Pride-Ego-Humble-Patient Centered Care

[akflightmedic]

It has been a while since I started a new thread and I often tend to post on the more abstract, introspective side of medicine when I do. So without breaking tradition, here I go again. I have two points of observation here, so feel free to hit one or both.

First, I have noticed over the years as my educaction increased, as my experience lengthened, so did my conversation, my chattiness if you will. By this, I mean I take time to speak to patients. I engage them in conversations. I ask questions unrelated to their presenting condition, I give concern/regard for things in their life other than the issue in front of me. Don't get me wrong, I am not sitting on scene running the clock, however I do not rush through every little thing required. I know they need X, however I also know X can wait two more minutes if they are in thought or telling a story. I do not overtly control every little thing on scene as much as I used to. I know it will get done, I know how and when to get it done, so I have subconsciously removed the mechanical, robotic response of our scene action. My assessments can vary widely depending on the ebb and flow of whatever is transpiring in front of me, I do not systematically check off X Y Z. I will get to it. If urgent, sooner than later of course.

I bring this up mostly because it has been a verbalized trend among students, and younger/newer "peers" I have worked with. Their feedback is positive and they ask how I came to do this. I really do not have an answer for them, I usually just say years of practice and leave it at that. To my fellow experienced providers, is this common for yourself? Are you able to objectively see a shift in your patient interaction techniques through the years? Is this all just muscle memory like everything else we do repeatedly? I do enjoy keeping scenes calm, conversation flowing...is this an area we can improve upon with new students? Effective communications, psychology, etc?

Anyways, for the disappointing part of this post, see below (And you QA/QI guys will maybe enjoy this and have a takeaway for your own crews).

I happened to be on scene in my small town as a volunteer responder backing up the paid Paramedics from a town over. We had a sweet, 70ish y/o female feeling unwell and weak. I have been to her before, she is usually rapid A-fib. Sure enough, once the Paramedics arrived with their monitors, they confirmed she was tachy around 140-150 and their desire was to give metoprolol per standing order. To do this, they needed IV access. This crew does not know me personally, and their assumption was I am maybe a basic if that. I stood in the truck and watched as the first medic blew a 22g twice in her left arm. Then the second member (an advanced EMT), said I got this. So he boldly took a 20g and went for the right AC. This lady had spider veins, his medic just blew two 22gs...why go for a 20? She needs medication, not fluids...end result, he blew the 20g in her right AC.

I then politely suggested, why not just drop a 24g in her hand? It is enough to get the medicine on board and address the issue without further sticking this lady. The medic looked at me and for brief second his eyes flashed like it was the greatest idea and then his face changed and he said "I cant wheel her into the ER with a 24! No one uses a 24g".

To which I said "access is access and you are doing the right thing for the patient". Anyways, he then told his partner to do a slow Code 3 to the ER and they were departing, he would attempt again en route. I do not know what the outcome of the patient or his care decision was....and I do not care to hear bashing on this particular medic. My point of this is...when did we become so proud that we base our competency on the size of needle utilized as opposed to bragging that we used an appropriate sized needle to deliver the appropriate care to a patient in an appropriate time???

Had the service I responded with been licensed above a BLS level (its a rural FD FYI), I then could have done some medic stuff and absolutely would have completed all this prior to their arrival, however this is not the situation. Anyways, back to the topic...where did we "go wrong" in our training and education where we instill this line of thinking?

 

[mgr22]

On your first point about slowing things down and speaking with patients, I was discussing this with another medic a couple of days ago. We agreed that it's a sign of maturity for EMS providers to adjust priorities and become better communicators. Making small talk with patients was never a natural act for me, so I might have had to work at that harder than most.

Regarding your second point, for sure, the size of the cath was a matter of pride when I became a medic in the '90s. I'm sure I heard the remark "Go big or go home" dozens of times. That is, of course, silly and possibly dangerous. I suppose it's easier for medics to compare capabilities according to IV gauge, but it's sad when a routine manual skill attracts more attention among peers than assessment, communication, and outcomes.

