My good friend Ambulance Driver has written an excellent post titled What Every Paramedic Student Should Know. Read that post first and then come back here, because much of what I am going to say references what he wrote.

Despite the title of my post, the advice can also apply to BLS providers.

I generally, but not always, agree with AD on things EMS. More so on things not EMS, but that’s not the topic today. Despite our generally similar world view, we do come from different backgrounds and different EMS environments. That probably accounts for where we differ.

That being said, here is my advice to new paramedics.

Every ALS patient starts out as a BLS patient. Before you put on the $22,000 cardiac monitor, before you start thinking about what size IV you’re going to use, before you start calculating drug dosages, you need to assess the patient. All assessments start with the very same ABCs that you learned early on in EMT school. The difference is that you now know, or should at least, more and better ways to fix those problems. Just don’t forget that you have to fix those problems before you go on to the rest of the exam and start treatment. I’ve seen more than one paramedic worry about placing an IV while the patient struggled to maintain their airway. It’s bad medicine, pure and simple.

Sometimes you don’t get beyond A. I recently had a patient where we spent almost the entire call trying to secure the airway. I won’t go into the gory details other than to say it involved head trauma, beer, lousy anatomy, and frustration. We used a lot of ALS equipment to secure the patient’s airway and end up with something other than an endotracheal tube. It wasn’t optimal, but it was light years better than not being able to secure the airway at all. You can’t get anywhere if you don’t take care of airway first.

Sometimes you don’t get past B. Breathing is good, not breathing is bad. However, breathing without effective gas exchange at the cellular level is pretty useless. You doubtless have all sorts of protocols that require application of equipment to help diagnose and treat your patient. None of that does a bit of good if your patient can’t breath. We’re supposed to get a 12 lead EKG on every patient that has “symptoms suggestive of ACS”. Sometimes, such as when the symptom is respiratory distress so severe that the patient can’t speak, we don’t get that far. Treating the respiratory distress takes absolute precedence over everything else (except airway).

You need to document a whole lot more than you did as an EMT. The expectation is that you know more and can do more as a medic than you could as an EMT. Along with that expectation comes the expectation that you’ll be better at documenting. Unfortunately, paramedic schools don’t seem to do a good job teaching people how to write a report. So, you’re going to have to work on this one yourself. AD makes a book recommendation, but that seems to be out of print. Here is my advice. Write more rather than less. Write in detail. Don’t be redundant. If your system uses an electronic system, this might be easier. Then again, it might not. And check your spelling. Really.

You will be judged by how you speak. One of the most frustrating, nay, infuriating things, about the 1994 BLS curriculum revision is that it pretty much deleted well recognized medical terminology from EMT courses. Before that, EMT students learned the medical terms and a lot more anatomy and physiology. After that, it was the medical version of Pidgin English. What the people who re wrote the curriculum didn’t realize is that doctors, nurses, and other people that EMTs interface with would recognize the change. As a result, EMTs are now seen as pretty dumb by other medical professionals. As a paramedic, you can’t afford that. If your paramedic program didn’t cover Anatomy and Physiology well, preferably with a separate course, then get a text book and read. Then get a medical dictionary and use it as often as you need to until you are familiar and comfortable with commonly used medical terms.

Sometimes our report is the most important thing we can do for the patient. Our observations can, if presented properly, help the hospital staff tremendously as they treat the patient. But not if they don’t pay attention to it. Much of that will be determined by how much they respect you and your report.

Case in point. Not to long ago I was conversing with someone who will soon be working for my service as a paramedic (maybe). I mentioned Aortic Stenosis to him, and got a blank look followed by some BS about what he thought it was. After advising him not to try to BS a doctor like he tried to BS me, I suggested that he go read up on the topic. I don’t think he was very happy with that, but he did it and the next time was able to quote chapter and verse about it to me. Not bad, but I think he still considered it hazing on my part. Which is where things would have stayed had he not had a patient with Aortic Stenosis a couple of days later. He came back to me and told me how cool it was to be able to discuss it with one of the treating physicians and know what he was talking about. Knowledge comes in handy sometimes.

Don’t use words whose meaning you don’t know. Really, nothing makes a medic look more stupid than tossing around words and not knowing what they mean.

Which brings me to the next point. Don’t try to bull shit your way through a call. Don’t let your ego make you do something stupid. No one knows everything, not even Ambulance Driver and he’ll be the first to admit that. Sometimes it’s hard to admit you don’t know something, but remember it’s about the patient, it’s not about you. That’s one of the benefits of a two paramedic per unit system, but you can also ask medical control if you get stuck. I’ve walked into hospitals with really sick patients and the first words I’ve said to triage are “I really don’t know what’s going on here.” In cases like this, revert back to the ABCs and you’ll likely keep the patient from getting worse until you can get to the hospital. If you follow up on these patients, you’ll often find that they were as big a mystery to the doctors as they were to you.

