Tough Paramedic School Topics

[DigitalFusion04]

Just wondering what people found to be the hardest topics to process in, during and after paramedic school. Anatomy drugs, pt assessment? and why.
comment away!

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[deleted6669]

dealing with the difficult partner.....

 

[leviathan]

Dealing with difficult patients.

 

[deleted6669]

a difficult partner is worse than a difficult pt.....
at least the pt is gone after an hr or so...the partner might be yours for months.....

 

[leviathan]

a difficult partner is worse than a difficult pt.....
at least the pt is gone after an hr or so...the partner might be yours for months.....

I agree. I was just adding yet another thing you don't learn in class. So far I've never had a problem with any partners, except for a couple being exceptionally quiet and withdrawn.

 

[canjosh]

nursing homes

 

[DropkickMurphy]

None of it should be that difficult, seeing as it is a bare bones program (compared to what it should be) in 99% of places.

 

[Vince]

Here's a thought based on my experience...

I am a former paramedic, now a physician and have had the fortune to see both sides of emergency medical services...pre-hospital challenges and in-hospital results.

I think the biggest challenge for Paramedics is to continuing education with respect to medical knowledge and physical assessment. I used to teach EMS as a paramedic and the pattern that I saw is continuing education too focused on procedures, new techniques, etc. For example, bringing RSI or
12-lead EKG's to the prehospital setting. These can be a valuable tool in the prehospital setting but I don't think enough focus is on medical knowledge and decision making, and especially evidence based pre-hospital care. Just because these techniques exist doesn't mean you should do them. Sometimes learning new procedures or techniques just means that you are going to perform new procedures or techniques....but I think there has to be a strong foundation of continued medical knowledge and physical assessment that must continue after paramedic school. Unfortunately there is little feedback that paramedics get about the consequences of management decisions that are made in the field and how they impact the patient in the long term.

On the flipside, emergency physicians and others that work in the emergency department have to take a more active role in paramedic education....my recent experiences in the emergency department as a resident involved witnessing paramedic students trying to learn how to start IV's, intubate, etc. but not many of the paramedic students were generally interested in the delivery of health care, the disease process, and the clinical management.

That is my challenge to future paramedics and current paramedics...keep trying to learn more to stregthen your knowledge and thus skills. I think that's the most difficult challenge for paramedics after paramedic school. And for those in paramedic school, you will eventually become proficient in intubation, IV's, and other skills, but its important to know the indications/contraindications, and theories behind those skills/treatments.

Just my $0.02.

 

[a_ditchdoc]

Here's a thought based on my experience...

I am a former paramedic, now a physician and have had the fortune to see both sides of emergency medical services...pre-hospital challenges and in-hospital results.

I think the biggest challenge for Paramedics is to continuing education with respect to medical knowledge and physical assessment. I used to teach EMS as a paramedic and the pattern that I saw is continuing education too focused on procedures, new techniques, etc. For example, bringing RSI or
12-lead EKG's to the prehospital setting. These can be a valuable tool in the prehospital setting but I don't think enough focus is on medical knowledge and decision making, and especially evidence based pre-hospital care. Just because these techniques exist doesn't mean you should do them. Sometimes learning new procedures or techniques just means that you are going to perform new procedures or techniques....but I think there has to be a strong foundation of continued medical knowledge and physical assessment that must continue after paramedic school. Unfortunately there is little feedback that paramedics get about the consequences of management decisions that are made in the field and how they impact the patient in the long term.

On the flipside, emergency physicians and others that work in the emergency department have to take a more active role in paramedic education....my recent experiences in the emergency department as a resident involved witnessing paramedic students trying to learn how to start IV's, intubate, etc. but not many of the paramedic students were generally interested in the delivery of health care, the disease process, and the clinical management.

That is my challenge to future paramedics and current paramedics...keep trying to learn more to stregthen your knowledge and thus skills. I think that's the most difficult challenge for paramedics after paramedic school. And for those in paramedic school, you will eventually become proficient in intubation, IV's, and other skills, but its important to know the indications/contraindications, and theories behind those skills/treatments.

Just my $0.02.

