EMS: I Wish I Knew This Then

So, there you are, finishing EMT or paramedic school. The key question: What have you learned? More importantly, what have you retained? Realize it or not, actually, you know a lot.

Some might say that you learned just enough to be dangerous. Your inner self might be thinking in the figurative realm that you only can pull up your pants and can’t quite tie your shoes.

All that said, it isn’t just you; it happens to all of us. To this day, I feel as though I struggle with a lack of knowledge as well as with overall self-confidence issues. I include this here not only because this is the beginning of the first column that I am authoring for Firehouse Magazine but more so because everyone should know that we all are in the same predicament.

Let me offer some quick tips and tricks that helped me in the early stages of my career as a paramedic. Frankly, I still use each and every one of them to today.

Don’t overextend

Don’t expect to make a diagnosis on every patient. Type A individuals have this overwhelming feeling that they must finish all of their tasks in their entirety and make sure that these tasks turn out perfectly. The problem is that reality strikes down and beats that ambition to a pulp when your patient’s presentation makes you question everything that you ever learned about emergency medical services.

As an EMS provider, you aren’t expected to know what exactly is wrong with patients during your time with them. You aren’t a physician, and you aren’t expected to make those diagnostic decisions. Obviously, there will be times when you will know exactly what’s going on with the patient. However, your only goal is to keep your patients the same or make them better. You accomplish this by sticking with the ABCs and by managing your patients’ signs and symptoms, all the while staying within your scope. Be sure to keep the patient’s best interests in mind. Do this, you certainly will go far.

The safety net

This previous tip leads me directly into my next rule: Build a safety net on which you base every call/scenario. Yes, that’s every single call. If my patient complains of chest pain, my mind goes into a global-thinking mode. As a result, I consider what kind of things can kill or injure a person who presents with chest pain? Pulmonary embolism, pneumothorax, abdominal aortic aneurysm, etc.? It isn’t always coronary artery disease that causes chest pain.

Think big and build a massive net of differential diagnoses and start working through each of them, ruling them out or in, one at a time. What does this process do to help? By building a large safety net, a smaller number of conditions have the capability to be missed. A good example: Consider that a diabetic patient who has history of cerebrovascular accident (CVA), or stroke, is suffering from a urinary tract infection (UTI)—all three of which can cause altered mental status. Of these possibilities, the urinary tract infection seems the easiest way out. Diabetes is something that you can treat, and cerebrovascular accident is a rapid transport. However, when you look at all of them with the global perspective, you have the ability to devise what is the worst of the diagnoses and which of them to rule out to begin with. Start with the most critical diagnosis. If you can’t rule it out, then it still is a possibility. After that, continue working through each item on the list of differential diagnoses.

Trust the basics

The other reason that you should build a safety net is to resist the possibility of tunnel vision and, thus, missing a pressing issue. Go back to our diabetic/UTI/CVA patient. What if you went in with the mindset of UTI because it’s obvious that this is a problem, and the patient stated the need to follow up with the primary care provider rather than a trip to the hospital? What if you failed to realize or ascertain that the patient also suffered from a fall earlier, has a prescription for anticoagulants and is suffering from a head bleed? Yes, such a circumstance is an extreme case; however, it still is a possibility if you fail to build or cast a safety net so you won’t miss an issue.

So, whether you are fresh out of the gate of school or you have been around the block for a few years, these tips and tricks could hold value for you. In essence, this is enough to help to get you through the call. Just remember to utilize your tools, experience, common sense and the people who are around you to keep the patient’s best interests in mind. Build your safety net, and never be afraid to fall back to the basics for the patient.