunately, the patients usually only encounter us once. If the crew they encounter is a pair of card holders instead of real EMT’s, guess who is now the representative sample of your profession in that patient’s eyes?

So what was it that helped your mentor mold you from a mere card-holder into an EMT? What magic did they possess, and how might you learn that magic when your turn comes to be a steward of our profession?

Luckily, by learning a few simple principles -  precepts, if you will – of mentoring, you can develop your own technique in molding a card-holder into an EMT. Like watching Penn Gillette explain one of his tricks, you realize it wasn’t really magic after all. The real magic is in how skillfully those techniques are applied:

Be the EMT you expect them to be.

The first rule of teaching in the affective domain is simply to model the proper behavior. Be an example.

Be exemplary.

It’s harder than it sounds. We all have days when we aren’t at our best, when fatigue and frustration whisper in your ear that it really isn’t that important to come to work with your boots shined and your pants pressed. But when you feel it necessary to counsel your trainee that patients don’t trust a paramedic who looks like a friggin’ hobo, it really boosts your credibility not to look like one yourself.

“Do as I say, not as I do,” only works with toddlers, and it doesn’t work that well on them, either. It’s a parent’s way of saying, “My attitude isn’t as important as your obedience,” and don’t think for a second that the toddler – and your trainee – won’t eventually be perceptive enough to make the translation.

Likewise, your attitude toward others is going to have some effect on your trainee. Either they’ll adopt it – wrong or right – or they’ll spot it for the bad attitude it is, and vow never to treat others the way you do.

Congratulations, you’ve become an example. A bad one. Instead of a mentor, you’ve become a cautionary tale.

Every experienced medic has a hundred nursing home horror stories, and most are willing to regale you with them at the drop of a hat. Within each of those stories is a kernel of truth, that nursing home care does leave a lot to be desired, and that’s what makes them so toxic.

It’s easy to belittle a nursing home nurse, because you’ve heard the clueless reports, and you’ve seen the shoddy care with your own eyes. You’ve smelled the aroma of poop, urine and bleach that permeates the halls.

What’s harder is respecting them for the job they do, and how hard it is. Until you’ve walked a mile in their shoes, you might want to rein in the condescension a bit, and teach your trainee instead how to assess and treat his patient under challenging circumstances, with very little information to go on.

You know, like we do every single day outside the nursing home, without bitching and belittling the people who called 911.

And on those days when you aren’t at your best, man up (or woman, as the case may be) and admit it. No one expects their mentor to be perfect, but they should be worthy of respect. Earning that respect means being willing to admit when you’re wrong.

Which reminds me: Hey, Peter Griffin? Next long distance transport is on me, man. Or one Genevieve transport, whichever.

Teach more, evaluate less.

I notice an interesting phenomenon among some of my preceptor colleagues. Some of the most talented medics I know, people who will tirelessly coach, critique and encourage a paramedic student, shift gears into Evaluation Mode whenever they’re precepting a newly certified paramedic. It’s as if they expect the new medic to prove his mettle, the attitude almost, “Show me what ya got, kid.”

The question is, what have they got? What have they proven, other than the ability to successfully negotiate a standardized test designed to weed the minimally competent from the outright dangerous? What do they know this week that they didn’t know last week?

Formal education can give a student the pieces to the patient care puzzle, but it takes a talented preceptor to show them how to put it together. What the new EMT-Basic has taken from the sum total of their classroom and clinical education is a set of instructions along the lines of, “Draw a square, with a triangle on top. Now, in the big square, draw two smaller squares, and a rectangle. On the rectangle, draw a little circle.”

Luckily, he drives better than he draws.

A preceptor translates those instructions into, “Draw me a house.”

None of the shapes change. The skill set is no different. The artist doesn’t need you to draw it for him. He only needs you, his muse mentor, to show him what the picture is supposed to look like.

What he doesn’t need is for his mentor to systematically deconstruct everything he learned in the classroom. None of this, “Well, that may work in the classroom, but this is the way it works on the street,” bullshit. You’re supposed to provide confidence and clarity, not contradiction and character assassination.

