Lessons Learned as an Inner City Medic Part 2

Not all EMTs are equal. It’s a title that’s often applied to any person on an ambulance but it’s not quite accurate. The organization that monitors standards of care and makes licensing and certification requirements is the National Registry of Emergency Medical Technicians (nremt.org). Most states require that you obtain and maintain a state issued license. Most states requirements are modeled after the NREMT and often use their exams for obtaining a license or certification. The NREMT specifies different levels of EMS certification; emergency medical responder (EMR), emergency medical technician (EMT), advanced emergency medical technician (EMT-A), and paramedic.

You’ll notice there is no certification for an “ambulance driver”. It’s an antiquated term that started with the birth of EMS. The first EMS services evolved from the mortuaries. You’d find some kind of medical training with the individual in the back of the hearse and then a driver with zero medical training. If they couldn’t save your life, they just went ahead and took you to the mortuary.

An EMR will have any where from 48-60 hours of training. You typically find these in areas that still have volunteer fire departments or areas with minimal access to medical facilities. EMTs require around 150-190 hours of education and can perform basic skills (bandaging, vital signs, basic non-invasive interventions). An advanced EMT will often be able to start IVs and have an additional 60 hours of education. The paramedic curriculum typically exceeds 2000 hours of education and a varied skill set that allows them to start IVs, give medications, and perform invasive procedures. Sometimes this involves an associates degree but most states offer a technical certificate. Specialty courses are frequently offered to help improve the skill set among all levels of EMTs. Regardless of the certification level, all levels of providers are required to renew their certifications/licenses every two years by maintaining training requirements.

An ambulance crew consists of two people at a minimum. Depending on the skill level, you may often find more people if the typical transports require it. Your EMS partner becomes an important part of your life. We often spent more time together than with our significant others. It’s a dynamic that is unlike any other. You get the opportunity to know your partner in a way you never really know your friends. Working that closely in a team of people is another learning experience. Here are a few more lessons I learned from my partners.

Lesson 4: You only take credit as a team.

Some partnerships last and some do not. It’s most similar to a marriage but without the physical relationship. Well, for most people, it’s without the physical relationship. There have been people I knew in my career who worked together and did eventually marry. That’s a tale for another time. Picture yourself spending twelve or twenty four hours at a time with one person. You eat together, sleep in the same area, and sit in the same truck. At one point I was staffing an ambulance with no station and we spent twelve hours in the truck together. Based on our schedules, that meant that I spent a minimum of 2,184 hours per year with that person. There is only so much small talk that can fill that time and you end up getting to know that individual very well.

Healthcare is not designed to be a one person show. It takes multiple people from the time you first interact with a patient to when that patient is discharged. It’s like a bridge and you need to get someone from one side to the next. There’s never one person who does all the work. It’s a team effort.

Early in my career we were dispatched to an injured person. It’s a blanket dispatch that could be anything from a few scratches to bones sticking out of someone’s leg. This particular night we were going to the Indianapolis Motor Speedway (IMS). The IMS is a race track that accommodates over a million fans for the Indy 500. The race had been over for several hours and we were sent to the infield. As we followed the golf cart across the field, I watched a man stand up and fall. He then stood up and fell again. It happened probably three times before we got to him. As I approached him I could see that his femur was pointing in a very unusual direction. I asked him to stay seated and began my assessment. When I asked him if he knew why we were there he simply replied “I forgot how to walk”. He was clearly intoxicated and while he wasn’t openly fighting us he was not the most cooperative either. It took myself and my partner, plus a couple firefighters, to get him splinted and loaded into the ambulance. We transported him to the hospital and left him in the care of hospital staff.

