Final Exam


You should never have been precepting. You did not have enough street experience, not to mention you were not even old enough to buy a drink when you started. But these days like too many of your peers, you go from EMT school to paramedic school without putting in the time on the road. Sure you worked for another service for awhile, but the volume was low and you mainly did transfers. Had I been in charge I would have insisted on your putting in a year in the city, banging out 911s, cleaning up the mess your paramedic partners would make in the back of the ambulance. But it was what it was. You showed up in your new yellow reflective coat and the freshly sew paramedic patch on your sleeve, and a copy of Tim Phalen’s 12-Lead in Acute Coronary Syndromes under your arm, and they put us on the road together.

My first impression was you were you are nice young man, extremely polite, very nice to patients, respectful of other responders and health care professionals. Your work ethic was good. You were always there before me, always checking your gear out when you came in, even before you were permitted to punch in. After a call, you always listened to what I had to say, and thanked me, even if you made me feel like an old headmaster and not your partner, with yoru “thank you, sirs!” And when I didn’t have anything to say, you had your pencil out and were filling in all the answers to the questions Tim Phalen asks in his book.

Your IV skills were surprisingly good, which didn’t mean I didn’t have to step in a time or two, but that is what preceptors are for. I tried to teach you to be thorough, and met no resistance from you. It didn’t take you long for you to get into the routine. I would start to think you were doing okay, and then we would get a really sick patient, and you wouldn’t perform as well as I wanted to see. You were slow to recognize, slow to react, and at the hospital, your reports were so jumbled, I often thought we had been on different calls.

That was were your lack of experience showed. It was hard for me to imagine you out on your own. You felt it too. You asked me twice if maybe we should end the experiment and have you put in your year of BLS in the city. I have never had a preceptee say that to me before. Normally, when they aren’t doing well, they are demanding to know how much longer until they are cut loose. They feel they paid their money for their course, they passed it, got their license and now they just want to know how much longer until their misery ends and they can start being their own bosses.

How many ALS calls have we done together these last three or four months? A lot. We bang out 9-10 transports a shift. Maybe from those we did two, three hundred ALS calls. We did three codes, you got two tubes, and on the one you couldn’t, you got a combitube in. While you weren’t as forceful as I would have liked to have seen, you weren’t completely lost. We got pulses back twice and kept them to the hospital (thanks epi and dopamine for contributing to yet more ICU deaths). We did a few STEMIs, some room one traumas, stroke alerts, used CPAP a few times, did a lot of 12-leads, and were exchanging controlled substance kits nearly every day.

I was still undecided about you. Every day I discovered something you didn’t know, but I suppose that also meant every day you learned something new. I tried to remember back when I was new, and how unprepared I had been, but that was a long time ago, and I am getting old and my memory is hazy.

Last week we got a call for a young adult with dyspnea. Young, early twenty something year old kid in the North End, complaining of difficulty breathing. They initially sent a BLS unit, but because we were floating, we said we’d take it on the theory the more calls we do the better. The kid was laying on the couch on the second floor, holding his chest and moaning. He said he had a history of asthma.

You set your gear down and knelt down in front of him and introduced yourself by name  like you always do, while I leaned against the wall, staying out of the way watching you. As you asked questions, you felt his forehead, which appeared dry, listened to his lungs, which were clear. You checked his vitals which were normal. His pulse SAT was 100% on room air. This was not asthma. Everything appeared normal in this otherwise fit young man who had this sudden onset of chest pain that he said felt like a squeezing in his chest.

You looked over at me then. I waited to see what you would say. “I guess I should do a 12-lead,” you said.

“Good,” I said. “Go ahead.”

You explained to the patient, you were going to put these stickers on his chest to check his heart. Then you entered his young age and pressed the button. You cautioned him to sit still. Finally, the 12-lead came out like so many we had done before. I watched as you tried to peel the 12-lead off the machine. All this time and you still have difficulty ripping it off smoothly. I saw you look at it. You seemed to stare at it. You kept staring and then saying nothing you walked over to me and held it up in front of me. You looked at me, then back at the 12-lead, as if to say. “Is this really what I think it is?”

It wasn’t like the pictures in your Tim Phalen book for pericarditis and it wasn’t like the ones for early repol. Twenty-two years old, be damned, it looked like the ones for an anteriorlateral STEMI with hyperacute T waves.

I nodded my assent.

A quick question about family history. Yes, with death at a young age. History, presentation, diagnostic 12-lead.

To our partner, get the stair chair, immediate STEMI alert from second floor, aspirin, down in the ambulance, transmit ECG, transport, strip patient, two big IVs, NTG, defib pads applied, …

100% occlusion in the cath lab.

I think of all the paramedics who might have blown that kid off. He’s only in his early twenties, his vitals are fine, he looks like he could outrun Wily E. Coyote. Walk him down the stairs, sit him on the bench seat, put him in the waiting room with all the other pleuritic chest pains.

So that patient was your final exam. I have made up my mind to pass you. That doesn’t mean you know everything there is to know. You are not close to that. But as I see it. You will never not medicate a hip fracture who is in pain. You will never not do a 12-lead on an elderly woman with weakness. You will never not treat a patient with respect. You may know less than other new paramedics, but at least you know that. And I would rather have you out there being cautious than someone who knows more, but thinks they know everything.

Your parents raised you well. And you will represent your profession and your service well. Sure there will be times, you will screw up. I have been doing this longer than you have been alive and I still screw up, but you will learn from your failures and your triumphs. And someday, you will sit in my seat and train a younger, less experienced paramedic. And when you do, remember what you went through.

You are not done with me yet.  I’m going to hold you for another week or two for final polishing, and then once you are on your own, I will still be around if you have questions or want to go over calls you did, and I will want to hear about them.  I will rejoice in your triumphs, and will talk your through the ones that don’t go as well.

Now get out there, and do some good!


  • Brooks Walsh says:

    Great essay Peter.

    When I finished my EMT-B, I immediately applied to an EMT-I program. Working for the World’s Worst Private Ambulance service, I soon had my minimum 50 calls needed to enroll. When I found myself surrounded by EMT-Bs with years of experience, who had worked with medics, and even pushed meds in codes, I realized I was pretty intimidated, and possibly cocky, to try and move up the food chain so quickly.

    When I confided these insecurities to another student, someone who I imagined would be bothered by my inexperience, he shrugged his shoulders. “That’s a good thing, actually,” he told me. “You haven’t had time to develop bad habits.”

    So, it sounds like you got to this guy before he learned the WRONG lessons from experience!

    • medicscribe says:

      Thanks, Brooks, I hadn’t thought of the preventing bad habits angle of precepting less experienced medics, but there is something to be said for that. Fortunately our company afforded us a lengthy precepting period, and did not try to rush a verdict. I think in the end, the most important thing is not experience, but mindset.

  • EMS Artifact says:

    In my experience training new EMTs or paramedics, I’ve found that attitude counts for a lot. A new guy who doesn’t think that he knows it all and that training is just a formality is unfortunately rare these days.

    You did a good job with this young paramedic, but you also had good raw material to start with.

    Nice work by both of you.

  • Squad51KMG365 says:

    Wow, you hit it right on the head. Being a Preceptor, especially towards the end, can feel like being a parent, getting ready to send your kid off to Basic Training or college. They’ll most likely end up fine and will probably surprise you in some ways, and at the end of the day, hopefully make you proud. Great writing, from a fellow New England Medic!

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