I agree completely. As a paramedic, and former instructor, I think the most commonly overlooked parts of EMS training are those you pointed out above. If your assessment skills are not adequate, you certainly can never know how to treat a patient appropriately.

Great post...

 

[chimichanga]

Any monkey can do many of these skills...(no not a crich, or other advanced skills, relax you cowboys )

I am referring to medic, RN, and doc skills...

You are correct Vince...

My buddy and I were talking yesterday...He works weekends as a charge nurse in a nursing home...

He called 911 (a rare occurance for him) for an unresponsive pt...

While waiting for EMS to show, he initiated CPR w/ NRB oxygen...

He actually got a pulse just before EMS arrived...

Immediately upon their arival, the local FD medic broke out the new, harpoon - like, sternal IO (without even looking for a vein)...

It didn't take, and now they were doing chest compressions while dealing w/ a bleeding chest wound...

Pt was intubated soon after, but they could still not get a line...

She went right for another IO, forgetting that meds can be delivered through the ETT...

My buddy reminded them of this, which gave way to blank stares, and a collective "oh yeah"


You said it best...Just because it exists, doesn't mean the skill should be done every time...

Better yet: Just because you can, is likely why you shouldn't...

Focus on the basics...

Poor lady was pronounced in the ER...

 

[canjosh]

Here's a thought based on my experience...

I am a former paramedic, now a physician and have had the fortune to see both sides of emergency medical services...pre-hospital challenges and in-hospital results.

I think the biggest challenge for Paramedics is to continuing education with respect to medical knowledge and physical assessment. I used to teach EMS as a paramedic and the pattern that I saw is continuing education too focused on procedures, new techniques, etc. For example, bringing RSI or
12-lead EKG's to the prehospital setting. These can be a valuable tool in the prehospital setting but I don't think enough focus is on medical knowledge and decision making, and especially evidence based pre-hospital care. Just because these techniques exist doesn't mean you should do them. Sometimes learning new procedures or techniques just means that you are going to perform new procedures or techniques....but I think there has to be a strong foundation of continued medical knowledge and physical assessment that must continue after paramedic school. Unfortunately there is little feedback that paramedics get about the consequences of management decisions that are made in the field and how they impact the patient in the long term.

On the flipside, emergency physicians and others that work in the emergency department have to take a more active role in paramedic education....my recent experiences in the emergency department as a resident involved witnessing paramedic students trying to learn how to start IV's, intubate, etc. but not many of the paramedic students were generally interested in the delivery of health care, the disease process, and the clinical management.

That is my challenge to future paramedics and current paramedics...keep trying to learn more to stregthen your knowledge and thus skills. I think that's the most difficult challenge for paramedics after paramedic school. And for those in paramedic school, you will eventually become proficient in intubation, IV's, and other skills, but its important to know the indications/contraindications, and theories behind those skills/treatments.

Just my $0.02.

^^^Exactly why I so strongly advocate for medics to work in the ED.

 

[DropkickMurphy]

Any monkey can do many of these skills...(no not a crich, or other advanced skills, relax you cowboys )

I am referring to medic, RN, and doc skills...

You are correct Vince...

My buddy and I were talking yesterday...He works weekends as a charge nurse in a nursing home...

He called 911 (a rare occurance for him) for an unresponsive pt...

While waiting for EMS to show, he initiated CPR w/ NRB oxygen...

He actually got a pulse just before EMS arrived...

Immediately upon their arival, the local FD medic broke out the new, harpoon - like, sternal IO (without even looking for a vein)...

It didn't take, and now they were doing chest compressions while dealing w/ a bleeding chest wound...

Pt was intubated soon after, but they could still not get a line...

She went right for another IO, forgetting that meds can be delivered through the ETT...

My buddy reminded them of this, which gave way to blank stares, and a collective "oh yeah"


You said it best...Just because it exists, doesn't mean the skill should be done every time...

Better yet: Just because you can, is likely why you shouldn't...

Focus on the basics...

Poor lady was pronounced in the ER...

