Precepting

I’m assigned a paramedic student. And while I love students, I’m not too happy to be precepting this one. She is as close to clueless as you can get and still be allowed to ride.

I precepted her a couple weeks ago. She talked a good game so I figured it would be an easy day. We did a call for a violent psych. We get there and find four mental health workers holding down a screaming fifteen year old, one adult on each junior, though muscled limb. I call and get orders for ativan and benadryl. I draw up the ativan and hand it to her, then turn my back to draw up the benadryl. When I turn back, there is blood all over the place. I look at the patient’s AC, and see that is where the blood is coming from. She gave her an IM shot in the AC. The other medic, who was at the call, watching, says he was going to say something, but thought maybe they were teaching a new technique in school these days.

Today she blows an IV on a chest pain, blows it bad enough that I switch places and do the IV myself instead of giving her a second shot. I run off the 12-lead and ask her what she thinks. She looks at me for an answer. I show her the inverted T’s in the anteroseptal leads.

“Reciprocal changes,” she says.

I shake my head and show her there are no elevations in the any of the other leads.

“Should we do a right-sided ECG?” she asks.

I shake my head again.

At triage she tells the nurse there are reciprocal changes.

We go over it after the call. She looks at me, almost coldly like she is pissed that I am semi-scolding her. I’m not scolding. I am just telling her some of the basics of cardiology.

Her assessments are poor, her IV skills are terrible. We do a shooting, 18 year old shot in both arms in a drive by. Right elbow, left proximal humerous. He’s alert, warm and dry. Good pulse. We get him in back. I tell my partner to drive. The student is already trying for an IV.

“How about a blood pressure?” I ask.

After she gets that, she goes right back to the IV. She uses a 16, and gouges a hole in the kid’s AC, and grinds it so hard, the kid who’s right elbow is completely shattered, shouts at her to stop.

I switch places again and pop an IV in.

In the trauma room, I am showing the trauma doctor, the bullet holes. Right elbow, left proximal humerous.

“What about there?” the doctor says pointing to the left AC. “There’s a third.”

“No, no, no,” I say. “That’s an IV attempt.”I

t’s almost time to head in for the day. The student reluctantly hands me her evaluation papers, then we get a call for an unknown, not far from the hospital.

We show up and see the telltale relatives standing outside, urging us frantically to hurry. The fire department has arrived just before us.

“Step it up,” a fire fighter says.

We charge in through the old house. I can hear people yelling and crying. When I get in the room, I see a man doing mouth to mouth on a woman who looks to be in her thirties. She has a dialysis port coming out of her naked chest. The fire guys are putting the defibrillator on. Shock advised. Shock.

I hand the rider our monitor and tell her to attach it. I tell the fire guys to start CPR, as we ease the family member out of the way, and I get out an ambu bag.The woman is in V-fib.

“Go ahead and shock,” I tell the student.

I get out the intubation kit, lay the laryngoscope to the side of the woman’s head, then stick a stylet in a tube and attach a syringe, as the student shocks again.

“Ready to tube,” I ask her.

She looks surprised like she didn’t think after how the day had gone I was going to let her tube.”

Go for it,” I say.

She scoots to the head, and sticks the blade in her mouth. She seems to struggle with it.

“You’ve got it?” I ask. I’m not giving her a second change if she can’t pass it.

“Yeah, yeah, I do.”

And I see her pass the tube. I hand her the ambu-bag and it looks good. Check the lung sounds and they are present and equal.

“Good job,” I say.

We work the lady hard. She’s got no IV access, and its dark in the room, so we move her out to the ambulance, where I put in an EJ, and we slam some IV drugs. She’s still in and out of v-fib, and then settles into ventricular asystole. They work her for a little while at the hospital.

The student is ecstatic. She is wired, running around the ER like she just scored the winning basket in the NCAA championships, telling everyone about it in detail.

I see the family coming down the hall. They look distraught. I ease the student outside where she can do her funky chicken dance out of the family’s sight.

The truth is I am happy for her. She had a shitty day, then she got her code, got her first field tube. I remember when I got mine. I was just as excited.

I’ve been doing this for twelve years. The truth is I was clueless once too.

2 Comments

  • Anonymous says:

    I start paramedic school next week. Reading this makes me paranoid. I’m worried that I too will be that clueless. My wallet has an EMT card in it. According to the National Registry, the state where I live, and my EMT class instructor, I am qualified to functional at the level of an EMT. But the other day, when doing a call with the local ambulance service, I fell apart it felt like. The patient had inhaled some noxious fumes. The medic asked me what I should be worried about. Well the guy was looking like he was about to puke, so I said, “Uh, vomit?” He said, “What else?” I didn’t know. Then he said, “How about airway?” Duh. Airway swelling. ABC. I forgot A. Felt stupid. Felt like the more encounters with patients I have, the less I feel like I know. The reality is that I am being tested in the streets, not the classroom where the patient is plastic, where there isn’t a family, two cops, and five firefighters watching me. There isn’t a stretcher I don’t remember how to operate properly, a heart monitor that I can’t attach the leads to, and an O2 tank that isn’t buried in a bag I can’t find in the back.I try and remind myself that the more I learn and the more encounters I have that the more my limited knowledge is stretched and pulled — the more holes I see. I didn’t know those holes existed, and now I can start to fill them in. It doesn’t feel good at the time, however.

  • Lisa Aulbert says:

    I hate to break this to you, but you are a part of the problem. Having an easy day is not dependent on if a student “talks a good game” and being a good preceptor does not mean that you give a student that has CLEARLY demonstrated deficiencies during several calls during the shift, the chance to fail during advanced airway management. You got lucky that she was able to place that tube. If she failed again, would that be HER failure, or YOURS? As a preceptor, and the medical authority on a scene, you are required to have absolute control. Your patients are counting on YOU to not turn their back while the student mainlines a medication and they are counting on YOU to determine before that GSW or cardiac arrest call drops if your student has the competency to place an IV or intubate. Being there to save the day when your student fails at an IV or a tube may make you feel like a successful preceptor and a great medic, but being there in a controlled, calm, and observant fashion is what actually makes you a good preceptor. She obviously has a lot to learn as a student, but I think that you have more to learn as a preceptor.

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