The picture isn’t any clearer when the trainee is a newly minted paramedic. Bryan Bledsoe delivered a lecture once on critical thinking, and in it, there was one slide defining the levels of practitioners that really stood out:

Novice practitioner:

*Rigid adherence to taught rules or plans

*Little situational perception (symptom management only)

*No discretionary judgment

Competent practitioner:

*Able to cope with pressure

*Sees actions partly in terms of long-term goals and broader conceptual framework

(disease management)

*Follows standardized and routine procedures

Expert practitioner:

*No longer relies on rules, guidelines or maxims

*Intuitive grasp of situations

*Uses analytic approaches only in novel situations or when problems occur

One might think that paramedic school is what changes a novice practitioner like an EMT-B into an expert, but is that really the case? Does paramedic school actually teach you to think critically, or does it just produce another novice practitioner with a broader skill set?

Actually, rather than teach critical thinking skills, most formal EMS educational programs do just the opposite.

They systematically – either by accident or by design – suppress any innate critical thinking skills the student may have had. What emerges is a practitioner who has faithfully memorized the ACLS algorithms, can recall drug dosages, indications and contraindications at will, and can recite system protocols verbatim. They learn to pass a multiple choice exam, when real life is more on the order of an essay question. They’ve memorized all the rules.

What they don’t know, is how to apply them, or more importantly, when they shouldn’t. Teaching that sort of nuanced thinking is the role of the preceptor. It’s your job to turn them from novices into experts, or at the least, competent practitioners.

More teaching, less evaluating.

Know your trainee.

Past street experience can be both blessing and curse for both the trainee and the preceptor.

Experience is hard to quantify, and the plain truth is, not all experience is good. Every EMT filters a patient presentation through a prism of his past experiences. If they’ve been good experiences, that prism can refract a muddy clinical presentation into a clear diagnostic picture.

If they’ve been bad experiences, well… even the clearest set of symptoms can be hopelessly distorted when seen through the eyes of a trainee who has learned all the wrong things on the street.

When I trained retrievers for a living, I described it as a mental photo album. When your retriever steps to the line in a field trial or duck blind, he’s flipping through a mental photo album of all the past retrieves he’s catalogued, until he finds a picture that matches the scene in front of him. As a handler, it was my job to make sure my retriever was looking at the right picture. The only way to do that is to know the retriever. You have to know his personality, his mannerisms, be able to read his body language.

As a preceptor, it’s an easier task, because your trainee can talk.

And that’s what they should do; talk, talk, talk, and then talk some more. Have them plan possible scenarios on the way to the call. Let them speak first in the post-call critique. Encourage them to ask questions. Let them gather most of the patient history, and only speak when you feel they’re missing something important.

The more they talk, the easier it is to learn their weaknesses and strengths, learn what motivates them, learn what they fear, learn how they process their thoughts. But while they’re talking, keep one thing in mind:

Communicate clearly.

While they’re doing all that talking, don’t sit there silently like the Sphinx. Use Socratic dialogue to guide the conversation. Ask rhetorical questions that begin with “why?” or “why not?” Parse your words carefully, and allow your trainee to arrive at the conclusion on his own. Play devil’s advocate occasionally.

But never, ever just assume that your trainee understands why you do things a certain way. For you, it may be intuitively obvious, a shorthand you’ve worked out through years of experience. For your trainee, it may be incomprehensible, or even worse, wrongly ascribed to a different motivation entirely.

Case in point: My trainee and I treated an elderly patient in the nursing home who had fallen and injured her hip. By the time we had arrived, the staff had already picked her up and put her back in bed. They were busy turning her this way and that, cleaning her where she had soiled herself, changing her diaper, putting her in a fresh gown…

… and I chose not to immobilize her. Despite her medical issues, including early Alzheimer’s, she was a fairly reliable patient. She didn’t know what day it was, but she could clearly relate the circumstances of her fall, and the pain wasn’t so distracting that she couldn’t participate in her own NEXUS exam. She followed all commands appropriately, and focused clearly on my instructions.