A few weeks later a thank you card arrived at our headquarters from this man and his family. It was a beautifully written thank you. It would have been easy for my partner and I to take all the credit, and the card was addressed only to us. When you request your ambulance run report, it gives you the name of the individuals on the ambulance. It also becomes part of the patient’s medical record and they can request a copy at any time. This individual took the time to do so and send the note. I was grateful for this and was even more grateful when my partner suggested we share it with the firefighters who helped us that day. It would have been impossible to get everything done in a timely fashion. We spent a few minutes at the fire station and shared the card. It was a bright spot for all of us. It’s amazing how much a simple thank you card can mean and sharing it was the right thing to do.

On the flip side, there is nothing worse than working with an individual who takes credit for everything. You’ll often hear people retell an event and consistently use the word “I”. They make it sound like they were the hero, the only person to do anything, while the events actual involved multiple people. I remember hearing people tell stories about runs they were on, bragging about their skill sets, and making it sound like they have super human powers when saving a life. Some of the stories would have you believe they have five sets of hands and can perform multiple life saving interventions all at the same time. Sometimes we all want to feel important and there will always be those people who feel they need to tell you how important they are. People who are truly important have humility, and I found the people who are truly important won’t feel the need to point it out. When your eye is on the prize, preserving an individual’s quality life, teamwork will come naturally.

Lesson 5: Own your mistakes.

Most ambulances will have either two EMTs or an EMT and a paramedic. Some places you will find two paramedics on a truck together. It’s unusual and makes the manpower rather expensive while utilizing a lot of paramedics that are often in short supply. Due to high stress, poor working conditions and pay, the average length of time spent in EMS is usually less than five years.

I had lots of partners over the years. Some of them were paramedics and some were EMTs. Having a paramedic as a partner can be wonderful, but I firmly believe there’s no replacement for a good EMT. A good EMT can anticipate what their medic will ask for and have it in hand before the words leave your mouth. They can find any hospital and get you there safely and without throwing you around like a ping pong ball in the back while you’re trying to get things done. A good EMT is priceless. Sometimes when working with a paramedic, you forget that one of you needs to make decisions and the other one needs to be the EMT.

I remember this particular run like it was yesterday. My paramedic partner and I were sent on a “difficulty breathing.” We pulled up outside the building and I saw her right away. She was standing right off the sidewalk and I could hear her breathing when I got out of the truck. Even competing with the rumble of the diesel engine, her wheezing was pronounced, lips swollen, hives on her arms. It was pretty obvious she was in some serious trouble. We got her to the truck where she admitted she ate a frozen meal with some nuts in it. She knew she was allergic to nuts but stated that she couldn’t see them so she thought it was okay to eat the meal. She then left her apartment without her Epipen and walked a few minutes to the building where we found her. The security at the building stopped her and called 911.

Allergic reactions can go really bad really fast. When my partner asked me what I wanted, I replied with the “kitchen sink”. In this situation, she was getting a nebulizer with Albuterol, Benadryl, and epinephrine. We didn’t really talk much as we set to work. My partner started the nebulizer, hooked up the cardiac monitor, and started drawing up the medications. I took a quick blood pressure to see how far the reaction had progressed. The patient was hypotensive and I knew we needed to work fast and get to the hospital. I started the IV, and I was securing it my partner handed me a 3 mL syringe. I was in such a hurry that I never stopped to ask what it was or how much was in it. I was trusting that my partner gave me the right thing. Shortly after pushing the medicine the patient’s heart rate greatly accelerated and she grabbed her chest. I felt a moment of panic and quickly realized what I had done. I pushed the epinephrine straight into the IV when it was meant to be an intramuscular (IM) injection. I watched a lot of funny little beats roll across the screen of the cardiac monitor. Thankfully they resolved quickly, and the patient reported she was feeling much better. My partner drove us to the hospital and I sat there with a sick feeling in my stomach knowing I had messed up.

