Awesome Paramedic school I applied too

[Asysin2leads]

Unless its a Ph.D. in something cool like particle physics, or anthropology, usually Dr. without the MD or DO to go with it equals touchy-feely-pass-the-talking-stick-crap.

The worst thing about this mythos of teamwork being the most important end all and be all is that it overlooks the fact that the patient's well being is supposed to come FIRST. It comes BEFORE me trying to assist a struggling team member, and it comes before who is having a fun time on the scene.

Or at least its a supposed to. These are the same a--holes who told us not to keep score in the little league game, I tells ya. Patient care is not a matter of opinion. It is not based on the democracy of the group or the urgings of the majority. It is based on rules, evidence, and fact that is written down and handed to us by our medical director. If somebody is not doing what we are supposed to be doing, they are wrong, and should be removed, end of story.

By the way, the hospital analogy doesn't work. The lowest team member in the ER may be (hopefully) nurse or specific technician. They all have lots of standards, training, and education. The lowest person on the prehospital care team may be Jimbo the vollie fireman or the homeless guy who is helping me lift the stretcher in. Big difference.

[Mateo_1387]

Mateo, I said *inevitably*... not *every time* which indicates a probability at some future point... maybe it was kind of unclear. Regardless, the attitude that you *always* know what is best is a great way to paint yourself into a corner. In any aspect of life.

I took what you said as every time. My attitude of teamwork is to be receptive to your team members and listen to what they say. Usually having to be an authoritarian is rare. Most providers know what they are doing, and can give appropriate care. The team members are usually educated, understand what is going on, and things run smoothly. When a conflict arises between cert levels, I say the leader has final say.

As for the nurse doing what the doctor says or getting out, I'm not planning to risk *my* license after graduating nursing school if a doctor orders something that I know is *not* in the patient's best interests, and I will take it up the food chain if necessary, as well as refusing to carry out the order. Doctors make mistakes. There is a reason malpractice insurance is mandatory...

You, or a nurse, is not compelled to perform any procedure on a patient simply because you were told to..this is negligence to some..malpractice to others.

I do not buy either of these comments. What if the doctor decides NOT to do something that is in the best interest of the patient. Does that mean that you will take the initiative to do it yourself. The answer is no, you are not an autonomous provider, the MD is.

Again, most providers are intelligent, and when they make mistakes and are corrected by others, they can shift their treatment plans. It is great to have a checking system of other educated providers who can assist with treatment and question(in a professional manner) your treatment. For example a fatigued doctor orders amiodarone for sedation (I know farfetched, but applicable) may be appreciative of you asking if he would rather have versed.

Sometimes, our educations do not prepare us to know as much as an MD about treating people. That is the reason we follow orders even when we do not understand why. We cannot know everything. Usually this is not the case. When it comes down to the patient dying without time for debate, and you are ordered to do a treatment, and you question the doctor and he says "do it, I need that to be done now with X or Y" then it should be done.

You missed my point. I am emphasizing that each provider at their level has just as much of an ethical and legal responsibility to provide excellent care as the doctor does. Therefore, we must act accordingly, so that our superior doesn't take a fall needlessly... instead of just relying on the fact that "they're in charge, so they must be right."

I agree with this 99%. The other 1% is that we do not know everything, so sometimes we just have to be sheep and follow what we are told.

This is an arrogant and self important statement. By discounting the rest of the players on a scene, YOU will be the one who ultimately misses something..Only my opinion, but I believe you have some growing to do..I have yet to see a paramedic that was a one-man-show..at least a good one :shock:

Maybe this was poor wording on my part. What I guess I should have said was "As a team member they are assigned a specific task, they should be busy doing something else, they will possibly miss points that I see ultimately."

I have never said do not listen to what others have to say. There is chance to miss points that others may see.

When working in a team though it is expected that the team members are followers. They understand that when there are too many leaders that things become disorganized and then things will be missed. When things are going on fast the leader is calling the shots. He should not have to explain every little thing to every other person twice. Sure the team members need to try and keep up with things, but as a team member you should expect not to follow everything going on.

Only my opinion, but I believe you have some growing to do

Elaborate. I have engaged in discussion and have provided a basis for my view. The personal attacks are not necessary.

[Laura Anne]

Did you just comment about how people need to be sheep??????

Are you serious? Am I somehow misinterpreting what you wrote? You don't think RN have the right to be autonomous in their care provided? WOW. :shock:

This is my understanding of your comments posted above: doctors know all and rarely make mistakes. If they do, just suck it up in a critical situation and follow the orders given, even if they harm/kill the patient because you're a lemming and must follow the line of ignorance and mistkaes provided....... again, WOW. I have really nothing else I can say because I am so stunned by the comments you provided. Yes, you do have a lot of growing up to do. It's not a personal attack, mind you. It's just what I and others have come to realize due to your comments above. 8)

[Mateo_1387]

Did you just comment about how people need to be sheep??????