 

[DrParasite]

Honestly, the older I get, the more comfortable I get with EMS, the less I rush, the more I speak to people, and the less stressed I get over the little things (I can't bring a patient into to the ER without xyz, what will they think!!).

The exception being, if I have a "circling the drain" patient, who needs immediate ABC intervention or else they are going to die, my small talk and friendly demeanor take a back seat until the patient is more stable.

Throughout my career, I've had people treat me like I'm a dumb firefighter, just a volunteer, or just an EMT.... to be totally honest, the worst paramedics I've seen are the ones who only do things one way (and heaven forbid any one, especially a non-paramedic, suggest something a better way), ignore everything the first responders tell them (if they even bother to ask for a report on the patient), and think that once they arrive, everyone else if good for lifting muscle and that's it. Some grow out of it, but unfortunately, the culture of some EMS agencies has become one of "if you aren't a paramedic, you are nothing" or "if you aren't with my agency, then you are useless to me," which often results in sub-par first responders. Why strive to be the best if you are going to be treated like you know and do nothing? The best providers (and supervisors) I have seem are the ones that utilize all of their resources, take every suggestion at face value, not based on who suggests it, and to what is in the best interests of the patient, to make the patient happier.

Since I have transitioned into education, one thing I have found is newbie EMTs often see their "patients" as a mystery, one they need to solve, forget that they are people too. Even in EMT class, when we teach them OPQRST, SAMPLE and DCAP-BTLS (and they are struggling to remember what each letter stands for), they end up so focused on the algorithms, and where they are going to go next, that they don't realize that there is a living person in front of them, who is often more scared than they are. I have never taught a medic class, but I would imagine it's the same way, esp for the zero to hero classes.

As for size of the needle, it's all about functionality. Can you do what is needed with a 24g? sure. is an 18 or 20 preferred? absolutely, because you can do more if needed, but if you are having issues with it, access is access, and it allows you to give the medications, and stabilize the patient.

 

[VentMonkey]

To the IV thing: having recently taken the 9th edition PHTLS, an 18 is now the acceptable “large bore” for trauma patients. And it’s preferably done in the forearm as opposed to how many of us were taught, with a 16g angiocath in the A/C.

Sadly, I doubt the bravado will ever cease to exist. It’s almost as if you have to grow out it, though many don’t.

As far as conversing with patients, etc.

Agreed with everyone else. It mostly becomes second nature to those who have been around not only patients, but the “walks of life” in general that afford such conversations.

To me, this is a badge of honor because it’s hardly something that you can be taught. You develop it on your own, or you don’t, and are a robotic provider. Fun.

@akflightmedic it’s interesting you mentioned the BLS part of it. Oftentimes I can tell who is a paramedic regardless of their provider level ATM with our FD’s. Typically it’s based off of jargon and assessment terminology.

 

[Peak]

I think that with good experience clinicians become more comfortable and calm. Most of the time that I see clinicians who become very task oriented and lose sight of the big picture they are pretty new, only had low acuity, or low volume. With experience comes the ability to stay calm in crisis, and be able to both manage tasks and the big picture.

Specific to the IV thing, the IV you get is always better than the one you missed.

That being said a 20 or 18 isn't an adult trauma line if the patient needs volume resuscitation. An 18 gauge is never going to flow like a 14, cordis, or RIC. Even on a rapid infuser it's going to take 5+ minutes to infuse a bag of PRBCs through an 18.

I've put 22s in neos, 20s in infants, 18s in toddlers, and 14s in school age kids. If the patient truly needs life sustaining volume resusitation bigger is better.

 

[Lo2w]

When I did my clinicals to get my Colorado IV cert I was told at the start of my shift that there was no reason to get anything smaller than an 18.

Working in the ED now I can't tell you how many times I've had patients say something along the lines of "are you guys always so judgmental?".

