Mid-level Provider Minimize Symptom Syndrome

[Kaisu]

I now consider myself a mid-level provider. While only on the streets for 3 years, 2 1/2 of them were in a high-volume station where I got 2,500 calls under my belt. I have been running 911/CCT for the last 5 months.

When I was new and enthusiastic, every chest pain was an MI, every shortness of breath was a PE or flash pulmonary edema. A seeker with great dramatic abilities was in excruciating pain. I was pretty harsh with my colleagues for what I perceived were some laissez-faire attitudes.

The long hours and the disadvantaged demographic that I ran in have taken their toll. Although more seasoned and experienced now (usually drugs find their way into the patient as opposed to being squirted across the ambulance) I have caught myself twice on calls with an attitude of less than concern, where the patient was really sick.

The first was an adult syncope with a systolic of 68. It wasn't until I saw that number that I felt any sense of urgency on the call. It was 3am, the guy was a complainer and he was a frequent flyer. I am ashamed of myself. The second was an amputee complaining of extreme pain to his stump. It wasn't until I saw the gentleman's full stash of narcotics (which he avoided because "I don't like how they make me feel") that I took him as something other than a seeker.

Even though I know about Midlevel provider minimization of symptoms syndrome, the intellectual knowledge of it didn't prevent me being susceptible to it. I found a great article about it here:

Minimize

This site has always helped me. I am coming to you again for your assistance. Have you fallen into this trap yourselves? How have you dealt with it?

Thank you in advance for you advice and feedback. I really appreciate it.

edited to try and correct the link

Edited April 9, 2011 by CrapMagnet

[HERBIE1]

Well, on the plus side, it seems you have progressed to a level usually reserved for folks with more than 3 years experience in the field. I'm not sure exactly when I got to that point, but it was indeed longer than 3 years. My call average for the first 20+ years was 20-30 in 24 hours. I have no idea how many total calls that was, but I used to work a rig that has been ranked in the top 10 across the country for all that time and still is- if that tells you something.

Several factors come into play here.

1. Your partner. If you have a good partner, this minimalist attitude is usually delayed for awhile- regardless of how busy you are.

2. Your system/working conditions/pay. If for the most part you are satisfied with these things, it will also delay the onset of such attitudes.

3. Your perception of the job- ie- did you realize what you are getting into from day one? Were you wide eyed, thought that every call was a "real" emergency, and were devastated to learn folks actually call 911 for things like stubbed toes, foot pain for 3 months, and rides to get medication refills?

I eventually "hit a wall" and became very frustrated with all the BS. As you probably know, in the busy ghetto areas, there are generally 2 types of calls- the completely routine, nonemergent taxi rides, and the folks who find new and creative ways to die. There seems to be no in between. The ones who are really sick are generally obvious, and so are the others. Or so I thought. All it takes is a couple folks who appear to be completely stable- ie the same drunk you've had for years and they suddenly are really sick with a massive GI bleed, you let your guard down, and it turns out they are a half step away from meeting their maker. It scares the hell out of you, and you realize that complacency kills patients and careers. If you are doing this job for the right reasons, it will be a wake up call. It was for me.

Part of the solution for me was taking a step back, and going back to school on my days off. I got my masters degree, and found a spot in administration for awhile. Problem was the position was actually a pay cut. 40 hour week, no holiday pay, no OT, AND I had to pay for parking, gas, and the occasional working lunches. I really enjoyed the new environment and challenges and would still be there if I could afford it. I had to leave and go back to the field, but it gave me a new perspective AND a new outlook on the job. I have a great partner, am on a rig that is a lot slower, but we still get a good mix of trauma and medical/cardiac calls. For the last few years I teach a class I created(EMS administration) part time for a Fire science bachelor degree program. I get to impart my "wisdom" on the next generation of providers. Teaching will be my next career when I am ready to leave the streets for good and retire. (Maybe 5 more years or so)

Is this the path for you? Who knows? You need to figure out why your attitude slipped or changed, and see what you can do to rectify the problem. Change of scenery, new partner, new rig, new position, work for a promotion, go back to school, teach- you need to find your outlet, your own solution and your niche in the business. You have a long way to go before you are done.

Do I still get frustrated? Yep. Do I let it affect my patient care? No, but if it does my partner will gladly kick me in the arse to remind me.

Hope this helps...Feel free to send me a message PRN.

Good luck.

[DartmouthDave]

Hello,

An excellent and honest post CM.

I read that article in JEMS and I have been there as well.

For me, the key has been taking adequate vacations and avoiding falling too deeply in to the OT trap. Avoiding 'toxic' colleagues and taking on new educations challenges and new jobs as well.

Cheers

[crotchitymedic1986]

Dont worry CM, the EMS Gods always take care of these type of problems: You dodge a BS call you are closer to, you are guaranteed to get the next nasty call. Get a little too full of yourself, the Gods give you a call that shows you what you do not know. Get a little too complacent or jaded, the Gods will give you a call that straightens you back out.

[zippyRN]

was the amputee on anything other than opiates for pain ? as his stump pain may well be neuropathic in nature ?