You need to go back and read everything to put it into context.

Are you serious? Am I somehow misinterpreting what you wrote? You don't think RN have the right to be autonomous in their care provided? WOW. :shock:

I am not sure what you read.

No, a nurse is not autonomous. If they are, correct me and explain how.

This is my understanding of your comments posted above: doctors know all and rarely make mistakes. If they do, just suck it up in a critical situation and follow the orders given, even if they harm/kill the patient because you're a lemming and must follow the line of ignorance and mistkaes provided....... again, WOW.

Again, it looks like you just read my above post and nothing else. Go back and read all the post in this thread, and what I said, and it should make more sense to you. I really think it will.

I have really nothing else I can say because I am so stunned by the comments you provided. Yes, you do have a lot of growing up to do. It's not a personal attack, mind you. It's just what I and others have come to realize due to your comments above. 8)

It is a personal attack. He is trying to discredit what I say by saying I need to grow up because of age. There was no need for that comment. He needed to just do what he did previously and explain why he is arguing that point. This is a learning forum and the improvement is gained through discussion.

Why not come in and join the discussion. I did not obtain any sustenance out of your post. Show me where you think I am wrong. I have tried to explain a viewpoint. Please explain yours.

[Eydawn]

Mateo... (good discussion, by the way! )

If a doctor fails to initiate necessary care, again, I will be taking it up the food chain if I feel the situation warrants it. I won't do it WITHOUT authorization from someone higher up from me, but I will do my damndest to make sure it gets done.

Yes, you default to a superior in a critical time situation-- unless you know for a *fact* that the act is wrong. I accept that I may not know the reasoning behind a treatment order, in which case, I will perform that order to the best of my ability. If an order falls within the realm of things I absolutely understand, and I feel the order is wrong, I will not obey the order. End of story. Or, I will do as told and document everything, including my objection to the order.

I believe that ccmedoc's opinion is not that you are an inadequate provider due to your age... I think he's referring to his opinion on the leadership style you indicate you have based on the posts above. I think he's saying that (as all of us do) you still have growing to do in order to become the absolute best paramedic and leader. It's not a personal thing. It's a professional thing.

I think it has to do with (as I have gleaned from the posts above) your portrayal of everyone on the team with you as being automatically subordinate because you are the paramedic, and only capable of action delegated to them, and as such they should not be deviating from said action to question any of your treatment decisions.

Wendy

CO EMT-B

[ccmedoc]

It is a personal attack. He is trying to discredit what I say by saying I need to grow up because of age. There was no need for that comment.

The statement was not meant to be a personal attack on you, only a personal observation by me.

It appeared a bit arrogant to me that you would put yourself in the place of being the only one to gather information, any meaningful information anyway, and be the only one to see the big picture. It also appeared to me that you were saying if the other people did not do exactly as you say, they will surely miss something (of importance)..As if you would be the only professional on scene to see the entire operation in its entirety..:

I am the one who is taking in all the information, I see the big picture, I see what is going on with the whole scene. As a team member they are assigned a specific task, they should be busy doing something else, they will miss points that I see ultimately.

I was taking this as seeing the medic as the all knowing one and discounting all other input..that the medic speaks and all others do...without question. If I was wrong..sorry 'bout that...

Although I do insist that the paramedic, or lead paramedic, be the ultimate medical leader on scene...I think it a failing to believe that this one person is the only professional with the vision to see all important facts and presentations.. and that any input should be stifled in the understanding that if 'it isn't my idea, it's wrong'.

I do not buy either of these comments. What if the doctor decides NOT to do something that is in the best interest of the patient. Does that mean that you will take the initiative to do it yourself. The answer is no, you are not an autonomous provider, the MD is.

I have seen, numerous time this week as a matter of fact, nurse input change the plan of care for a patient..to have treatments initiated by a physician that he thought was previously unwarranted....This is not a sign of weakness on the docs part..the patient is far better off with these changes, as the dialog between the nurse and the doc changed the care plan..strength in diversity and everything..

The dialog is not always productive, and presentation is key..mutual respect..Simply because the physician is higher license, doesn't mandate the nurse, or anyone else for that matter, to do something they believe to be not in the best interest of the patient.

If care was not initiated that some individuals, that were not physicians, thought was necessary...I have seen cases taken to attending docs if the problem was a resident..

I have seen the chief of staff contacted in the case of a questionable attending..

So anyway...personal attack, absolutely not. I am sorry you took it that way.

