Precepting

Today is the last day my latest preceptee will be with me. Tomorrow he rides with our chief paramedic, who if all goes well will formally approve his being “cut loose” to be a paramedic on his own. My preceptee has been with me for nine weeks and has been, by all standards, “a shit Magnet,” “a dark cloud,” “a horseman of the Apocalypse…” On most days, the tones start going off when he walks in the door and don’t stop until he leaves.

While I have had preceptees who couldn’t buy a critical call, we’ve done cardiac arrests (five), respiratory arrests, multiple motor vehicle accidents with prolonged extrication, stabbings, falls from roofs, countless major medicals alerts, seizures, CVAs, internal defibs going off right and left. You name it, we’ve had it, including all the routine ALS calls as well, the UTIs, pneumonias, nausea and vomiting, weakness and malaise calls. He’s done his share of all of them and done them well enough that it is now time to boot him on. Besides I’m ready to start doing calls on my own again. My preceptee, perhaps feeling sorry for me, even let me do the intubation on our cardiac arrest yesterday, while he got a chance to use the EZ-IO drill for the first time.

Back when I was being precepted, I remember feeling hurt one day when my preceptor told me he was going to cut me loose because he was getting tired of me. I know the feeling. While I enjoy precepting, sometimes I just want to do the call, get it over with and move on to the next one or at least go back to reading my book or the movie that is paused on the DVD player back at the base. I remember one time my preceptor looking at me like I was an idiot as I fumbled through a call. Finally, in front of the patient and bystanders, he wrote me a note on a piece of paper and handed it to me(instead of slapping me upside the head). “This is a cocaine overdose!” the paper said. I also remember how he would pace about at the hospital as I carefully, painstakingly, tried to write a proper paramedic run form. What now takes me only minutes to write used to take me twenty to thirty minutes, not counting the ones I had to rip up and start over on.

When I first became a preceptor I believed that the closer you were to being precepted yourself, the better a preceptor you would be. And now all these years later, in many ways I still feel that is true. While I am much more patient with a new medic’s skills than I was as a new preceptor (miss the IV or the tube, try again, no problem where before I was more likely to elbow a preceptee out of the way,) I find I am less patient at letting them work their way through a scene. I am too quick to say, you can do that in the ambulance (ask a stable alert patient for their democraphic information) or let’s get going (instead of sitting there on scene in the ambulance when we are facing an easy twenty-five minute ride to a distannt hospital) or to interject, ask them when this all started (already!). While part of a preceptor’s job is to teach, the other part is to sit back and be invisible – to let the preceptee figure it out for themselves, but I am finding it harder to be “invisible.” I think maybe I am so far removed from what a new paramedic knows or doesn’t know that I can’t relate as well. I may assume what I shouldn’t or not assume what I should.

I had a writing instructor tell me once that the beauty of Chekhov (the great Russian short story writer)’s work was you felt the effects throughout the story and were deeply moved at the end, but you could not see how he produced it. The first novel I ever wrote when I was in college, I had another writer read and his comments were “I never understood how hard it was to write a novel until I read yours.” The point I think was you could see every board and nail, every paint brush stroke. It was very painstaking and transparent.

On a routine medical a few weeks ago, a new EMT charged ahead of us, racing down the nursing home hallway and then into the patient’s room where she immediately stuck her fingers on the patient’s neck to count the carotid pulse. The only problem was the patient was alert and oriented and the call was for skin tear to the knee. While the EMT wasn’t wrong to get vital signs, you could painstakingly see the attempt to put classroom learning into the real world. On another call, an EMT interrupted our questioning of the patient with chest pain to proudly announce the patient was allergic to penicillin.

In both cases, these EMTs were showing the boards and nails of their craft (getting pulses and taking allergies) but not demonstrating any artistry. They were in fact being quite clumsy. Chekhov probably had a harder time explaining how he put his story together than a freshman English teacher has explaining how to write a basic paragraph.

I am not claiming to be a Chekhov of paramedics. Far from it. In addition to having many clumsy moments of my own, paramedicine because it is done in real time, prevents a paramedic from ever demonstrating the flawlessness of a writer, who has ample time to rewrite, and iron out the rough edges of each performance. What I can say is that I do calls better than when I started. I am both more thorough and more concise, and certainly more efficient. There isn’t a lot of wasted motion or time. Ask me how or why I did what I did and the answer is not simple, but more of a dissertation. Not I did B because B follows A and comes before C, but I did G because of K, B, Y, L, P, and several other factors that don’t have letters. When I started precepting I had more simple advice. Never do this. Always do this. Now I find that rules are less rigid. The instruction is more zen theory than facts. I probably am more confusing and make a lot less sense than I did when I started precepting. I know what I told you to do after the last call, but this situation was different. Here’s why. Etc. Etc. And I wonder then if they really understand when they say yes, but have that puzzled look in their eyes. What is he talking about.

The preceptee/soon-to-be-medic-on-his-own will do fine. He is an affable young man who treats patients, their families, and other medical staff with respect. While I have had more advanced preceptees and certainly less advanced preceptees, I have to remember that when I precepted years ago, I was far from being at the head of the class in terms of knowledge and experience. What I do know now is that being a good paramedic is less about knowing everything when you first hit the streets than it is about being willing to learn from each call, critique yourself, and constantly seek out ways to improve, to develop your own theories of practice and a style that works for you and your patients.

I will give you high marks for your potential. Good luck tomorrow. It has been a pleasure precepting you.

6 Comments

  • Tom Reynolds says:

    A good post about the art/science continuum of ambulancing and how it’s less a straight line and more a jumbled ball of string doubling back on itself.

  • Anonymous says:

    Being fresh from Paramedic school and an extensive field precepting and now a baby medic precepting for my county command I’ve seen many different ways to precept. As a student I found the type of preceptor who at my worst days was patient enough to drag me along through the call and debreif it after. Or the preceptor who on my best days stood in front of other department staff and boasted of my sucess. I looked up to my paramedic school precetors as mentors, and I’m sure you do a great of job teaching new medics the way of the streets.

  • PC says:

    Thanks for the comments.I think one of the things I am learning is just as every EMS call is different, so is each preceptee, and you have to use an individualized approach to each. The main things, which I don’t always follow, but try to, are to be patient and recognize that your preceptee, for better for worse, in some ways, some big, some small, may end up as a reflection of you. You can’t alsways make them better or who they are not, but you can make them worse if you are not careful. It is easier to teach bad habits than good ones. I’m am proud of some of the precpting jobs I have done, less so of others.

  • Witness says:

    You sound as if you are the type of person I’d want to precept me, even if you’ve become a bit removed from your roots. My first preceptor was just removed from preceptor-ship for being too aggressive with knocking me out of the way when I stumbled. I feel bad, but it wasn’t me that complained. My new preceptor has years of experience at it, and he’s very helpful.

  • Anonymous says:

    I am in to 150 of field internship, had a rough night last night. This helps

  • Anonymous says:

    HEY PC, This was a great blog 😀 I’d just like to say thanks again for sharing your wisdom and experiencfes with me. I believe that you have done a wonderful job as a precepter in my opinion although you were my first and only. I’m still feeling hungry to know more since I’ve been unleased to Wreak Havoc in our little slice of paradise. With Respect, MRE.Ps. I remember all of those calls, but you forgot the one where the EMT just let go of the moving strecher only to let it fly into some poor woman in the gymnasium, nearly knocking her over… or the time that… well we all get the point!

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