New-Medic Blues

Your stomach turns and your hands are moist as you drive into work. You go over the protocols in your head, and worry because you can’t remember if you need orders to give steroids to a patient in anaphylactic shock. A few months ago, you finished paramedic school and last week completed your ambulance service’s field training program. Now you have an EMT-Basic partner and are on a new platoon where you don’t know many people. It’s your first day as a released paramedic.

At the station, you greet your new partner, and the offcoming shift wishes you luck. As you check out the ambulance, your hands are shaky, and you wish you hadn’t had your morning cup of coffee. Now you wonder what the first call will be, and you’ve pulled out your protocols to find the answer to your steroid question. You aced your medic class and quickly completed your field training, but now you can only think of how much you don’t know instead of how much you do.

A little more than an hour into your shift you get your first call for difficulty breathing at a nursing home. On the way, you think about all the potential causes of respiratory distress—CHF, COPD, pneumonia, pulmonary embolism—and what you’ll do for the patient. Your hands are really shaking now, and you wonder how you’ll be able to start an IV.

You arrive to find an 80-year-old female in bed, who appears to be in moderate distress. The staff tells you they noticed she was having difficulty breathing a few hours ago during her scheduled vital signs check, and she hadn’t gotten any better since. The patient has dementia and isn’t able to answer your questions, so you obtain what history you can from the staff while your partner obtains vital signs. The patient has a history of MI, CHF, hypertension, pneumonia, GERD, urosepsis and depression, and takes the appropriate medications. She has a heart rate of 110 and sinus tachycardia, a blood pressure of 140/100, SpO2 88% on 2 LPM from the nasal cannula applied by the staff, and a respiratory rate of 32, with rhonchi and crackles in the lower and middle lobes. You move the patient over to the stretcher and decide to start an albuterol treatment. Your first thoughts while moving the patient to the ambulance are whether her distress is caused by CHF or pneumonia, and whether she would benefit from nitrates and furosemide. Your next thoughts turn to how the veteran medics you’ve worked with in the past would know exactly what to do, since they have treated patients with similar presentations a hundred times before.

You start an IV en route to the hospital and notice that your hands have stopped shaking. The rest of the call is uneventful. The patient’s vital signs don’t change significantly; she seems to be moving more air when you listen to her lungs again, and her SpO2 increased to 96% with the albuterol treatment and increased oxygen. You move the patient to the bed at the hospital and give your report to the nurse. Now you wonder if you made the right choices, if you were aggressive enough, and if the more-seasoned medics would have treated her the same way.

No matter how thorough your paramedic training or field training program, it is scary when you are on your own for the first time. Even if your mentors and trainers feel that you are ready, there is nothing that teaches like experience.

“Even though they said we were ready, I still wasn’t secure in my abilities,” says Justin Jackson, who was released as a paramedic with New Castle County (DE) EMS within the past year. “I knew I could do it, but there were a lot of things that I had not done enough on my own to feel confident.”

Evan Tsurumi, who recently began working as a paramedic in the Bronx area of New York City, had similar feelings. “As EMT-Bs, we always looked up to the medics. Now, BLS, firefighters and police officers all look at us as the last line of defense, and it was intimidating at first.”

New paramedics face a variety of challenges when, for the first time, they are responsible for assessing patients and making clinical decisions without the comfort of an experienced set of eyes and hands behind them. Even experienced paramedics who move to a new system face the difficulty of getting acclimated to new coworkers, protocols, geography and emergency department staffs. A variety of field training programs are designed to evaluate and prepare new paramedics, some of which have specific competencies and patient contact requirements, while others may have just a few shifts with no skill requirements.

When Are You Ready?

After a paramedic completes his/her training program and becomes certified, most individual agencies have their own training or precepting program that new paramedics must complete. In Delaware, all paramedics, both recent graduates and experienced paramedics who move in from out of state, must complete a rigorous field training program that ensures competency in a number of areas.

