Welcome to paramedicine!

Perspiring foreheads, stressful grimaces, and the occasional trembling hand were bedfellows in rooms all across New York State this past Thursday. The 2015 crop of paramedic hopefuls arrived with their knowledge, their test ticket, and a couple of number two pencils in their scabbards to slay the dragon of the State Paramedic Exam.

The people at the agency I work for all passed - as we expected. They are good people. Driven, motivated, and looking to better themselves. I congratulate them and every person in NYS who attained a passing score. It's well deserved.

And now that I have congratulated everyone, I want to share some principles of paramedic care. They are messages that probably didn't appear in your textbook. They may or may not have been broached in your didactic sessions. They may be things you've thought about or even discussed indirectly with colleagues and classmates. They're a part of a philosophy of EMS practice that has worked for me, that I trust, and that I want to share with all providers - especially new paramedics.

You'll please read these things with a knowledge that I:

• am by no means perfect;
• still make mistakes; and
• occasionally exercise poor judgement.

With that disclaimer, I present the First Principle of Paramedicine: 

You barely know anything about medicine.

Stay with me here before you start to throw the eggs and generate "boos" and hisses. You've been through a one-year program. It was tiresome. It was grueling. For many of you it was academically challenging. But keep in mind what it was: one year of school and alot of time in the back of the truck with someone else who initially went through one year of school (or an old guy like me for whom it was even less time.) You know ACLS and PALS. You might know some regional protocol. You know that epi (maybe) helps in cardiac arrest, you know that albuterol makes the wheezes go bye-bye, and that ST elevations on an ECG are very bad 90% of the time. Beyond that, however, you are already forgetting the little bit of A&P that you covered over the last year.

I have had the pleasure of being in the field for over twenty years. Being an educator and a training manager has showed me how much I still have to learn. Every time I create a training session or do research for a class, I realize how little I really understand about many aspects of medicine - and how much I have forgotten! If you tuck that golden card in your back pocket, puff out your chest, and only do the minimally required CME for recertification, you will one day exemplify one of the greatest quotes I have ever read: 

"A lot of people in business say they have twenty years experience, when in fact all they really have is one year’s experience, repeated twenty times." - Author Unknown.

What does that mean? Quite simply stated, you will be the medical practitioner you are in twenty or even ten years not because of what you have just accomplished but because of what you continue to accomplish over the coming months and years. How will you improve yourself? What will you do to even the intellectual playing field when you are interfacing with Emergency Physicians and nurses who have more years just in their education than you have in your entire career? If you haven't thought about this, or if you intend to not think about this, then twenty years hence you will indeed be an EMS provider with one year of experience repeated twenty times. You'll have grown very little. By spurning training and education, and resting on your current knowledge, you'll stagnate. Your reasons for administering a medication or performing a procedure will be things like "that's how it's always been done" or "because it's protocol." But, be advised - the reason you give albuterol to a patient with wheezes is NOT because it's protocol. It's not because we've always done it, and it's only partially because it is a bronchodilator. It's because (and you WILL forget this) albuterol is a selective beta-2 agonist which acts on adrenergic receptors causing smooth muscle relaxation and therefore bronchodilation. 

Don't be content with the knowledge you have now regardless of how hard you worked to get it. (And I know you've worked hard.) Seek more. Learn more. Read. Research. Widen your knowledge base and then apply that knowledge to your practice. The first time you have a leveled, collegial discussion with an ED physician and your confident use of terminology and wide breadth of understanding compels her to speak to you as a medical professional, you will reap the benefits of bettering yourself; your patients will reap the benefits, too.

The Second Principle of Paramedicine: 

Medicine is science, and science is evidence-Based.

"Why should I care about science?" you ask. I'll tell you why: Because the rest of the medical community is practicing medicine which is based on science! 

We have all lamented our place in the medical food chain. If you haven't, then you simply haven't been in the field long enough. We all want to be treated better by peers and nurses and doctors. "We want to be treated like professionals" is a common mantra among EMS providers. Yet we shoot ourselves in the proverbial foot when we do things in the field and justify them by saying things like "I heard that this works" or "this one time I tried it and I had a good outcome." What we are lacking in saying these things is evidence. 

I once heard a story about a paramedic who had a patient in cardiac arrest. They transported the man pulseless to the ER, and as they were bringing the patient out of the ambulance, the paramedic took a nasty fall. He landed on the patient and basically drove his elbow into the patient's chest in a desperate attempt to break his rapid descent. The patient spontaneously converted into a normal sinus rhythm and experienced ROSC. Wow! Cool story!