[Kaisu]

was the amputee on anything other than opiates for pain ? as his stump pain may well be neuropathic in nature ?

his stump pain was secondary to a fall.. went to get into his wheelchair, it wasn't locked, "jammed" his stump

[DwayneEMTP]

Dont worry CM, the EMS Gods always take care of these type of problems: You dodge a BS call you are closer to, you are guaranteed to get the next nasty call. Get a little too full of yourself, the Gods give you a call that shows you what you do not know. Get a little too complacent or jaded, the Gods will give you a call that straightens you back out.

I have found this to be completely true for myself. If I get arrogant the EMS Gods will certainly kick my nuts right up between my tonsils. If I convince myself that I am such a loser that I don't belong anywhere near sick people I'll get a call that allows me to empty my drug box for a multi-system/multi-pathology patient and come out looking like a rock star. If you want to be a good medic, if moving forward and upward is your goal...EMS seems to be a good tutor.

Does anyone here not believe that EMS will set you straight if you get off track? Take this challenge....when you go to work next time spend your entire shift bragging about the fact that you have never puked in the back of an ambulance... report back... :-)

Great topic CM! You're pretty smart for a chick.. I have to admit that if I've been there I've not recognized it, though I've not run in the type of system that you have. I do though, every now and again, come to believe that I can pretty much tell what's wrong with someone by looking at them and getting a good set of vitals, despite the pts reported issue... X

If X = behavior previous tagged as ignorant

Then = go to line 1

(Tay 'ello to mah 'itttle freeeennn! )

Dwayne

Edited to adjust formatting. (Why is it that 'edited' only has one T but 'formatting' has two? Who decides this shit?)

Edited April 10, 2011 by DwayneEMTP

[crotchitymedic1986]

"Great topic CM ! You are pretty smart for a chick !!" Dwayne I suggest you start apologizing profusely; I know you didnt mean it, but that quote is going to cost you big time in your "popularity score", or does that only work when black people say something controversial ? Guess we shall see. If your score does not drop by atleast 10, then we know the truth.

[Richard B the EMT]

Mentioning that amputees sometimes have pain where there is nothing, as a BK leg amputee who's toes are itching (my dad actually had that a few times).

Somewhere on this site, I must have mentioned a local frequent flyer, who had been transported to the ER by another team, and put on a gurney in the corridor, by an ER Charge Nurse, to "sleep it off", as he was a habitual ETOH abuser. I actually saw him that night, when he got off the gurney to go to the toilet, then got back on the gurney. My topur ended at midnight, the nurse's at 6 AM.

The next evening, the crew I relieved told me the guy had died on the gurney! The Charge Nurse coming on at 6 AM found him dead, when attempting to do a pulse check. The overnight Charge Nurse was reassigned, and reduced in status and responsibilities. No blame was assigned to the EMS crew that had brought him in.

[DwayneEMTP]

"Great topic CM ! You are pretty smart for a chick !!" Dwayne I suggest you start apologizing profusely; I know you didnt mean it, but that quote is going to cost you big time in your "popularity score", or does that only work when black people say something controversial ? Guess we shall see. If your score does not drop by atleast 10, then we know the truth.

Ahh...there you are! I'd wondered where the bigot had gone but as most often happens you were just hiding behind the logical, intelligent, though fictional persona.

I don't believe that it will cost me, and I'll tell you why. People here, for the most part, are not looking to jump on limp dick causes. In my City experience, you are unique in that. They are aware of my previous posts, will remember my feelings concerning women and other special need groups (oops! See, there it is again!) and see the humor.

Also, people here will remember CrapMagnets previous posts and have every confidence that she can eviscerate me and wear my guts for garters should she choose to do so. She has no need of a cause, or a parade to remind her that she is not only one of the most intelligent and powerful people I've know despite being a woman, but because of it. The City has been blessed with several women cut from the same cloth. And not a single one of them requires your protection. You're really not that strong brother...even when you wave the hate flag.

And lastly, they will not kowtow to your most recent desire to turn something racial, that isn't. It was a quip, I threw it in to give her the opportunity to kick me in the balls is she should choose to do so simply because I think it's funny.

I don't apologize to the boob people...(Dang it! I mean women!)...simply because I'm unaware of any that think so little of themselves, or so much of me, that they would be offended.

Your attempts to turn silly things racist are getting weaker Crotch...you need some new material man.

Back to the topic at hand...

I think part of my different thinking may have been because I got partially inoculated against it in Afghanistan. In the first clinic that I worked we saw patients one after the next..often 15-25 in a 12hr period, or more, with full documentation. Two things contributed to bad medicine there, though I also did, and saw some of the best medicine that I've seen to date.

The first is that there were about 5 common things that we saw over and over. Even when we saw something different, we often saw these things combined with them. A resp issue, a GI issue, some Derm issues, dehydration, hypertension. So if you didn't really want to do medicine, you could just lead people down the most likely road to getting them gone.

The second being very little oversight so it was easy to see what you wanted to see. A cough was 'The Crud", etc...

Both of these things made me batshit crazy! In fact I developed such a dislike for them that I started using this system that said that I would gather my information, develop a DDx, and then ask at least three questions that I hadn't asked before that were likely to prove my DDx full of shit. And way, way too often those few questions did. And that convinced me that I am not nearly as smart as I think I am.

Not sure if this is still on the subject, but it was meant to be!

Dwayne

Dwayne