How little is too little?

[chbare]

I find my self in an interesting situation as an educator. I am not spending much time in the field doing direct patient care. Over the past year I have only spent about 400 hours in the hospital doing direct patient care. It is a 255+ bed hospital with a 20+ bed ER and a 40 bed medical/surgical ICU that specialises in post cardiac (PCI & CABG) care. In addition, I did about 150 hours of community health clinical rotations for a degree that I am completing. The hospital time has me spending about half of it in the ER and about half in the ICU working with paramedic students. We are able to perform to the full scope of practice allowed in the state and we also get to work with ventilators, balloon pumps and invasive lines along with medication infusions in the ICU (I know several of the RT's and several of the nurses quite well, so we are able to do allot.).

My point being, how little clinical experience is too little? I feel fairly confident in my patient care abilities and still perform patient assessment and care including placing IV's and so on; however, I worry about loosing my ability to be an effective provider. While I assume there is no magic number, are you guys aware of any evidence on the optimal amount of patient contact time and performance of procedures? For example, I was doing several IV's a day during my full time ER days and now I am only doing 3-4 per week.

So, what do you all think?

[island emt]

Chris:

I don't think there is a quantifiable minimum of hours that is a go/no go when it comes to the practice of emergency prehospital care.

Yes there are certain skills that erode a little when not used regularly. whether you start 10 IV's per shift or 10 per month, it's not something that you forget how to do.

Once you learn 12 lead cardiology you don't forget the basics, you only learn how little you know.

On the other side of this equation, you are spending much more time in critical thinking skills and assessments of your pt's in Cardiac ICU & step down units, than you would ever do on the job in the street. you are using much more invasive technology than you would normally on the street.

You won't forget your basics when you are using many of them regularly, just in a different setting..

Now a relatively newbie might not have the same exposure and experience levels to feel comfortable not practicing daily those skills and assessments which are new to them.

[DFIB]

I think that only you can define the parameters that answers your question.

[DwayneEMTP]

I can't speak to skills Chris. I know that I worried about certain skills as I use them so seldom in my current gig. I've only started about a half dozen IVs in the last 6 months. But each was a good start on significantly volume challenged patients, so I've stopped worrying about 'forgetting' how to do that properly.

Though our clinic sees 40-70 patients per day, I only see 5 or so, not counting dealing with the 2-5 significantly ill/injured patients per week. I like to listen to lung sounds, feel pulse qualities, etc to try and keep a decent baseline for more or less 'well' patients. 5/day seems comfortable for me, to see if my clinical findings match my impression of the patient presentation, though I certainly can't defend that as a valid number.

On thing that I've found that surpised me in seeing fewer patients is that it feels like I do 'cleaner' assessments and I'm seeming to see that I do better medicine now. Not sure though of course, as I don't have anyone onsite to critique such thoughts. I seem to find, and this probably sounds silly, that I seem to start with a cleaner chalkboard when developing my differential than I did when I saw many more patients.

I think all that work in this field find that patients often come in groupings. The flu is going around so many of the patients that we see are victims, at least partially, of that illness, so we begin to group certain symptoms in with other patients that we've recently seen believing that we "know" what's going on based on the recent, common knowledge. I know that this is a weakness that I guard against with dehydration at my current site. "Aches and pains, headache, relatively elavated B/P, Pulse rate....I'm pretty sure that I know what's going on, but let's verify." I don't think that that is bad as long as it's on the radar, but I've found that without having so much constant exposure to those patients that I seem to be a stronger clinitian without those thoughts in my head...I'm not sure if this is making sense or not....

I guess what I'm trying to say is that seeing less patients seems to have dropped my general, intuitive confidence level, and having less confidence has seemed to highten my focus even more strongly on assessment skills and I seem to be doing better medicine now, than when I saw 25 patients per day, because of it. I know...lots of "seems" but that's the danger of a single medic gig with no one to verify your thoughts/assessments.

So other than "monkey skills" perhaps less patient exposure can be turned into a strength instead of a weakness?

[chbare]

I appreciate the replies. I agree that much of what I am asking is probably rather subjective. However, I do not want to become clinically irrelevant. Not only simple skills such as IV placement scare me, but higher risk modalities such as managing, transducing and zeroing invasive lines and managing balloon pumps are modalities that concern me. I am just trying to get a feel for what others in my situation have done to ensure they remain clinically competent.

[slymedic1]

If you dont use it you lose it sir.....bettering yourself is what we all strive to accomplish however you must remain true to yourself and spend time on the street, how else can you really teach the upcoming paramedics how to do something? You can make it all work if you want it just takes a little bit of planning is all....you will figure it out, best of luck!!!

[chbare]

Sly, I think we have already established that not using may lead to loosing. My question is not about refusing to work clinically, but rather how much clinical experience is needed.