Let's take a step back now. Was the ROSC connected to the flying elbow drop? Even if it was, I still wouldn't recommend doing it to your patients. This is an example of an "anecdote." It happened once in a non-controlled environment. Maybe the elbow simulated a perfect precordial thump. Or maybe it was the medic's scream that converted the patient. Or maybe the patient had already converted and nobody noticed until after the smashing of his ribs. Whatever the case, this is NOT a treatment modality that has been studied through experimentation and reproduced again and again. It's an outlier. Perhaps a coincidence.

Anecdotal evidence is fun and interesting, but it's not a very good reason to change anything about what you do to a patient. Science strives for strict scrutiny. Experiments occur with all variables monitored so that the most accurate results can be recorded. They are performed and then analyzed. They're then re-performed by independent scientists who are actually trying to prove the first scientists wrong! When a test yields the same results again and again, we have evidence - in medicine the evidence turns into a paradigm shift which in turn creates a standard of care which then trickles into EMS protocols.

A very cool thing is beginning to happen in EMS. We are beginning to see more studies in the field and subsequent changes to our protocols. Those changes are based on evidence. "Evidence-based medicine" is entering our arena, and we need to be darn sure that we understand it. Read the literature. When you hear that something "works", be skeptical. Research it. Go find reputable sources to verify it. Much like "we've always done it that way" is a terrible reason to do anything, "I heard it from So-And-So" by itself is a terrible reason to believe anything. If you hear something that sounds avant-garde, go right to the source. Take the fastest route to the truth: evidence.

The Third Principle of Paramedicine:

Compassion is as important as competent medical care.

As much as this sounds like a no-brainer, I see a good deal of "medical care" being done with very little "caring". We forget that we got involved in EMS because we had a desire to help others. Somewhere along the way our expectations change from "I am going to come in to work this shift and help people." to "I am going to come to work and do X,Y, and Z - which I personally find enjoyable." Invariably, X, Y, and Z don't happen. The calls we want are not the calls we get - which leads to unfulfilled expectations, and that leads to... complaining. It also leads to poor service - because you can't give great customer service when you spend your whole shift disgruntled. Let's dissect the term Emergency Medical Services and consider what the parts say about our job.

Emergency - sure, we occasionally respond to a true emergency - somebody who needs medical intervention right now or they're going to die. Yet most of our calls are not "emergencies." Most patients are not going to expire within the next few minutes or even the next few days. Yet many providers come to work expecting to handle mostly emergencies, and with this expectation they set themselves up for disappointment.  

Medical - perhaps we use medicine a bit more than we experience "emergency responses." Medicine is anything from taking vital signs to administering IV medications. Our assessment and investigation allows us to treat patients properly. We could say that we use "medicine" on virtually every call, but we're talking about new paramedics, so lets focus on ALS skills for a moment. I'll speculate that calls which require some advanced life support comprise about 25-30% of our total call volume, depending on where we operate. So, again, the expectations of intubations, hanging drip meds and cardioverting multiple times each shift are off-base with real life, and that causes frustration as well. 

Service - In this term, we have a winner! No matter what call we take, we are providing service to someone. Whether it be a lift assist, a cardiac arrest, or even an interfacility transfer, we are helping someone. To truly help a person requires compassion. It requires the smile you give to a frightened elderly patient, or the joke you tell the middle aged man with chest pain to try to ease his mind. It requires a willingness to show up and do what needs to be done in an attempt to make someone's life better. It requires us to not be judgmental. It requires us to (shudder) BE NICE. 100% of our calls are service calls. Compassionate care does not mean that we should take abuse from people. What it does mean is that we should try to find a way to leave the patient better off than when we found them. The venerable poet Maya Angelou once wrote:

"I've learned that people will forget what you said, people will forget what you did, but people will never forget how you made them feel."

To some degree, this is merely whatever version of the "Golden Rule" you aspire to. "Do unto others." My formula for this is to take a deep breath when I am frustrated about a particular call or patient. I then do my very best to try to view the world through the eyes of that patient. How would I feel if I was laying on the floor? If I was suffering pain that I did not understand? Would I be worried about my house? My family? My pets? My medications? If we can reach that degree of empathy and truly understand how another human might be feeling, we have made incredible strides toward becoming compassionate caregivers.

So as you step up into the world of EMS with your new paramedic skills and knowledge, remember that you're representing more than yourself or even the agency you work for. You are representing EMS as an industry - an industry that is still evolving and which is beginning to demand the respect of the rest of the healthcare field. If you always continue to learn, always act on solid evidence, and establish yourself as compassionate medical clinician, you'll help EMS take a huge step toward that goal of respect.

Best of luck to all of the new paramedics! May your careers be long and enjoyable!