Well, the new ACLS guidelines have strongly downplayed the use of the ET route and put new emphasis on IO as a route for access in the setting of failed IV access. From speaking with members of the ACLS committee that I know, they came very close to recommending it as a the preferred initial measure for vascular because of the rapid nature of the procedure and the high success rate (>90% in most services). It is in our prehospital protocols as an option to skip the IV and go for an IO in the setting of cardiac arrest or "impending" arrest, and then gain standard IV access as soon as possible and this has become our standard practice.

Granted, I'm not specifically defending the medics in the above described incident, but I can say that a LOT of nurses (I'd say the majority actually) have little to no idea what our protocols entail and it leads to frequent misunderstandings on both sides- "Stupid medics", "bitchy self-important nurses", etc. Perhaps they didn't "forget" that you can give the meds down the tube, but rather were aware of how ineffective (and even detrimental according to some studies) this has proven to be in actual practice.

By the way, this "poor lady" probably would have died regardless of how well the code went. Remember that even in healthy young adults the outcomes are less than stellar in the majority of cases and this lady was likely in a nursing for a reason. Before seeming to go about blaming the medics, remember the deck was stacked against her survival before they ever were called or arrived on scene. Oh, and not to nitpick, but CPR with a non-rebreather, well....that quite frankly doesn't do a lot for a patient that is maybe exhibiting at most agonal respirations......sounds like the medics weren't the only ones with a questionable grasp on resuscitation.

 

[emtcsmith]

Let me stray a little and say If you haven't seen EZ-IO in action when the fecal matter is hitting the rotating device above you then you haven't seen 21st century Emergent care.

Try this one on for size...
Bi-lateral IO acess with medication and fluids running as medic #2 sets up, does and confirms intubation. B-e-aiful for the GSW cardiac arrest.

 

[DropkickMurphy]

Agreed.....IO's are very useful, and I imagine the troubles encountered by the medics (which are probably being overstated by the nurse who "witnessed" thenm) were probably due to the woman in question having osteoporosis that affected her sternum. I've heard a couple of anecdotal reports of this being a problem in very old patients.

 

[chimichanga]

...Oh, and not to nitpick, but CPR with a non-rebreather, well....that quite frankly doesn't do a lot for a patient that is maybe exhibiting at most agonal respirations......sounds like the medics weren't the only ones with a questionable grasp on resuscitation.

uhh, have you any knowledge of what's at your typical nursing home as far as a code cart?

they had to go to the supply room to find a NRB, that was encrusted w/ an inch of dust...there is no face shield...do you want to give mouth to mouth w/ vomit?

not to nitpick, he's an ACLS instructor, that is burned out on the ER...though, NOT your typical NH nurse...

oh, and they hadn't even TRIED a peripheral line yet...

my point is (though I wasn't there) was that she appeared to be overzealous (like maybe she had just attended an inservice)...I know I'm not a medic, but me thinks trying a peripheral line comes before an IO...I know, I'm just a nurse...

 

[chimichanga]

Agreed.....IO's are very useful, and I imagine the troubles encountered by the medics (which are probably being overstated by the nurse who "witnessed" thenm) were probably due to the woman in question having osteoporosis that affected her sternum. I've heard a couple of anecdotal reports of this being a problem in very old patients.

"witnessed" is referring to, I'm guessing, that NH nurses leave the room when the fecal matter hits the rotating device?

maybe in most, but not all...

 

[DropkickMurphy]

oh, and they hadn't even TRIED a peripheral line yet...

my point is (though I wasn't there) was that she appeared to be overzealous (like maybe she had just attended an inservice)...I know I'm not a medic, but me thinks trying a peripheral line comes before an IO...I know, I'm just a nurse...

Please note that I said that many services (including my own) are moving towards IO's as a front line practice in cardiac arrests, etc.

"witnessed" is referring to, I'm guessing, that NH nurses leave the room when the fecal matter hits the rotating device?

maybe in most, but not all...

Well, in several states (according to the state nursing boards), in the absence of patient specific orders, a nurse is expected to yield to the medics, so I guess it depends on where you are at. So yes, most of the time the nurses and CNA's step aside and let us do our job as we are in charge once we arrive on scene.

 

[DropkickMurphy]

uhh, have you any knowledge of what's at your typical nursing home as far as a code cart?

Last time I checked our state mandates at least a BVM or pocket mask on each wing of a nursing home.

