Practicing Medicine

      My boss, Kevin, is not an excitable man. I know this because I've occasionally tormented him for the sole purpose of escalating our North-South rivalry. Other than suggesting I take notice of the unemployment rate, he's been imperturbable. That's why I was intrigued by his animated demeanor one day last month.

   "Did you hear about the arrest?" he asked. I told him I hadn't. "Well, I got a tube. First one since I've been here (almost two years)." I didn't ask about the outcome; I knew Kevin would have led with that if there had been a happy ending. We briefly debated whether Mr. Miller or Mr. Macintosh had designed the better tool for airway incursion, before concluding that the intubation of Kevin's lifeless, morbidly obese patient was, at the very least, "good practice."

   When I use that term to characterize my intervention in someone's misfortune, I worry about sounding like a carnival sideshow barker, treating tragedy as opportunity instead of adversity. I usually compensate by declaring that I don't actually hope for illness or injury. What I really mean, though, is that I rely on the inevitability of trauma and disease to hone my craft; that my therapeutic skills will erode without repetition and reinforcement from favorable outcomes. In short, I need the practice.

   A benign, productive route to performance enhancement, practice is goal-directed repetition of behavior. Although we tend to think of practice as a physical process, it has a mental component as well. Practice leads to proficiency when we train the body to respond with minimal interference from the mind's limbic and sympathetic nervous systems. In mission-critical environments like EMS, it's particularly important that neither emotions nor fight-or-flight instincts impede performance.

   Like many of you, I discovered the importance of practice long before I was affiliated with EMS. When I was playing hockey competitively, I needed at least three on-ice sessions a week to subordinate fear of failure (and, as a goaltender, fear of a broken face) to intuition. The stakes aren't as high on a rink as they are in an ambulance, but the need to focus without overthinking is similar.

   We don't often deal with end-of-life events where I work—not a bad thing, considering we're an entertainment complex. Although Kevin and I have a few decades of street experience between us, we rarely ride with that crowd anymore. Consequently, we're challenged daily to prepare for the most difficult scenarios we can imagine, while lacking that extra measure of confidence afforded by daily exposure to complex cases.

   Even when I served in busy systems, I didn't feel I was getting enough practice in all of the skills I was presumed to have mastered. Cricothyrotomies? The next hole I make in someone's throat will be my first. Intraosseous infusions? Fading memories of forcing stylets into drumsticks limit my inclination to try that on any limbs that don't come with feathers. I knew enough about those procedures to pass my initial exams, but practice in those days was dedicated to memorizing scripts associated with contrived scenarios. It's easier to succeed in test environments where each input is well-defined and leads to a discrete outcome:

   Student: "I administer 1 milligram of Drug A. What do I see?"

   Examiner: "Your patient becomes unconscious."

   Practice is more important in the field, where our choices and their consequences are almost unlimited. Only by treating real patients do we learn how enigmatic the human body is and how dangerous complacency can be. Without recent hands-on experience, we might as well carry cards with disclaimers like, "Warning: Certification does not guarantee the competence of this individual outside the classroom."

   How, then, can we stay current?

   Some EMS systems have partnered with local hospitals to offer field providers clinical rotations similar to what is mandated for students. Patient assessment, IV insertion, medication administration and airway management are examples of procedures that can be monitored by in-house nurses or paramedics. Know your place on the food chain, though. If the attending physician's accountant is invited to try a tube before you are, focus on skills where demand exceeds supply. Let your preceptor know what you hope to accomplish. It helps if you also offer to assist with less-glamorous tasks, such as blanket retrieval and bedpan management.

   If you work in a system with a volunteer component, donating 5–10 hours a week can supplement your exposure to problematic cases. Already a volunteer? Consider adding to your commitment. The bottom line isn't how much time you contribute; it's how much you can contribute during that time.

   Mental simulation is a technique that might help when opportunities for hands-on practice are scarce. Try visualizing a challenging scenario—a cardiac arrest, for example—and then picture the steps you would take to treat your patient. If you have privacy or indulgent companions, you can even go through the motions—literally—of deploying and using your equipment.

   Should EMS mandate practice? Some systems do. I needed at least three intubations every six months to keep one job. However, I believe practice, like "duty to act," should be driven more by conscientiousness than regulations. We don't care about people only when we're uniformed, and we shouldn't practice only to update our cards. By monitoring and supplementing our clinical experience, we renounce mediocrity as an acceptable standard.

   Call it "duty to practice."

   Mike Rubin, BS, NREMT-P, is an EMS educator and consultant based in Nashville, TN, and a member of EMS Magazine's editorial advisory board. Contact him at mgr22@prodigy.net.