How can you be sure a horse is just a horse?

[DwayneEMTP]

Deciding that a horse is just a horse...

You know, I'm into my phase one clinicals and I think the most difficult thing for me is deciding that sometimes a horse is just a horse...when I've spent the last two years (nearly) learning to look for zebras.

In medic school there were no horses. Every scenario (more or less) has someone looking pretty good that ends up dead, or looking pretty much dead and ending up smiling and happy. See...No horses, all zebras.

Now that I've 80 or so patients on the streets, all I seem to see are horses, that I'm trying to turn into zebras. AHA! Gunshot victim! Horse. Chest pain! Horse. Two year old difficulty breathing! Horse.

In each of these cases, I pulled out my paint can and tried everything I could to find the 'zebra within', but simply ended up looking like an ass to those around me. I did get some kudos from the ER doc for my reasoning a couple of times,...And was surprised how good that can feel..

I don't think I'm attempting brain surgery on hangnails. It just seems that everyone around me knows that there's 'nothing to see here', where I was taught there are possibilities for bad outcomes if not caught early, so I better watch for them!

I'm hoping that seeing some more patients, and observing others will help find a happy medium...but man...at times I think it's time to head back and see if they have any room in the upcoming basic class.

For instance...91 y/o female, confused, no s/s of acute neurologic event, got her car stuck on the median going the wrong direction, she believes it's 2230 and she just left a friend's house, it's actually 0240...I put on the pulse ox along with a full set of vitals. Afterwards was reprimanded by the medic “She's just a little confused, why do you want to cost her another $75.00 for the SPO2 when she didn't need it? All she needed was transport, if you weren't a student you would have cost her several hundred extra dollars with all your screwing around!” I guess I was looking for zebras. I'm not sure, though even now it seems logical...clinicals are making every thing much more murky instead of clearing them up...though perhaps that's how it's supposed to be.

Did I just go off into the ditch somewhere? Is this mentally where I belong at this stage? I don't know.

I believe much of this will resolve with experience, but I'm not sure that good medicine is what I'm being exposed to now...I don't want to 'experience' myself away from the education I've fought so hard for. Know what I mean? I don't want to mimic the experienced folks, only to find they really aren't that good...

Well, I guess, after typing this, I'm not sure even what my question is. I'm just hoping someone will recognize this rambling as s/s of something more logical than how it feels at the moment.

Have a great day all.

Dwayne

[Scaramedic]

Hey Dwayne,

I think you are starting to learn your "gut instinct" you still have a long ways to go but I think you are getting it. Your gut instinct is your millisecond diagnosis, sometimes your right, sometime your wrong. You do not base your treatment on this, it just gives you a starting point. You have to have a starting point with each patient and with each patient it is different.

You walk in on an ashen 90yo male,severe dyspnea, audibly junky lungs. Your first instinct is CHF, so you start from there. Maybe it's Pneumonia, maybe its Ebola Marburg, but at least you have your starting point. This is your gut instinct.

Now for your example, I disagree with your preceptor. How does he know the confusion is chronic? Maybe Grandma is totally with it normally, may she is on the local Election Board. My mom was, into her 70's. So your instinct was to check if it was a perfusion issue, I find nothing wrong with that. Just do not over rely on machines use your senses also. But I have no issues with your examination of this patient in regards to SP02.

My opinion is that there is a fine line between worrying about what it is going to cost the patient and bad patient care. Yes, you should be aware not to over treat/over analyze but you should also not let it cloud your instinct. I believe that some Medics use the cost issue to be lazy and justify minimal treatment.

You cannot learn instinct, it comes with time. Give yourself a break and enjoy it while you can. Soon the mistakes you make are going to be on your shoulders, and then it gets real.

Peace,

Marty

[brentoli]

I put on the pulse ox along with a full set of vitals. Afterwards was reprimanded by the medic “She's just a little confused, why do you want to cost her another $75.00 for the SPO2 when she didn't need it? All she needed was transport, if you weren't a student you would have cost her several hundred extra dollars with all your screwing around!”

My unrelated question here....

How is that a $75 procedure. The only thing lost is a disinfectant wipe when you clean it afterwards, and a few C batteries after a couple of months.

[VentMedic]

My unrelated question here....

How is that a $75 procedure. The only thing lost is a disinfectant wipe when you clean it afterwards, and a few C batteries after a couple of months.

Ambulance services are getting reimbursed at that? Billing at that?

I do know that is also the charge in the hospital. As a Respiratory Therapist, I can run up your hospital bill to well over a $1000 with just a neb, EKG and ABG in about 20 minutes of time. Add another $75 for the SpO2 check if I did that also. Sometimes, I throw that in as a freebie as just part of my routine assessment. I can also tack on an MDI instruct, smoking cessation teach and a peak flow for about another $500. Let's not forget the O2 device and set up charge. Of course, Medicare is going to pay pennies on the dollar for what is actually billed.

[paramedicmike]

Your preceptor's an idiot. Find another one.

Marty is on to something with the idea that you're developing your gut instinct. It doesn't happen overnight. It's something that is honed after seeing many different patients. The more you see, the more you'll be able to walk in and say, "Cripes! Sick!" and go from there.

You're right in that paramedic school preps you to always walk in on the worst type of situation, or the strangest presentation, or the most off the wall disease processes. While that isn't the case in real life, it works to get your brain thinking. I think what you'll find, too, is that while no two patients will present the same way, there will be enough similarities that you'll be able to add one and one to get two.