 

[chimichanga]

...Well, in several states (according to the state nursing boards), in the absence of patient specific orders, a nurse is expected to yield to the medics, so I guess it depends on where you are at. So yes, most of the time the nurses and CNA's step aside and let us do our job as we are in charge once we arrive on scene.

I guess I presumed you meant that the NH staff run from the scene when EMS arrives, as has been my experience, rather than stick around to help, if needed...

And I have to apologize...I was in a meeting thinking about my post...I meant to say that he initiated CPR w/ a BVM (wrong letters ) - NOT a NRB

He says: "I showed up in the room, and said let's bag her...The CNAs and LPNs thought he meant a body bag...Now THAT'S scary, and all too common in a NH...

 

[DropkickMurphy]

No worries....I was confused a bit by the NRB thing, and I didn't mean to malign nurses as a group (I've got two nasty PM's from different people regarding this). I have worked with several exceptional nurses and numerous ones who I respect a great deal. We (my EMT's and myself) tended to have a decent working relationship with NH staffs mainly because I tried to avoid turf wars, and often the nurses were more than happy to take an "assisting" role since they realized we had our area of expertise, just as they have theirs.

 

[leviathan]

And I have to apologize...I was in a meeting thinking about my post...I meant to say that he initiated CPR w/ a BVM (wrong letters ) - NOT a NRB

Ah, now that makes sense. I was wondering how you could get any ventilation if your only positive pressure is coming from a 10 litre O2 flow.

 

[Paramedicwanabe]

Last time I checked our state mandates at least a BVM or pocket mask on each wing of a nursing home.

That's It!!!

that's insane! There's tons of old people around

 

[canjosh]

I guess I presumed you meant that the NH staff run from the scene when EMS arrives, as has been my experience, rather than stick around to help, if needed...

And I have to apologize...I was in a meeting thinking about my post...I meant to say that he initiated CPR w/ a BVM (wrong letters ) - NOT a NRB

He says: "I showed up in the room, and said let's bag her...The CNAs and LPNs thought he meant a body bag...Now THAT'S scary, and all too common in a NH...

The unfortunate thing is that your initial post referring to a NRB was TOTALLY BELIEVABLE. Many of us (myself included) have responded to codes at NHs where a NC or NRB was the only resuscitative measure attempted by the staff. Sometimes nothing was done--I mean what's the point in being at a healthcare facility at that point?! Not a bash on you by any means (or against all nurses--I'm married to one!), but it is sad to say that I actually believed your reference to the NRB.

 

[chimichanga]

The unfortunate thing is that your initial post referring to a NRB was TOTALLY BELIEVABLE. Many of us (myself included) have responded to codes at NHs where a NC or NRB was the only resuscitative measure attempted by the staff. Sometimes nothing was done--I mean what's the point in being at a healthcare facility at that point?! Not a bash on you by any means (or against all nurses--I'm married to one!), but it is sad to say that I actually believed your reference to the NRB.

indeed...I worked on an RN ambo, and used to run calls in NHs (when all the medic cars were busy), and used to find pts on NRB @ 3 litres, pts in resp distress lying flat, or my favorite, the ALOC, who is a diabetic, and NOBODY did an accucheck...

and the "nurses" were more concerned about copying the chart...

The pt with ALOC, I remember the nurse nowhere to be found, the pt is drooling, and the CNA is brushing the hair of said patient

 

[DropkickMurphy]

That's It!!!

that's insane! There's tons of old people around

Well, there are other things required too....but I was just referring to the things you could use to ventilate someone.

 

[DropkickMurphy]

indeed...I worked on an RN ambo, and used to run calls in NHs (when all the medic cars were busy), and used to find pts on NRB @ 3 litres, pts in resp distress lying flat, or my favorite, the ALOC, who is a diabetic, and NOBODY did an accucheck...

and the "nurses" were more concerned about copying the chart...

The pt with ALOC, I remember the nurse nowhere to be found, the pt is drooling, and the CNA is brushing the hair of said patient

*twitch*

 

[chimichanga]

Yes...

Soon you pre meds and residents will get to assume care of these pts when they show up at your doorstep...


The inhumanity!!!!!!!!