 

[E tank]

Couple of things going on here, I think...with regard to the OP, sounds like the IV was more important that getting the HR down which isn't bravado, but a lack of experience and/or training.

That said, having the ability to give meaningful amounts of fluid quickly when dealing with impaired cardiac output is a thing...just because a patient doesn't need volume per se doesn't mean he doesn't need an effective and timely medication delivery mechanism to his heart, vis a vis a briskly running IV. A 24 ga by definition does not provide a briskly running IV in an adult.

There is no way of knowing what a beta blocker will do in a situation like this and considering the possibility that doing nothing but transporting in the absence of a bomb proof IV may be the better part of valor here. She isn't feeling well, but she isn't necessarily unstable. If she were she might need a shock. She didn't.

These guy's ignorance may have saved an event that may have lead to harm, i.e., it is arguable that they did the wrong thing for the right reasons and it isn't necessary that they understand why...

 

[NomadicMedic]

To touch on the first part of this original post, I find the same thing happens with me. I tend to have long rambling conversations with my not so sick patients, yet I still manage to get a very complete history and a view of their overall condition. Our newer EMTs and paramedics often lack the simple ability of one on one communication, and I preach it through our recruit classes and at our new hire orientation. My favorite expression is, “it’s more about handholding then life-saving.”

 

[Lo2w]

To touch on the first part of this original post, I find the same thing happens with me. I tend to have a long rambling conversations with my not so sick patients, yet I still managed to get a very complete history and a view of their overall condition. Or newer EMTs and paramedics often lack the simple ability of one on one communication, and I preach it through our recruit classes and at our new hire orientation. My favorite expression is, “it’s more about handholding then life-saving.”

Even with just a few years in, I find you tend to get a better idea of what's going on if you let them talk, like the 27 year old rambling on about his chest pain and WPW who eventually tells you he's had 9 energy drinks over the last 8 hours.

 

[mgr22]

Working in the ED now I can't tell you how many times I've had patients say something along the lines of "are you guys always so judgmental?".

I don't think I've ever heard that from a patient. Can you give an example?

 

[Lo2w]

I don't think I've ever heard that from a patient. Can you give an example?

Its usually coming from patients with a history of or admitted substance abuse. Their perception is that they're being treated poorly because of their drug or alcohol use and to be fair they're not wrong.

 

[StCEMT]

For the main part....it honestly depends on my mood. I'm not naturally the most outgoing person, so if it's a day I'm tired and getting beaten jnto the ground, I'm not likely to be super conversational. For people that have a legitimate need though, I always try to talk them through what's going on though no matter what mood I am in. Other days where I am well rested and don't have a back log of stuff to do I might be more conversational.

 

[NomadicMedic]

a couple of things that you can always have a conversation about:

where are you from? (Did you grow up here?)
what do you do? ( what did you do before you retired?)
what do you do for fun?

most people like to talk about themselves to someone who’s new and interested. I can make a 30 minute ambulance ride go by in a flash with a conversation

 

[StCEMT]

most people like to talk about themselves to someone who’s new and interested. I can make a 30 minute ambulance ride go by in a flash with a conversation

That can be the other tricky part. I have calls that last 30 minutes in their entirety, much less a ride to the hospital. Hell, my stabbing the other night was 6 blocks from the hospital. That wasn't a get there 5 minutes ago situation, but still one that warranted some brevity and efficiency.

 

[Tigger]

"It's about them, not about us."

This is what I've been trying to preach for the past month or so during our mostly informal trainings. We are not practicing medicine to make ourselves feel better and lately for whatever reason I've seen a lot of folks providing a lot of ego driven care. Looking for Trosseau's sign of latent tetany is not going to alter your decision making for a syncope patient that you're going to transport to the hospital, though it will hurt the patient. Dropping EJs on patients that already have large bore peripheral access is for your ego, not the patient's care. Talking down to patients with non-emergent complaints and trying to talk them out of an ambulance ride because you believe "ambulances are for emergencies" makes you an *******, not a good paramedic.

