An Open Letter To My Paramedic Students

Given our rapidly changing circumstances it is a challenge to offer guidance that will both hold value over time and has yet to be shared.

When we first met, we talked about “the water” and the responsibilities that go along with the tremendous undertaking in front of you as healthcare providers. I would like to build on this metaphor and address navigating the inherent uncertainty of  "the water" using six maxims compiled and taught by an ICU attending from my residency at St. Barnabas Hospital, Dr. Richard Stumacher.

"Stumacher's Rules" were drawn from his clinical experiences and cited often on teaching rounds—often solely by their respective numbers. They were referenced with a humble desire to provide a framework for reflection while offering guidance about how best to move forward. We memorized them, did our best to apply them, and joked about them over lunch. We also tried to convince the man himself to ratify new ones—without success. In my own measured experience, “Stumacher’s Rules” have kept up with the changing landscape of medicine, regardless of the situation, and I find myself applying them often. I hope they will prove useful to you as well.

Rule #1: Ask why

We told you this on Day 1 for several reasons. The first rule is not only about encouraging you all to become lifelong learners. Rule 1 keeps you safe when you encounter the unexpected—it’s a reminder about situational awareness and to trust the “Spidey-Sense” telling you something isn’t right. It also encourages re-evaluation of your plans in the face of new information, especially after an unexpected result or change in clinical course.

Rule #2: Trust no one

Bear with me, because Rule #2 sounds harsh when you first hear it. It was also the most often-cited rule on morning rounds.

“The night-float doctor told me the CAT scan was normal.”

“The dispatcher said it was a PUI negative call."

“I know she is coughing and febrile, but her doctor said she has a UTI.”

Mark Twain wrote, “What gets us into trouble is not what we don’t know. It’s what we know for sure that just ain’t so.” I am not suggesting the hypothetical examples above occur with malicious intent. They are reminders that we all need to be cautious before incorporating new data into our decision-making. The source may be presenting the best information they had at one point in time—this doesn’t (necessarily) make it true NOW.

Corollary to Rule #2: Trust, but verify (preferred)

The off-going crew says, “I checked the drug bag, the PPE supply, the intubation equipment.” Say “thank you” and then check it yourself. As a practical matter, try not to be all “up-in-their face” about it.

Rule #3: “The Golden Rule”

We see people, too often, in their worst, most panicked moments. To put it in perspective, we are witness to a Polaroid (for the millennials that’s a selfie taken without permission) of one unpredictable moment, on one day in their life, and they didn’t prepare for it—kind of like seeing your grandmother without makeup. Chances are they are not having the day they anticipated when they woke up this morning. But that's why we’re there, right? Brené Brown suggests that if you are going to make an assumption in this situation, it should be this: "This person is doing the best they can.” I am willing to accept the risks associated with this assumption, but not at the expense of safety.

Hence, Rule # 3 and the reminder to "take the high road”—especially when the initial response does not immediately match your intentions. Don't allow someone else's maladaptive behavior (intended or not) enough power to negatively affect how you respond or treat others. This is easy to say from afar and more challenging to execute in the moment. Be firm. Be fair. Maintain safe boundaries. Just don’t be “judgey."

Rule #4: Don’t order a test unless you know what you are going to do with the result

Great point about the testing, decision making and the value of information. Testing, especially point-of-care testing, is an invaluable tool when it can rapidly sort patients, identify a critical emergency or significantly modify a treatment plan. Right now, I am trying to contain my frustration over the lack of utility of asymptomatic NBA players being tested for COVID and posting positive results on Instagram. Someone might have neglected Rule #4. Our healthcare system can be inequitable and we are seeing this play out on social media. I see one fewer test for a sick patient and less PPE for healthcare providers who are going to need it. However, we don’t have to follow suit—see Rule #3. Just saying.

Rule #5: Less is more

One way to apply this rule is in how you communicate, especially when a patient is struggling with uncertainty. Talk less, listen actively, and then integrate the patient’s words in your response calmly so they know they were heard as you answer their question. Prompting with, "Please tell me what you are the most concerned about" can be useful. The facts and data supporting your response won’t change, but you will communicate more effectively and convey the patience and empathy they need.

Rule #6: “The obstacle becomes the way”—Marcus Aurelius

We are being asked to adapt and modify plans almost continuously in the face of new information. Consider this: the Roman emperor who authored this statement over 2,000 years ago faced plagues (and I mean the ACTUAL Plague), threats from invading armies, and the risk of being overthrown by political rivals on top of his own health issues. He applied this concept to all of it and thrived. When facing ANY event, irrespective of scale, the principles governing how you respond shouldn’t change. Marcus Aurelius didn't try to force a desired outcome or waste invaluable time balking at changing circumstances outside of his control. In the face of uncertainty, he recognized the only thing he could control was the decision to be ready.

Granted, no single rule is earth-shattering. Taken as a whole, I can firmly attest to the value and completeness of “Stumacher’s Rules.” In the face of uncertainty, they offer a framework for constructive thinking and a way to move forward. I hope you will consider them carefully.

Stay safe out there.

Look out for one another.

Michael W. Schmitz, DO, MS, FACEP, is medical director for the paramedic program at Southern Maine Community College in South Portland, Me.