Ten Rules for EMS Newbies

I know a rock-climbing instructor who likes to say he’s the least talented climber he knows. He only summits any wall through grinding perseverance, and takes three times as long to master skills as most of his students.

And yet he believes this is what makes him a good teacher. You don’t want to learn from the guy who nails everything the first time; you want to hear from the poor sod who had to slog through it the hard way. They understand the mechanics because they’ve seen every side of it, including the errors.

Me? I’ve seen every side of EMS. Starting as the proverbially useless FNG who’d never before held a real job, I spent months frustrating my FTO before he grudgingly cleared me. What I contributed to patient care in my first year you could fit into a thimble. Since then I’ve been fired more than once; I’ve done things so dumb they were later named after me; I’ve been written up, dropped the ball, annoyed my partners and failed my patients. Like many young EMTs, my powers of judgment started out mostly absent and had to be learned the hard way.

Over the years I don’t know if I’ve developed common sense, but I’ve discovered how to fake it. Once you’ve discovered smart and sound principles to guide your behavior, it’s not so hard to protect both your patients and yourself. Here are the rules that have kept me in the game:

1. Help your patient any way you can—What’s this job about? Saving lives? Maybe, but if you’re looking for excitement, most of the time you’re going to be disappointed. But if you’re merely looking for opportunities to help your patient—the human being lying upon your stretcher—you’ll find them every day. So if you see a chance, don’t ask if it’s “your job” to do something—just ask if it would help. Fluff a pillow? I’m on it.

2. Be nice to everybody. It’s your job—I never had as much respect as I felt for the grey-haired EMT my partner was berating for blocking our ambulance. Rather than enjoying a justified retort, he just smiled and made a self-effacing joke. I doubt that’s what he wanted to do, but I’ll bet he understood something important: If you habitually vent your feelings, one day your target will have the power to make you regret it. Treat your behavior like part of the uniform. Part of the job is keeping it professional.

3. If you can’t save their life, make their day a little better—So the call for a child choking turned out to be a baby spitting up. Don’t be disappointed. Instead of airway and breathing, turn to kind words, a gentle joke and a reassuring presence. Maybe a cute glove puppet and a warm blanket. The old adage of medicine is true for us in spades: We may cure seldom, but we can relieve often, and we should comfort always. The EMT who can play tablet tic-tac-toe with a sniffly 12-year-old will have far more chances to use that skill than the medic who can nasally intubate with his eyes closed.

4. Protect your partner—It’s a tough world out there, and among all the slings and arrows you face, you’ll rarely have anybody at your back except your partner. Whether or not you like each other, you’re stuck together, and you’ll weather the best and worst as a team. So short of breaking the law or hurting a patient, try to be there for one another. Doing this job, especially doing it well, often means walking onto shaky ground, and you can’t do it alone.

This one’s tricky, because partners are like family: You don’t get to pick ’em. If you work with certain types of people, eventually someone’s going to go farther out on a limb than you can follow. The lesson isn’t to try to decide between conflicting duties; it’s to prevent trouble from happening by steering your partner in the right direction to begin with. There’s no better way to watch their back than that.

5. Have a reason for everything you do—“Always slide the driver’s seat to the back when you leave the truck,” my preceptor admonished me.

“Why?”

“That’s just what you do.”

It took a year and a half before I figured out the reason: The guy who precepted him (now long retired) was 6-foot-3 and liked the legroom.

Far too much of this job is guided by mindless tradition, habit and fear of change. If you don’t understand why something is done, don’t reflexively throw it out—often the reason is merely obscure. But if you discover there is no reason, don’t do it. Sometimes we must do things for bad reasons, but you should make that decision with open eyes, and it starts with understanding all the angles.

6. Leave the patient better off than when they met you—Often we can’t do much for people, and sometimes it seems like all we bring them is more hassle. Is that what you’d want if you were in their shoes? When in doubt, ask: After following the path you have in mind, is the likely result going to be a happier patient…or the other thing? Act accordingly. That’s patient advocacy.

It’s not always easy to predict whether you’re going to make things better or worse, of course. So use this law to grade yourself after the fact. If you clear a call and realize that due to your decisions—because of fear or habit or momentum, through tunnel vision or blind adherence to protocol—the patient would have been better off if they hadn’t dialed 9-1-1, that’s your cue to reflect upon how to do things differently next time.

7. It should get calmer when you show up—I still remember the first time I saw a veteran medic yell at a bystander on scene. Mostly I remember how much smaller he suddenly appeared, and how much less he seemed to be in control despite his years of experience and formidable clinical acumen. And the truth is, he never got to apply that acumen, because once he started to feed the fire, the inherent chaos of the scene took control, and a simple patient contact turned into a free-for-all that needed the police.

The first reason people call 9-1-1 is to re-establish order in a confusing situation. Even if you know what to do medically, if you escalate the noise and energy when you walk in, you’re going in the wrong direction, and it’s a slippery slope from there. Take a deep breath, speak softly and take things down a notch. If you can look bored while defusing a bomb, you’ll create an eye in every storm, one that allows you and everyone around you to do their job.

Even fairly common complaints are only a few steps from becoming unhinged, and even simple tasks can be just seconds from potential crisis. Despite that, true disasters are never due to isolated bad breaks. They happen when mistakes compound, lining up like the holes in slices of Swiss cheese. The best way to let this happen is to become part of the problem by stepping on the gas instead of the brakes. As the saying goes, “When you make your first mistake, stop—because you’re about to make your second mistake.”

8. Good habits make doing the right thing easy—Your day involves making a lot of decisions, and toeing the line in every case can start to drag on you. The best defense is to turn routine choices into rote behavior. If it’s a habit, you don’t have to decide every time; you’ll simply become a provider and employee who’s effortlessly bulletproof.

9. Tomorrow nothing will remain but your documentation—You may be tired, it may be nonsense, but document every run like you just crashed your ambulance into Johnnie Cochran. Because five days or five years from now, you won’t be tired anymore, but those words will remain, and they’ll almost single-handedly define what happened today. You’re writing history here.

10. Everything’s a bigger deal to the person on the stretcher—We should all take turns being the patient occasionally, because it reminds us of a valuable lesson: This is just another call for you, but it’s one of your patient’s worst days. So when it comes to the “small stuff,” like comfort and privacy, a clear explanation or a simple favor, remember that it’s not small at all. For a vulnerable or suffering patient who can’t help themselves, it may mean everything.

Pretty simple ideas, right? But when questions loom, they’ll point you toward the right path more often than not. Remember that the kind of provider who wears your boots is determined by the principles that shape your behavior, and it’s never too early to establish those.

Brandon Oto, BA, NREMT-B, is a field EMT and PA student from the New England area, as well as editor of EMSBasics.com and LitWhisperers.com. His interests include BLS fundamentals, evidence-based medicine, ECG interpretation, and cardiac arrest care.