Certainly there is something to be said for experience giving you the ability to better interact with your patients as well. I can run most of my calls in my sleep realistically. It is not difficult to rule out badness, gain access, and medicate someone in pain, which is high proportion of my "ALS." When I didn't have that routine down as well, it was harder to multitask. Not so much the case anymore, and I think my patients appreciate that.

Taking the time to get to know your patients matters. Even if you don't really like people, I keep seeing all this research about how affect correlates to fewer lawsuits. Maybe do it for that? I dunno.

As for IV size, someone once told me that the size of the IV catheter isn't printed on the death certificate. Do your best to get the best access you can get. I don't give up easy, but I know my limitations in an ambulance and what I'm realistically using access for.

Incidentally I started a 24 in an adult patient for the first time in six years on an adult patient last night. My string of luck of getting 22s in strange and difficult places finally ran out I guess. Stage 4 cancer patient who fell and needed some fent. 24 worked just fine for that. We had a nice talk on the way to the hospital, so nice in fact that I think I actually shed a tear when she talked about where she wanted her ashes spread. Can't do that if you're obsessing over your ego...

 

[Lo2w]

Talking down to patients with non-emergent complaints and trying to talk them out of an ambulance ride because you believe "ambulances are for emergencies" makes you an *******, not a good paramedic.

I think there's a place for education and diverting to either POV or more appropriate destination after a proper assessment and evaluation. Not so much in a larger district or urban area with resources but definitely the smaller rural districts that have 2-3 trucks on and a 2-3 hour round trip.

 

[Tigger]

I think there's a place for education and diverting to either POV or more appropriate destination after a proper assessment and evaluation. Not so much in a larger district or urban area with resources but definitely the smaller rural districts that have 2-3 trucks on and a 2-3 hour round trip.

Which is not what I said at all. Education is fine. Telling the patient they shouldn't have called an ambulance in a disparaging tone because "there's nothing we'll do for you" is crap. I don't care how many ambulances you have (and I have seven years now of working in very rural EMS), that attitude is unacceptable. I want to help patients make the best healthcare decision possible. If I think a patient will not benefit from ambulance transport and they have an alternate means to further care, I will tell them that, because that is what is best for them. But if the patient wants to go, I'm going to take them. Doubly so if they're elderly and without much in the way of help.

 

[Lo2w]

Which is not what I said at all. Education is fine. Telling the patient they shouldn't have called an ambulance in a disparaging tone because "there's nothing we'll do for you" is crap. I don't care how many ambulances you have (and I have seven years now of working in very rural EMS), that attitude is unacceptable. I want to help patients make the best healthcare decision possible. If I think a patient will not benefit from ambulance transport and they have an alternate means to further care, I will tell them that, because that is what is best for them. But if the patient wants to go, I'm going to take them. Doubly so if they're elderly and without much in the way of help.

I don't disagree at all with that. I'm still amazed at how many providers treat patients.

 

[StCEMT]

I think there's a place for education and diverting to either POV or more appropriate destination after a proper assessment and evaluation. Not so much in a larger district or urban area with resources but definitely the smaller rural districts that have 2-3 trucks on and a 2-3 hour round trip.

This is our problem in the city though. We have such a high turnover rate that leads to chronic short staffing combined with a high volume of regulars and people who call for the most mundane ******** just because they can. We honestly don't have the resources to handle the call volume on a consistent basis. I've had many days where my UHU is near or over 1 and had done little to no "ALS".

 

[Lo2w]

This is our problem in the city though. We have such a high turnover rate that leads to chronic short staffing combined with a high volume of regulars and people who call for the most mundane ******** just because they can. We honestly don't have the resources to handle the call volume on a consistent basis. I've had many days where my UHU is near or over 1 and had done little to no "ALS".

I like what some of the cities are doing with mental health teams, intox vans like Denver, community paramedicine, nurse lines etc. But yeah, I feel your pain coming from high volume system that had the same issues.