Now, rigid adherence to our protocols would necessitate immobilizing this lady. But I’ve spent three years in this system, and I have enough experience with our medical director and the people who QA our reports to know that they are not prone to judge harshly, provided our documentation paints a clear picture of why certain steps were omitted.

To the trainee, the medical director is GOD, perhaps even an unmerciful one, and our protocols may as well be written on stone tablets.

So rather than allow my trainee to attend the patient and document the run, I took over. I had my reasons for doing this, but they weren’t clear to the trainee.

He said as much during the post-call critique, insulted that I didn’t trust him to run a simple hip fracture. Instead of replying, I simply asked him, “Why do you think I didn’t immobilize that lady?”

“Because it’d be a major pain in the ass,” he answered. “The bed was against the wall, you couldn’t get to her to log-roll her properly or hold C-spine alignment…”

Wrong.

I didn’t immobilize her because I judged that the procedure was 1) unnecessary, based on my examination, and b) likely to substantially increase my patient’s pain and discomfort, and c) perhaps even cause harmful sequelae like decubitus ulcers or respiratory decompensation.

I went on to explain to my trainee the difference between experience and expedience. Experience tells you when to omit certain things because it’s easier on your patient. Expedience means you omitted those steps because it’s easier on you, and that is never acceptable.

I also explained to him that, since I made a judgment call that differed with protocol, I chose to shield my trainee from scrutiny by handling the entire call myself.

When I document such a run, it’s an experienced medic using his clinical judgment. Were he the one to submit the electronic report, he’d be seen as a raw rookie making a mistake. Even now, when my judgment is sometimes questioned, I have the knowledge and experience to defend my decisions. My trainee has less ammunition.

View mistakes as teachable moments.

It is human nature to learn more from our mistakes than our successes. As the saying goes, “good judgment comes from experience, and experience comes from bad judgment.”

It’s the preceptor’s job to transform those mistakes into learning opportunities, while still ensuring good patient care. Some mistakes -the ones that negatively impact patient care or reinforce bad habits – must be corrected immediately, while others can be identified in the post-call critique. Simply by asking, “What would you have done differently?”you’ll discover that your trainee has often realized his mistake without you having to point it out.

For your example, if your trainee has chosen an IV catheter far too large for the vein he’s identified, you might want to intervene, and have him choose a smaller catheter rather than risk a blown IV and sticking the patient again unnecessarily.

On the other hand, if his venipuncture technique is sound, but you notice that he has placed all of his supplies on his non-dominant side, or out of reach…

… it might be a more valuable lesson to let him futilely try to occlude the vein while he scrambles to hook up the line. Nothing like a good blood stain on your pants leg to teach you to lay out everything within easy reach, is there?

And afterward, while your trainee is changing into a clean uniform, you can smile tolerantly and ask, “So what would you have done differently?” You might even make it another teachable moment, and tell him how to use peroxide and elbow grease to get those blood stains out of his pants.

It’s orientation, not indoctrination.

Part of your job as a preceptor is to familiarize your trainee with your agency’s organizational culture. Every agency has its own way of doing things, and there’s nothing wrong with that. As a preceptor, no doubt you have your own personal style, too.

But just because your trainee does things differently, doesn’t mean they’re wrong. Keep an open mind, and your trainee just may show you a better way of doing things. You’re trying to create a competent practitioner, not a clone of yourself.

Culture constantly evolves, and organizational culture is no exception. The day an agency, no matter how great, refuses to accept outside influence, is the day that agency starts the downhill slide toward mediocrity. As a preceptor, your responsibility to the agency is to consider whether your trainee’s method might have merit, and make suggestions to management accordingly.

If such suggestions are unwelcome, then you’re not orienting, you’re indoctrinating. Cults indoctrinate people, and they do not tolerate independent thought.

As a teacher, a mentor, and a steward of your profession, do you want a cult of protocol monkeys, or would you rather have thinking medics?

Your choice.

Enjoy.

Assessing the Patient With Altered Mental Status.

If you’ve ever documented AAOx4 on a patient care report or refusal, and felt safe doing it, here’s why you shouldn’t.