The clinical concepts that no-one teaches you about at university
You’ve spent the last three years or so getting to know the intricacies of morphine metabolism and the cardiac cycle. Those things are all important as background, but in your operational life it is at least as important to have a collection of rules of thumb to fall back on until you’ve got a bit of experience. Rules of thumb are formally known as heuristics, intellectual shortcuts which mostly work, most of the time – they’re not perfect but they can get you out of a lot of scrapes. Here are some which I’ve found useful, both clinically and in learning to live the paramedic life.
1 – Keep calm and check DRABC
The primary survey is the foundation of what we do but most of the time we don’t even have to check it. That causes two problems: First, we can forget to check the basics under pressure, meaning that an unconscious patient’s untidy airway gets checked and secured very late in the assessment. Not good, I think you’d agree.
The other issue is that after attending a lot of low acuity patients the junior paramedic can get spooked by a really unwell patient and get scattered in their approach. Take a big breath and check DRABC. For every patient, every time, even if that means insta-checking by having a conversation with them. Keep it simple and systematic.
2 – If you hear hoofbeats, look for horses not zebras
This is another thing that baby doctors are sometimes taught in medical school. In most cases, the obvious solution is the correct one. If you have a patient who has central crushing chest pain radiating to the left arm and jaw with ST-segment changes, assume that it’s cardiac in origin. If you decide that it’s pericarditis with a mandibular tumour and a soft-tissue injury to the shoulder you may have to explain your decision-making to the coroner. Again, it’s no guarantee but you’d be a fool not to be conservative about it.
3 – Don’t create problems you didn’t have already
At your level of experience you should be treating the obvious problem and being conservative. Don’t go throwing drugs at patients who don’t really need them – you may or may not get a benefit but you’ll certainly get the side-effects. If nanna has 1/10 wrist pain, giving her even a small amount of morphine runs a real risk of making her unconscious or apnoeic. Congratulations, she now needs narcan and a resus bed. Don’t thunder your elderly patient with fluid because you think he might be dehydrated. Guess what? He’s now in APO and needs an intensive care paramedic and another resus bed.
Also, “I needed the practice” is the worst reason in the world to be doing things like placing IV lines into patients – you may not have an issue with it but they’re now exposed to an ambulance-acquired infection. They won’t thank you.
4 – One thing at a time
There’s a lot to remember in your first year, especially in your first months. Remember this: Do one thing at a time and do it right. Multitasking is an excellent way to screw up both jobs. You will see more experienced paramedics gathering a history while taking a set of obs – it’s what you’re aiming for, but until you can do both tasks without thinking it’s better to do one at a time. One task at a time, one patient at a time. Don’t get flustered.
5 – Act the part and manage your anxiety
How do you become confident? Act confident. It’s an iron law of human behaviour and it works for paramedicine as well as anywhere. No patient wants a timid, quivering paramedic whose hands shake while they take a blood pressure. I certainly wouldn’t trust that person to treat my family member. But if you act the part, you become the part. Think of it as method acting for useful people. Rely on your knowledge and your partner, step up and take charge.
Parallel to that is an awareness of your own anxiety. Everyone gets anxious under pressure but there are no circumstances where anxiety makes you do your job better. Recognise when you’re getting stressed, accept what you’re feeling, and re-focus on the job. Your patients need you to be in control, even if you don’t feel it.
If you’ve read this far then I hopefully haven’t scared you off taking this big step into your new career. Even if I have, don’t pay too much attention to the doomsayers. Being a paramedic is a wonderful job, and the longer I do it the more I realise what a privilege it is to be looking after people who need my help (and even some who don’t). Working as a paramedic has made my life far richer and more interesting than it otherwise would have been and has provided some truly eye-opening moments. I hope it will do the same for any newly minted paramedics reading this, and as my first lecturer in university said to me, “welcome to the best job in the world”.
Thanks to the following people for their assistance with this article: