Prune Your Practice

One of the most rewarding elements of instructing paramedics is getting to watch the evolution of their individual practice of prehospital medicine.

Initially, growth is slow, because of the extraordinary knowledge requirements of the practice. For example, at my program, students will read roughly 8,000 pages of content during the first 6 months of class. Unlike a class on European history, where you can flush your memory banks immediately upon successful completion of the final exam, we need to develop a fund of knowledge we can be tap on demand, often under duress. Over time, the fund of knowledge gets wider and deeper as the provider learns many new things, while also learning more about what they already know.

Along with developing the requisite fund of knowledge, is the acquisition and mastery of the essential skills of the craft. Time and repetitive practice are the keys to success.

Collectively, with these two elements in place, the development of the practice moves along much more quickly at the same time an interesting dynamic unfolds. As a student becomes more successful in their assessment and management of sick or injured patients, they increasingly become more confident. With increasing confidence, they become more successful.

As a practitioner continues to move down this developmental highway on their way toward being “entry level competent,” i.e., safe to work on people, they will increasingly be required to make choices that will define the subtleties and nuances of their individual practice. Some of these choices are good and have a positive influence on the practice. Poor choices obviously have a negative influence, though each still represents growth.

Let’s look at some examples of negative growth:

Taking a blood pressure

At some point, you decide taking a manual blood pressure with a b/p cuff and stethoscope is too time consuming, so you begin to “palpate” all your blood pressures. Without the use of the stethoscope, you have now introduced an unnecessary margin of error into your assessments of blood pressure.

Let’s say you are assessing a cardiac patient with chest pain, and your palpated pressure is 94/68. Properly auscultated, the patient’s pressure is actually 104/72. But if you hang your hat on the palpated pressure, and as such, the patient cannot receive nitroglycerine for pain management (systolic b/p < than 100 mm/Hg), your patient will be heading to the hospital in misery, along with the potential for the MI to worsen, as well.

Doing a rig check

You come in for shift change and the off-going crew greets you with, “We didn’t turn a wheel all shift! You’re good to go.” With that news, you opt to not do a rig check, and decide to go ahead and put the rig in service. Unbeknownst to you and your partner, the off-going crew didn’t do a proper rig check either.

Shortly thereafter, you are dispatched to a man down that turns into a full arrest. As your partner applies the AED, you open the airway kit only to discover that the intubation roll is nowhere to be found; it’s still sitting back at the station, where it was left in the middle of being restocked by a provider called away to do some house duty yesterday. Because of this oversight you cannot intubate and secure the patient’s airway. You have no choice but to place an OPA and simply bag the patient during the resuscitation attempt.

Reading the transfer sheet

It’s your fourth nursing home-to-hospital transfer of the morning, and as has become a recent practice, you don’t even bother to read it. Instead, you just toss it in the rig and take the patient to the hospital. In the hand off report, you heard about a chief complaint of abdominal pain secondary to no bowel movements for the last four days which you pass on at the hospital. However, inside the transfer packet, there is also a request for the receiving facility to look at a suspicious rash under the left armpit that they suspect is MRSA, which it turns out to be. You and your partner have both been exposed.

Discussion

The examples above are just a few of many examples of what would be identified as a negative growth in a practice. Just as in nature, when plants have unwanted growth, that growth needs to be pruned away. In general, most all plants benefit from periodic pruning, and for fruit-bearing plants, proper pruning increases the yield from harvest.

The same type pruning event must periodically occur in the practice of prehospital medicine to keep it healthy. Close examination of your practice will almost certainly reveal a number of changes you’re accrued over a prolonged period of time. At some point you made a choice, and subsequent to that choice something changed in your practice. When you intentionally take the time to be introspective about your practice of prehospital medicine, you’ll clearly the unhealthy growth. From there the next step is easy, if you choose to take it—prune the unhealthy growth away, sprout fresh, new buds and increase your yield of quality medicine.

Until next month….

Mike Smith, BS, MICP, is program chair for the Emergency Medical Services program at Tacoma Community College in Tacoma, WA, and a member of the EMS World editorial advisory board.