ACP Student Life- Finding a Balance..

[J306]

Thank you all for the advice. I ended up talking to the instructor one on one to get a better idea of what kind of boundries we should establish. The end result was actually quite positive, we now see eye-to-eye and in the end I was told that it would be beneficial for me to continue to start these discussions in class, as long as we don't get too off topic of course.

I'd like to comment a bit on the new day and age of adult education as I see it. I understand that a lot of services out there have a whole "eat your young" mentality and "you have to put x amount of years in before you can even have an opinion!" I see it quite a bit in EMS, and I think it is holding us back as a profession.

Being a student, you make a lot of sacrafices. You have to take time off work, move away from friends and family and it's not cheap. As students, we have certain expectations going into school that we will be treated a certain way and have a certain amount of freedom in the classroom. However, we are the product of our instructors and our school. Our instructors are the ones with the power and have an obligation towards evaluating us to a certain level. I definitely do not want to border on arrogance, but I want my instructors to help me build confidence when warranted.

Having said that, there's also a fine line between confidence and arrogance. If a student is to receive too much hype, praise and flattery, it's a slippery slope that can easily carry them over the border into arrogance. It is not only toxic, it can be deadly. I've tried to make it my goal not to allow myself to get overconfident, especially now that I'm an ACP student, because that's when practitioners will miss a step, lose their focus and potentially hurt somebody. A balance is definitely required in an instructor between fostering learning and being critical towards bad attitudes and bad habits so they don't manifest throughout their career.

I liked that quote Dwayne, I think in this day and age we must really pick and choose who we want to learn from, and if it's not a proactive relationship then there's no harm in ending it.

[Arctickat]

Hmmm...you're close Jack but here's a different view on it. Your instructors are there to help you to learn, it's up to you how much work you want to put into learning. The more work you put into your didactic learning the more you will receive from it. Your confidence building should come when you're doing clinicals. This the point at which you take everything you've learned and apply it under the close supervision of a veteran. This is when you have the opportunity to treat your patient and actually watch all the pieces fall into place in real life. I've gotta admit, when I went into my first practicum and had an actual visual confirmation of what my treatments were doing, my learning truly began and my confidence grew significantly.

Classroom time teaches you what to do and how to do it, practicum gives you the skill and confidence to be able to do it on your own.

Besides, I think it would be highly unlike you to decide that you're going to walk away from ACP school because you have no confidence in your instructor. I just chose to learn in spite of him.

Edited August 31, 2012 by Arctickat

[systemet]

It's only been a week, and already I'm already running into situations where I'm voicing my opinion then instead of engaging in a discussion about the subject, it's being dismissed or overruled.

Are you doing this in situations where the opinion(s) of the class is being asked for? Or are you just randomly interjecting while the instructor is trying to teach? I don't mean to be rude here, but a possible explanation for your feeling that you're being dismissed is that your instructor may have a lot of information to cover, and little time allowed for discussion. This is particularly likely if you're reviewing BLS skills, that you'd assume people would have some understanding/mastery of before entering a paramedic program.

As to having your opinions "overruled", I'm not sure what you mean? The instructor can tell you that they disagree with a treatment plan you propose, and suggest an alternative. They can tell you that you misunderstand the pharmacology of an agent, or the physiology of an organ system, but I'm not sure how they overrule you?

My hope is that ACP would be a forum in which we could have those collaborative discussions in class, because that is how I learn, but if I am just being an annoyance to the teacher, I'm wondering if I should just hold my tongue and just try and focus on getting my work completed..

You should be having these collaborative discussions, but your instructor should be planning time for them. Spontaneous discussion in a classroom setting can be fanastically productive. It can also be a complete waste of time if it strays off topic or wanders into pointless "war stories", e.g. "15 years ago I saw a guy with cocaine induced chest pain given propanolol, so I think it's a good idea".

My suggestion is, if you think that you are annoying your instructor, ask them. "Hi, I got the feeling i was pissing you off when I asked a question the other day? Was I? Because I can stop, Would you prefer I ask questions some other time? Are we ok? Cool".

There's also a point where you've got to look at how many other people are in the class and whether your question is relevant for them. Or whether it's important in the bigger picture, e.g. "Why does epinephrine cause vascular smooth muscle to contract, but bronchial smooth muscle to relax?" might be an interesting question in terms of physiology, but in terms of the depths of understanding required in most paramedic programs, might not be worth spending an hour discussing.

I really am trying to find a balance between how much I should stand up for what I believe in, and what I believe is to the greatest benefit to the patient, or to save that for practicum or when I have completed the program.

You always have to be an advocate for the patient. But you don't have to expect everyone to agree with you. And you're not enrolled in this program to teach it. The fact that you disagree with an instructor may not be important for the rest of the class to know. The instructor may be wrong. You may be wrong. If the disagreement affects an important area of patient care, it might be in your interest to approach the instructor at another time and ask them what their thought process is. But you're not responsible for the learning of other students in the class.

As for workload, I have heard that this program becomes very intense and almost unmanageable at times. I don't want to be one of those people who are always studying and are always tense and on edge, but I also want to be able to gain as much knowledge and wisdom from the program as possible.. I am in the process of getting a tutor through the school I'm in, but I'm a bit nervous that it won't be enough..