Part of drawing up medications is using the correct syringe. Epinephrine is usually given using a 1 mL syringe which is much thinner than a 3 mL syringe. The two syringes feel very different and with practice you can quickly know what syringe you have by touch. Epinephrine can be given IV for allergic reactions but the concentration for that is 1:100,000. It’s greatly diluted and at a smaller dose when given IV. The IM dose is released slowly from the muscle into the circulation and is given at a concentration 1:1000. That particular day, my partner couldn’t immediately find the smaller syringe. I assumed what I was pushing was Benadryl because of the syringe and in my rush I didn’t stop to ask. Even though my partner drew up the medication, I was the one who pushed it. I was the one at fault.

When we got to the hospital, the patient was feeling a lot better. Her wheezing and hives were almost gone and her blood pressure had returned to normal. I told the nurse and the doctor what I had done and called my supervisor. Medication errors require a lot of paperwork. I filled out my statement, and had the doctor fill out the form indicating whether or not the patient was injured by my mistake. I felt terrible. It was one of the worst days of my career. The ER doctor was quick to tell me that she was young and healthy and would suffer no long term effects. I fixed her reaction but it happened a lot more abruptly than we would have liked.

One of the first things I was told as a paramedic was that if you make a mistake you need to own it. All medication errors get reported to the medical director. I knew I was going to have to face him after what I had done. It was apparently my unlucky day because our very next run we transported to our sponsoring hospital and the staff doctor working was the medical director. I pulled him aside and told him what I had done. I was ashamed and upset and afraid of what he would say. One word from this man and my career was over. As a paramedic, you work under the medical license of your medical director. If he wanted to, he could terminate my employment. Dr. Mike Olinger, or MO as we all called him, was a former military doctor. He was small in stature, didn’t speak much, and always had a somber expression. He was quite intimidating and demanded excellence from us. After explaining what had happened, he asked a few questions which I readily answered. He asked me if I knew why what I did was wrong and I clearly did. The next words out of his mouth shocked me. “Sh*t happens,” he said and walked away. I was floored.

It was my mistake and you better believe it never happened again. Mistakes can be learning experiences or they can be a crutch. I could have said it was my partners fault and put the blame on someone else for using the wrong syringe. Ultimately I’m the one who pushed the medicine. I could have asked or stopped to look at the volume in the syringe. Both would have prevented the mistake. I did neither. I’ve never forgotten how I felt that day. I’ve also never forgotten how a man who could have wrecked my career used it for a teachable moment. We are all human and at some point, even in healthcare, we are going to make a mistake. Thankfully for me, the patient and my medical director were both very understanding. I think the hardest part for me was forgiving myself. But by owning my mistake, and learning from it, I ensured that it would never happen again.

Lesson 6: Never undermine your partnership.

Relationships are hard. Whether it’s a personal relationship, family, or a work relationship makes little difference. At work we don’t typically get to pick our group. If you happen to work with friends it makes it so much more enjoyable and time passes by quickly. In EMS you often have a regular partner, meaning you work with the same person every day at work. There’s always overtime and people who float from truck to truck filling vacations and sick days. Some people move trucks every few months and others stay on that truck for years.

The EMS partnership is a very dynamic and unique thing. Some of those bonds will last a lifetime and sometimes there’s no bond at all. Trucks are sometimes assigned, but most of the time it’s a bid process with seniority determining who gets the spot. If you are fortunate, you and your partner get along. That is not always the case. The biggest fallacy of thinking, in regards to employment, is that you have to like someone to work with them. Mutual respect is usually the starting point.

The biggest mistake I saw people make was to undermine the partnership. You get a new partner and your initial impression is that you don’t like the individual. So you say some not very nice things to your friends and they tell their friends. After a few weeks or months, you find your rhythm with your partner and discover that they really aren’t so bad after all. While you may not become drinking buddies outside of work, you discover that they are actually decent to work with and you can get along. I was raised to believe this part of a partnership is called “adulting”. It’s that part of life where you work and get things accomplished with another adult even if you don’t agree on everything. This is about the time where those unkind things you said get back to your partner. Your partner no longer trusts you and feels betrayed. You can sometimes repair things but it’s difficult. Something that could have been functional and even enjoyable has been sabotaged by your initial impression.