Be nice to the BLS folks. Chances are they knew you when you were a lowly EMT. Don’t think now that you’re a paramedic that your crap smells like flowers. It doesn’t, it still smells like crap. EMTs can help you, or they can screw you up. What they do depends in a large part on how you treat them. What’s even worse than them screwing you up, is that you will be held responsible for them screwing you up. What a lot of new medics can’t seem to grasp is that the ALS providers are responsible for what goes on during a call. Unless your QA people are complete morons, they aren’t going to buy your whiny excuse that it was the EMTs fault that something went wrong. Managing the call, in addition to managing the patient’s care, is one of the harder parts of being a medic. And one of the things that they don’t teach you in school.

Experience is important. If it’s the right experience. As the saying goes experience is something you have five seconds after you needed it. Learn from your mistakes, it will make you a better medic. I differ slightly from AD in that I think that experience is important as long as that experience consists of reinforcing the right skills. Then again, maybe we don’t differ at all. This all goes back to the beginning of this post. Good solid BLS skills are what make a good paramedic. It’s like a building. Without a solid foundation, it might look pretty, but sooner or later (probably sooner) it will all collapse.

Relax. There is a lot to learn in school and after school is over. You won’t learn it all in a day. You have to work anywhere from six months to a year as a medic before you start to get comfortable in the role. As you gain more experience the number and type of difficult calls will reduce. Your comfort level will grow. You will still run in to calls that make you sweat, but they will be less frequent.

Don’t worry about being sued. If you treat your patients well and keep their interests first in your priorities, it is far less likely that you’ll end up in court. Being nice to patients and families is a key part of that too. You’re more likely to end up in court as a witness than as a defendant. Which is another reason why good documentation is important.

Never stop learning. Medicine advances ever more quickly. As AD points out, the text books are generally five years behind the journals. The internet can help you, but you need to seek out sources of education. I knew a doctor that practiced for almost 50 years. He once commented to me that nothing, not one single thing, that he learned in medical school all those years ago was still known to be true. Everything that he learned in medical school was wrong. He spent a lot of time unlearning the old and learning the new. As my kids observed when they were younger, it always seemed that I was either taking or teaching a class when I wasn’t working.

Trust your instincts. Some times all the numbers look good and there is nothing obvious that screams at you that the patient is really sick. Yet, there is a feeling in the pit of your stomach or the back of your head that something just isn’t right. Sometimes it’s what you don’t see that makes the difference. Or maybe it’s something that you can’t quite remember consciously, but which is lurking beneath the surface. Trust that feeling, what ever it’s source. If you don’t chances are you’ll regret it.

Transport is part of the treatment. As articulate and true as AD’s comments about us being special teams may be, the core of what we do is drive people to the hospital. At best we make them a bit better, at worst we should make them no worse. This does not mean that we should toss the patient in the truck and race to the hospital like panic struck dopes. It does mean that we have to balance what we do on scene with what we can and should do while we are moving towards the place where definitive care takes place.

Bad calls get worse. Once a call starts to go bad for whatever reason, it will continue on that spiral until it’s over. The best thing to do is move the call along as rapidly as prudently possible. It’s the best thing for the patient and for the crew.

Sometimes this job is teh suck. No one calls for EMS because things are just ducky. They call us because they have a problem. Sometimes a big problem, sometimes a small problem, but in any case their problem has just become ours to try to solve. Sometimes that’s as simple as a ride to the hospital, other times we will use all of our knowledge and skill and it still won’t make a difference. Sometimes the patient will show their gratitude for our hard work by dying right there in front of us. How you deal with the crappy stuff that happens on this job is up to you. I’d suggest something relaxing which is not self destructive, but the decision is yours.

Some people just aren’t cut out to be paramedics. If that’s the case, the sooner you know it, the better. Believe me, other people will know it and some of them won’t be shy about informing you of the fact. If after all the schooling, all the work, all the trying, you just never feel comfortable doing this job, you might want to rethink your career. This is a tough line of work, not everyone can do it. I’ve seen lots of people much smarter than I will ever be fail as paramedics. For the most part they’ve gone on to other careers where they’ve done quite well. Being a paramedic is complicated mix of knowledge, experience, instinct, and luck. Not everyone can do it.

That’s about it. Take my advice for what it is or isn’t worth to you.