“The system is designed so that, at a minimum, the provider demonstrates the ability to team-lead patient contacts on a consistent basis,” says Barry Eberly, a paramedic instructor with Bayhealth Medical Center in Dover, DE.

On each call, candidates are evaluated on 12 competencies, including multi-tasking, psychomotor skills, formulating a treatment plan and intervening appropriately within a specified amount of time. The specificity of the evaluation is designed for consistency among all of the field training officers (FTOs), and a candidate typically spends between three and six months in the field training process.

“Patient care is never compromised, and, if necessary, the FTO steps in and prompts the intern. Afterwards, the call is gone over point by point about what’s expected so that next time they can meet performance standards,” says Eberly.

Once the process is complete, the candidate is interviewed by the medical director before being released.

Beth Bratton-Heck has been an FTO with New Castle County EMS for three years and has evaluated several paramedic candidates under the state’s system.

“When I’m thinking about releasing someone, I ask ‘would I be comfortable working with this person as my partner, and would I be comfortable with him working on a family member?’ Maybe they can handle chest pain well, but can they handle a patient with an altered mental status?” she says.

Bruce Durante, also a paramedic with New Castle County, has been an FTO for seven years. “You’re ready when you have a variety of patient contacts, a good knowledge base and appropriate personal affect. Once you’re on your own, you have to know what’s being done (by the team), prioritize and delegate,” he says. “I make sure the new candidates are patient advocates, and that they always work in the best interest of the patients.”

Before working in New Castle County, Gary Peterson worked and volunteered with various agencies in Maryland, where he spent time as an EMT-B and a cardiac rescue technician before becoming certified as a paramedic. Because of his gradual transition, he found it easier working as a paramedic for the first time. “It really enables you to have an increased level of responsibility,” he says. “As a younger EMT, you have older EMTs to look up to; as a CRT, you have the paramedics to rely on if you need them.”

The Pressure to Succeed

In addition to now being in charge of crawling into an overturned vehicle at 3 a.m. or intubating a patient in a tiny bathroom, new paramedics often place a tremendous amount of pressure on themselves to impress colleagues and supervisors. No one wants to wheel an unintubated patient in cardiac arrest into the hospital while they are trying to build their reputation. While this is nerve-wracking at the time, many instructors view this pressure as good in the long run.

“Heightening self-expectation is a good thing, and patient care is improved,” says Monosky.

Eberly agrees. “Anyone who doesn’t have these feelings wouldn’t be intelligent enough to do the job.”

Delaware addresses this by allowing its intern paramedics up to six months to complete their field training, and a large part of the process is teaching rather than evaluation.

Still, with our fragile egos and love for gossip, the transition can be difficult.

“Unfortunately, some people who have been around for a long time enjoy giving new people a hard time,” says Bratton-Heck. “Let a lot of the sarcasm roll off your back. Do your job, don’t worry about what they say, and just manage patients.”

Durante believes that support from peers is largely dependent on the new paramedic’s attitude. “A new person comes in with a cocky attitude, like they’ve done it all and seen it all, and they’ll turn against you and let you know your attitude is inappropriate.”

Different Systems, Different Arrangements

Each system has a different way of dealing with new providers. Some paramedics may find themselves regularly partnered with seasoned paramedics, others with different partners every day; some may be partnered with BLS providers, and still others may be by themselves in chase vehicles. Each agency’s system depends on its philosophy, resources and tradition, and each has advantages and disadvantages for new ALS providers.

“The simple fact is that most patients can easily be handled by one paramedic,” says Eberly. “It’s the critical patients—the ones where we can make the most difference—where there is a benefit to having two paramedics. Two equally competent paramedics can get four times as much treatment done as one paramedic by himself.”

But should new paramedics be regularly partnered with veterans?

“There is a benefit to being partnered with a more experienced provider,” says Bratton-Heck. “Perhaps not so much with patient care issues, but say that the new person was having a conflict with medical control. The more experienced person could step in and help with that.”