By having some growing to do, I was insinuating that in time, you may see the Paramedic (you) as the leader of a group of professionals (hopefully), and take advantage of the strength of others by allowing input, altering care plans accordingly, and ultimately improving patient care by being receptive to input from 'subordinate' members of the group or team..although team seems to be a bit of a buzz word here...

I, this is only my opinion, think that you could change your point of view a bit...maybe with less emphasis on you as the gangleader with unconditional power and more emphasis on learning from others and using their strengths to your, and more importantly your patients, advantage and ultimate success..

I guess maybe, in my mind, it could be taken as a compliment more than an attack. The fact that you are young, intelligent, and ambitious....learn from others and take what they give you...use some and throw the rest away...

Learn to be an efficient leader and adjust your styles accordingly, I hope that criticism does not put you off, but strengthens your resolve....If nothing else it makes you think, and to me that makes it worth the effort..

....carry on... :wink:

[Mateo_1387]

I was taking this as seeing the medic as the all knowing one and discounting all other input..that the medic speaks and all others do...without question. If I was wrong..sorry 'bout that...

Although I do insist that the paramedic, or lead paramedic, be the ultimate medical leader on scene...I think it a failing to believe that this one person is the only professional with the vision to see all important facts and presentations.. and that any input should be stifled in the understanding that if 'it isn't my idea, it's wrong'.

That is not what I have been trying to say at all. I do believe that the paramedic or doctor is the highest medical authority in a situation (ex. Doctors over nurses, Medics over Basics). I also think it is a failing to think that one person is the almighty. My whole argument is more on the structure of the team and how things flow. Information should flow up to the leader and then back down the the team members. It is not to say that anyone is better than the other. The other part of what I am discussing is the pecking order, but this is only used in limited situations. What I did not focus on so much in my views was how much a leader should listen. In almost all my post I say that a leader should not discount the information given by the team members.

I think that overall we are saying the same thing. I personally am not an authoritarian (at least I hope not), even though it may seem so in my posts. There are skills to being a leader, and not so much to being a follower. That is why my argument was the school needed to focus on teaching leadership and not teamwork. I just do no see EMS as mutual group work. Things will work more efficient with one leader who can guide an operation.

I guess maybe, in my mind, it could be taken as a compliment more than an attack. The fact that you are young, intelligent, and ambitious....learn from others and take what they give you...use some and throw the rest away...

By personal attack I did not mean that you were trying to insult, or belittle me or anything of the like. I just did not see it as relevant to the discussion. To me it seemed an attempt to make what I said worthless. It was just something I though that maybe needed addressing. But its all good ! I am not really that worried about it 8) Thanks for the compliment !

[Asysin2leads]

ccmedoc, I understand your points, but I really am at a loss to understand your reasoning. Maybe you can explain it to me. You stated that "just because someone is of higher medical authority doesn't mean that other ideas should be squashed" or something to that effect.

But the notion I don't understand is that of the "idea". What type of "ideas" are we talking about, and in what context should those "ideas" be weighted?

My most common experiences is that of either an EMT-B, paramedic student, or very new paramedic coming up with the "zebra diagnosis" when in actuality it is almost always something more mundane. For instance, a paramedic student I was working with recently thought very strongly that our patient was having a stroke and needed to be intubated, while my ultimately correct diagnosis and treatment was that of hypoglycemia. Was I supposed to have a discussion with them on scene as to why they were wrong? What if our BLS was also convinced it was a stroke too? Was I suppose to let democracy rule and the patient receive the wrong and possibly harmful treatment?

Now my question is, exactly how much time and effort should be spent trying to entertain their ideas and creativity before we get to work and treat the patient? Am I suppose to hold a mini-CME lecture onscene until I have everybody at my level of understanding? How exactly is it supposed to play out? Please, I am really interested in what you have to say.

[ccmedoc]

But the notion I don't understand is that of the "idea". What type of "ideas" are we talking about, and in what context should those "ideas" be weighted?

Let me start off by saying that this is only my opinion on this topic..there are, as has been posted, different theories of how to deal with people..I do not see where any are inherently wrong, they just don’t all work for me. I know that some individuals need absolute control of a situation, while other like a more dynamic flow..If it works for you then awesome..but keep looking at other alternatives. I hate to see people stagnate in archaic business and professional beliefs and practices simply ‘because’…

This “idea” or ideas I am talking about are the variable..By ideas, I am referring to treatment options, transport options, communication options, anything that applies to the job at hand, etc...kind of an abstract notion..nothing concrete..whatever it takes to get the job done. Since they are just other means to the same end..the context they are taken in is situation dependent and up to you, as the senior provider. I don't mean to have a democratic debate over every decision, I am saying that if someone on your team or crew has another way of doing something, or a "better" way to treat a patient, let them present it to you as appropriate...what you do with it from there is your business, depending on you comfort zone and ability within your protocols to make adjustments..