I think you should accept that if you are in a decent program, even if you're a strong student, you should be studying a lot. I think you also need to expect to be tense and stressed if you have a full-time program and any sort of work or family commitments outside of it. Getting knowledge and wisdom is about making sure you understand why you do something (i.e. pharmacology/physiology/pathophysiology/medicine) and when you should do it, versus just what's next in the algorithm.

There's also a huge trap with paramedic school of finding something interesting, for example, organophosphate/nerve agent poisoning and devoting weeks of study time to trying to understand it in depth. This would be great if you were sitting around on an ambulance outside a Tokyo subway station a few years back, but generally represents a poor investment of time for return.

I would love to hear some of your personal strategies and methods from when you attended ACP school!

In my opinion, the bedrock of the program is the physiology/pathophysiology and pharmacology. Understand these, and a lot of the other things fall into place. Try your best to relate what you learn in classroom to situations in the ambulance, and imagine how this knowledge will transfer over before you hit practicum. Realise that psychomotor skills, e.g. intubation, are less important than the background knowledge required to know when they're indicated.

Accept that your instructors won't always know the right answer, and that they may give you inaccurate information despite the best of intentions. These people are your peers, not some god-like authority. Do your best to keep some sort of social life outside of class and EMS, but accept that it's probably going to take a big hit for a while.

[systemet]

One topic which came up today was in regards to pain management. Local protocols state that if patient cannot self-administer Nitrous because of billateral wrist or hand fractures than Nitrous is contraindicated. I spoke up and said that just because they are unable to grip the mouth piece or mask doesn't mean they don't qualify for pain management. My instuctor disagreed along with several other classmates. I responded with the solution that you could fasten the piece to an uninjured part of their hand or wrist so they can still self-regulate the Nitrous PRN.

Here's a decent page that discuss the pharmacology of nitrous oxide in more detail that an typical EMT program:

http://www.frca.co.uk/article.aspx?articleid=100358

A few highlights (that you may well be informed about already), are that nitrous oxide is too weak to be an anesthetic in most people (MAC = 105%), but has CNS depressant and myocardial depressant effects at higher concentrations, e.g. MAC around 80%. It may also exacerbate increases in ICP, and can diffuse into air-filled spaces, hence the concerns about use in COPD and suspected bowell obstruction.

You're giving 50% N20, which is going to produce a MAC of around 42-44% in most non-intubated patients (due to humidification of the N20/02 mix as it passes through the respiratory tract).

So, why are EMTs told to instruct the patient in self-administering the medication? Probably a combination of (1) Some patients become dysphoric when taking N20 - "they don't like getting high" - so this way they can stop if it gets to be too much, (2) If your patient starts to become anesthetised, they'll drop the mask from their face, and hopefully breath in enough room air to dilute the alveolar N20 concentrations. Now likely (2) is only going to happen if there's something else causing CNS depression, e.g. alcohol intoxication, benzodiazepines, evolving head injury, or there's some form of equipment failure causing a higher concentration of N20 to be delivered (i.e. the tank wasn't inverted properly, the ambient temperature is too cold, etc., or the patient is unusually susceptible to the cardiac depressant effect, e.g. overdose of vasoactive meds, hypovolemia from occult injuries. But this provides an extra safeguard.

Could you simply hold the mask to their face to deliver the medication? Of course. But you would have to be alert to a potential decrease in LOC, you're going to be completely tied up doing a mask seal, which may require devoting one crew member to that task, and if you do this as an EMT, you're probably going outside of your regions accepted scope of practice, and might be vulnerable to civil litigation, or to a complaint from one of your peers.

In the not-particular-common scenario of bilateral wrist fractures without other associated major injuries, you could try tying the device to the forearm. I think if you wave your arm around your face a little, you'll see quickly how difficult it would be to provide enough pressure to produce a mask seal on yourself with a device tied to a broken limb. Imagine trying to maintain that while partially sedated from the N20. It may not be a practical real life solution, and a better answer might be to simply call for ALS. As an ALS provider there are generally more effective medication options in most situations.

Still, we were unable to see eye-to-eye. I have a suspicion that if I were to do this in a scenario tomorrow, that I would fail if the instructor, or any other instructors sharing this viewpoint were evaluating me.

If your local standards are anything like mine were, I would expect an instructor to fail an EMT being evaluated at the EMT level for holding an entonox mask to someone's face. This would be independent of whether they thought they would particularly like to drink a beer with that student.

At an ALS level, it's hard to imagine too many situations where this would be the best option, and i think I'd avoid ever giving a scenario like that to cover a fairly unlikely event. [A situation where opiates or another agent wouldn't be a better option].

If your instructor would fail you on a scenario because you disagreed with them in class then you have an extremely poor instructor, and should consider looking for another program, immediately. Before wasting any more money.

I don't want to cause offence, but educated people realise that you can disagree about someone on a given topic without it reflecting some deep flaw in either person's character. You can discuss a situation, and disagree without having to dislike each other, or take it personally.