Durante feels that, in the beginning at least, it is better to have a regular, experienced partner. “On an individual basis, most would do better with an experienced partner so that you can get over the initial anxiety and have a safety net.”

Peterson transitioned from a system where he was partnered with another paramedic to one where he was by himself in a chase vehicle. “Having a medic partner gave me a chance to get a good base experience,” he says. “By myself, it was more difficult to manage priority patients, because you can only do one thing at a time and I had to decide what order in which to do it. I couldn’t bounce ideas off of my partner.” Still, Peterson didn’t always mind being by himself. “It’s liberating to know that you are the only one responsible for patient care, as well as things like vehicle and equipment inspections.”

Are regular partners better than a variety?

“While it may be more efficient for two partners to work together regularly, because they are both used to each other’s habits, the person who floats (has a variety of partners) usually comes out stronger because they see a variety of approaches,” says Eberly. “Still, there is a lot to be said for going to the same station with the same partner every day.”

Some Advice

I have been a paramedic for two years and recently moved to a new area when I changed jobs. Lately, I’ve experienced the challenges discussed above, and have a few points of advice for people who may be in a similar situation.

1. It gets easier

While you may be competent in the beginning, you will get even better with experience as you build a mental library of the different patient presentations that you encounter. Besides, wouldn’t it be boring if you’re as good as you’re going to get on your first day?

2. Choose a few role models

Watch how other people work, and learn from their strengths. Perhaps one of your partners has especially good communication skills or can fix malfunctioning oxygen tanks quickly under pressure, or perhaps he worked as a tech in a cardiac cath lab during paramedic school. Choose a few experienced providers whose opinions you respect and trust. They should have positive attitudes, be excited about the job and continue to educate themselves (these often won’t be the people who have a different war story about heroically saving someone’s life every day). There’s an old adage that says you can show an EKG to five cardiologists and get five different interpretations. If you asked different medics about the same scenario, such as managing a critical patient at home versus loading up quickly and treating them en route to the hospital, you would probably get a number of different opinions. Understanding these differences of opinion will make you a more well-rounded clinician. Also, don’t limit your role models to EMS providers. Nurses, physicians and ED technicians can be good resources; hopefully your medical director also fits this criteria. One of the challenging, frustrating and fun aspects of medicine is that there is often no clear-cut, right-or-wrong approach to patient care.

3. Follow up on your patients

Was your patient’s chest pain caused by ACS or a pulmonary embolism? What was causing her abdominal pain? Following up on your patients will greatly broaden your knowledge base. If possible, check on a patient after she is admitted to a floor or ICU. Find out how she was managed at the hospital, and see what worked and what didn’t. Creating a rapport with the hospital staff will make this easier.

4. Work on skills that you have difficulty with, and read more about what you don’t understand

If you’re have difficulty intubating, practice on a manikin. Try different laryngoscope blades and different hand positions to see which one works best. See if you can get practice in the OR. If you’re having an IV slump, hang out in the ED; most nurses will be more than happy to let you start IVs for them (provided that your agency’s or hospital’s policy allows it). If you get good at the easy tubes and IVs, the more difficult ones will follow. Read up on things you don’t understand. Don’t stop reading your paramedic textbook after you finish the class. If you never fully understood the complications of renal failure, find a book about it. Medical school bookstores and hospital libraries are good sources for this, as well as EMS journals.

Conclusion

So you’re on your own now. You have a patient who’s crashing and you feel like you’re in over your head. What should you do?

“For 90% of unstable patients—the ones who make you sweat—primary care is driven by the initial assessment,” says Eberly. “Go back to C-spine, airway, breathing, circulation and disability, and you’ll be pointed in the right direction.”

“Treat the patient, and don’t get hung up on something that you can’t identify,” says Bratton-Heck.

There’s no denying that the first few months as a paramedic will be frustrating at times, and at some point you’ll probably consider quitting. It’s all part of the ride and is something everyone experiences at some point.

“Completing your paramedic training is just the beginning of your education,” says Durante. As far as the job? “Just relax and enjoy it,” he says.