I’ll apologize in advance to this particular partner, but I’m going to tell our story. The first time Joe came to work with me I didn’t know much about him. Within the first few minutes I discovered he was a social butterfly and talked to everyone, had a very boisterous laugh, and his politics were very liberal. I stood there wondering if I was being punished. We had no crew room and I was going to be sitting an arm lengths across from him for a solid 12 hours. I didn’t have a regular partner and he was a float. We survived the shift. The next day I came back to work and to my surprise, there sat Joe in the truck. This continued for several weeks. I was raised in a conservative Christian household. Joe was a liberal atheist. Over those weeks we worked together I discovered the only thing we agreed upon was that we like music. Our genres of music were very different, however.

To make a long story short, it took some time, but we eventually became friends. Joe was my work husband. We would bring meals to work and would often bring enough for both of us. We talked about dating, politics, religion. His parents would cook on holidays we worked and dinner would appear for both of us. After initially thinking we had nothing in common, we found so much common ground. It was the longest partnership I had. If I remember correctly, we were partners for almost 9 years. At one point, we went to an Ambulance Strike Team Task Force Leader training through the Indiana Department of Homeland Security in Terre Haute, Indiana. As part of it you take one of those personality tests that tell your right/left brain. It’s the kind we’ve all taken at some point. After answering the questions, I was completely on one end of the spectrum and Joe was on the other. The instructors told us that we should never work together because it wouldn’t work. My coworkers in the class started laughing as we informed the instructors that we did in fact work together, were both paramedics, and had been partners for quite some time at that point. I’m not sure they believed us at first. Joe stood next to me when I got married. His mom and stepdad came to my wedding and played the music for the ceremony. His dad drove his Excalibur car for my wedding and I got to use it in my wedding pictures. Joe, even though we were very different, became my friend and his family embraced me as well.

Life happens and eventually we were separated due to a paramedic shortage. I was going to end up on nights because I was taking classes during the day. I was bidding to a particular truck on the far east side. I had so many people that tried to tell me not to do it because of the partner on the truck. She’s awful and you won’t want to work with her they told me. I bid the spot anyway and because I had built up over a decade of seniority, I got the spot. I knew her in passing but we hadn’t really spent any time together. The truck was a much lower run load than I was used to but that was why I wanted it. It would give me time to study at work when we weren’t busy.

Our first few shifts went quite well. For as much as people warned me against her, Jen was a good EMT. There were times I know she was irritated at me and times I got irritated with her. But I wasn’t going to let someone else dictate to me whether or not to be her partner. I firmly believe that you should judge a person based on your own assessment. Bill doesn’t like Mary so I won’t like Mary either. That kind of thinking just doesn’t work. A few months into our partnership, Jen told me that people had actually told her that she wouldn’t like working with me and that we wouldn’t get along. In this instance, we were not the people trying to undermine our partnership. It was people outside the partnership that felt it was right for them to sabotage it from the outside. We had our disagreements as most partners do. I was the grumpy day time student working 7p-7a, stressed out with exams, newly married, and exhausted most of the time. I know I’m difficult when I’m sleep deprived. But despite that, there were nights that I secretly filmed Jen watching online videos trying to teach herself to twerk. Now, if you’ve ever seen a white girl with no rhythm try this then you are truly missing out. (Sorry Jen but I still have that video!)

In most healthcare professions, you won’t work with just one partner. Whether it’s a partner or as a member of a team, the relationships you build can enhance the experience or it can hinder it. Too often we forget that just because we are different or we disagree that we can’t work together. Sometimes the best partnerships are those where you are not the same. Working together, with individuals you can respect, creates a cohesive team that will allow better patient care and outcomes because the lines of communication are open. If you give someone a chance to show you who they are without you deciding for them, they just might surprise you. And at the end of the day, you can have teammates and coworkers that become friends for life.

**Thanks to Joe and Jen for being willing to let me write about them. Photo credit to Holly Lewis.

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