I would agree that most students see obscure ailments in the most mundane of presentations. I don’t think the opinion of a student is going to change the treatment of many patients. What I am saying is to allow them to have these opinions, and use them for what they are.

In this scenario, the student thought they were seeing a CVA..maybe, while you were allowing them to obtain a blood glucose level, explain that you would take that under advisement…I would venture a guess that after the reading came back, no further explanation would be necessary..

I’m not saying to have a discussion at the patients side, what I’m saying is that if one of your partners hints that there is a different, better way to do something..and it is appropriate for the situation, then maybe everyone concerned may benefit from entertaining this thinking… instead of having a hard, fast, "I’ve done it this way for years so f%$k off and do it my way" attitude..

And the bottom line is despite what all of the textbooks, and psychologists, and social workers may say, I do NOT have to respect any body's opinion about my patient care decisions who does not have equal or greater knowledge and experience in regards to the same situation as I do

Agreed..but in my opinion, to take in other viewpoints may add further insight..to automatically disregard the information due to lack of licensure could lead to failure..You don’t have to do what they say but maybe they have seen it done some other way that will save you time and possibly improve patient outcome..

I shouldn't have to worry if my persona or my demeanor or my "rep" is enough to "command respect". I should be in a system that teaches enough respect in its subordinates that unless I am doing something grossly inappropriate, people should understand that their JOB is to follow orders, just like mine is.

I guess I don’t see my job as just a job of doing what I am told and simply following orders..I work in a dynamic field, and because of this I am allowed some latitude..Part of being able to make decisions based on changing conditions, whether it be a patients condition or the field in general, is continued education for me and my subordinates. Part of this, to me, is also learning from my coworkers..whether they have more experience or higher licensure than me or not. I am a get the job done in the most efficient, safe, and appropriate manner guy..If that includes doing something different than my usual, or taking good advice from a new guy, then so be it..I had the chip removed from my shoulder long ago..

It just seems very limiting to me to simply say that "this is your little insignificant job description so don’t think past that" and because of the fact that you job description is inferior to mine, you cannot offer anything of consequence to me" simply because you are the boss..

Now my question is, exactly how much time and effort should be spent trying to entertain their ideas and creativity before we get to work and treat the patient?

None..while the assessment and initial treatment plan is being formulated, you probably had a plan in a few minutes, your partners opinions could be noted..tell them you don’t agree, show them the reason (BGL), and proceed. I would venture if it was done in a calm, professional manner..you have gained their respect for not only listening, but handling the patient appropriately. No further discussion is necessary. I never advocate discussions between differing care views in front of patients. After the call is fine..unless it is a blatant dangerous course..then actions need to be taken immediately, albeit in a professional and patient friendly manner.

A note on the respect thing..It is said repeatedly in this and other posts that “I don’t need their respect, I need them to do what I say”..My argument against this is that outsiders can sense mistrust..especially when it is a loved one’s or their own well being at stake.

Since prompt, efficient, safe, and appropriate patient assessment, treatment, and transport is a priority for us, I think mutual respect is a must.

Bickering, off handed comments, or a simple gesture can make patient/caregiver rapport very difficult. This affects their outcome potential more than most people realize. Patients that don’t trust you can’t relax, will withhold information, will refuse treatment, and may not fair as well as someone that does trust you. The respect and trust of your crew that you will make the best possible care decisions, and be willing to change you plan of care in the best interest of the patient, goes a long way towards this end..in my opinion, from what I have seen..

Sorry about the length, I have a hard time getting my points across on this subject in less than 30 pages..if I get them across at all.....Take it for what it is worth.. :?

[Asysin2leads]

ccmedoc, thank you for your response. It was very well thought out and articulate. I'm not saying I don't take other people's opinions under advisement. I always do. In the case of the hypoglycemic, it wasn't so much the possibility of a stroke that we disagreed on, but rather the necessity to intubate. Luckily for me, I had a good student with me, who might disagree, and want to be more aggressive, but took my word on the matter an continued accordingly.

I have had many people, and unfortunately, usually the less knowledgeable they are the more persistent they are, who would sit there, and argue, and insist, and make comments to the other providers about my care and, and so on and so forth.

The bottom line is that while teamwork is important the bottom line is that we are there to do a job and follow orders. Sometimes, when the shit hits the fan, we all have to just shut up and do our jobs, including myself, and I really don't think the notion of medical authority is emphasized as much as it should be.