Hang in there. We all went through it. And I'm not kidding about your preceptor. Who the hell does he think he is? Find another one who's interested in working with you.

Good luck!

-be safe

[Ridryder 911]

Your preceptor's an idiot. Find another one.

Agreed!

There is a reason that residents have to perform "years" before they are technically turned loose. It is to help them develop methods to place that knowledge in application as well as to develop that " gut" or more technically known as "gestalt". As I was describing to newer anxious Paramedics yesterday, knowing when to "listen" to that little voice is important. Obviously, experience and knowledge sometimes hide itself well. Most find out by the aftermath, .."could have, would have, should had"..

In addition to all the wise and valuable previous comments, remember the 'personable" aspect. Even though this maybe the 6'th fractured hip of the day, it is the patient's first. Even all the clinical symptoms maybe the same, the traumatic event is not for the patient.

[DwayneEMTP]

He's a she.

Yeah, it's an ugly situation. And she just got a new basic partner, the only other person on the schools "don't precept with" list...lucky huh?

This chick is AMR's Medic of The Year, she told them not to let me switch schedules, and they won't. I was amazed. She's already made it clear that she won't pass me through phase one if I don't complete phase three requirements, and she hates basic to medic students.

When I called my school and said "When did she get put in charge of me clinical education?!" They said "Well, she's not. But if you choose not to ride with her AMR will not let you precept with them any longer."

So, though it's far from optimal, it is what it is. It's just hard sometimes when I'm not sure what's best, to know that no matter what I choose, I'll never know if it was appropriate, efficient or correct, because each thing I do MUST become a lesson on "Why you should have never been allowed to become a paramedic."

Anyway, it's wasn't my intention to cry about her...Hell, I'm 44 years old, have a 10 year old autistic son, and my favorite niece was recently diagnosed with a brain tumor with 80% mortality at two years...her being a bitch doesn't even cause a blip on the radar...

Do I feel I have the mentality to be a good paramedic? Yes.

Do I feel that I have the theoretic knowledge to become a good paramedic? Yes, if I can put it all together.

Do I feel I can put it all together in the field by myself? Man...I'm not sure...but it seems like a mountain to climb...

So for now I'll keep watching for zebras...and take your guy's word that little by little they will begin to look like horses... :wink:

Thanks all.

Dwayne

[paramedicmike]

Nobody thought you were cryin', bro. We knew what you were saying.

It sounds, though, as if there are larger issues involved. None of those issues paint a very positive picture of AMR. Not that AMR had a positive picture to start.

Is this an AMR school? Is this you're only option for ride time? Or is it simply your best option? From what you've said, if this is not an AMR school then you have grounds to go to the Dean and get some arses kicked around.

Can you put it together in the field by yourself? Yes. You can. You have the knowledge. I think you know enough what to do, what not to do, and when to call for help. As you learn more you'll push that "when to call for help" line.

Besides, with this dingbat as your preceptor you might not have any other choice.

Hang in there. Just keep doing what you're doing and you'll get it. If nothing else, the motivation to get it just to spite this woman should be enough to keep you going.

-be safe

[DwayneEMTP]

Thanks Mike.

Not an AMR school, it's a degree program. And I can ride with AMR or with fire, though rumor has it that fire doesn't care for ride alongs that aren't applying or currently employed with fire. I may ride one phase there, as they control the EMS in the Springs (fire controls the scene until released to the privates for transport, should they choose not to ride with the transport), where I'll likely be employed after graduation. I might as well see how they think.

The ice queen is the only thing standing between me and my AAS in emergency medicine, so she's got to be dealt with.

Like I said, I'm not intimidated by her, but by her motivation to help me fail, as it reinforces her opinion that 'people like me' don't belong as medics. By not having street experience I give her a lot of latitude to steer me wrong, or make me look foolish to my peers, so I'm ever vigilant for signs of that.

I'm just not that good at it...

For example, she claims that I gave her two different, incorrect, BPs on one patient (I'm convinced that I didn't) so on the next call she pushed fire aside and told them to let me take the BP as "He likes to make his vitals up! Anyone else need their BP taken?" Which of course caused a lot of laughter and scornful looks...She thinks that's pretty funny, I think it will take me a long, long time, with those guys seeing me do all the right things before they'll forget that. But having no street experience, I don't really know what plays, and what doesn't. I was afraid of being good at medicine, it appears I should have taken a few courses in politics as well.

My ace in the hole? The same thing that convinced me to get a degree instead of a certificate...all of you guys.

So for now, I'll ask your indulgence, and continue to bring my questions here. As silly as is sounds perhaps, it is truly huge to have access to a "no bullshit" zone. There is so much more to figure out than I'd ever imagined, pretty cool to have you guys to watch my back.

I have no issues being wrong...I just hate staying wrong. That's where a good preceptor could help...I guess I'll ride this phase with you guys.

Thanks again all.

Dwayne

[Scaramedic]

[align=center:8258610f52]The ice queen is the only thing standing between me and my AAS in emergency medicine, so she's got to be dealt with.

[/align:8258610f52]

[align=center:8258610f52][/align:8258610f52]

[align=center:8258610f52]Someday - and that day may never come - I'll call upon you to do a service for me. But until that day, accept this justice as gift on my daughter's wedding day.[/align:8258610f52]

Capisce?

Vito