By Fatskills Exam Guides Team — the exam nerds behind 28,500+ quizzes and 2.1M practice questions across 500+ global exams.
The top tips for new EMTs1. Know your protocols. Field training is a great time for learning, but it isn’t a time for learning protocols. By knowing your protocols before you get into the field, you give yourself the opportunity to use your field training to learn how to apply the protocols to the various situations found in the field. 2. Make a list. Knowing your strengths and weaknesses both in knowledge and in clinical skills is important. Understand that weaknesses are not failures; rather, they are merely areas with room for improvement. They are areas that we are often afraid to examine but can be the sources of our greatest successes once we master them. By knowing what you need to work on, you can focus on specific learning situations with your patients, preceptor, and training officers. 3. Communicate efficiently. This is simple yet complex and easy to do but easy to blunder. We hear only half of what is said to us, understand only half of that, believe only half of that, and remember only half of that. So listen to what people say—patients, mentors, or coworkers. To improve your communication, recognize the importance of listening. It saves time, cuts through people’s defenses, and you get more information without having to repeat the conversation. Communication also involves body language. We communicate through body language sometimes more than we do with words. 4. Facilities. Know what facilities in which you have to work within your region and the approximate transport time to each from your dispatch area. Be aware of any specialty centers where local hospitals can handle trauma, burns, pediatric, or maternity patients. Also, you may consult with a different facility than the one to which you transport. Be aware of which hospitals can give you online medical direction and which ones can’t. Some providers transport to nearby, out-of-jurisdiction hospitals but have to consult with a different, in-state hospital. 5. Use a mirror. Professionalism starts with your appearance. You want to make a good first impression to your patients. Take a moment and make sure you look like the professional EMS provider you have spent so much time training to become. If you need it, take the time to get a haircut. Don’t forget to brush your teeth and carry some breath mints in your pocket for those long shifts when you don’t get a chance to brush. There are no second chances for first impressions. 6. Ask questions. A paramedic’s job is to learn. That’s it, pure and simple. Ask questions before a call, during a call, and after a call. Good paramedic mentors will make sure there is time for you to ask questions and debrief after calls, but they may assume you don’t need this after every routine call. If you have questions, ask them. Every EMS provider has seen things that others have not, and the only way to share that information is to ask each other questions about how patients presented on a certain call or how a transport worked out. 7. “I don’t know!” These are three simple words that make you human, and nothing else. They are not a sign of failure, but of a willingness to learn. Saying these words to your mentor or field training officer means you are putting patient care first and your ego second. If you stumble along through a call without asking for help when you need it, you will seem like a poor, ill-prepared EMS provider. Mentors and training officers will think that you were doing the wrong things on purpose or were skipping important steps in patient care out of laziness. Put what you have learned from your education first. Learn to properly ask for help, and don’t be afraid to say “I don’t know” when you encounter untried territory. It’s the sign of a superior provider. 8. Review. Along with making a list of strengths and weaknesses, asking questions, and saying “I don’t know” comes reviewing at home after a difficult or problematic call. Pull out your class notes and textbooks to review recommended practices. Talk with your mentor after the call and then again the next day after you have reviewed in order to get your questions answered. Ongoing education is part of every medical field. From EMTs to physicians, all of us have to constantly go back to the classroom or read journals to refresh our knowledge and gain new education. It’s part of the job and part of being a professional. 9. Newer is not better. New EMS providers often enter the field setting with a great deal of enthusiasm and knowledge. They can’t wait to put that knowledge to use. Sometimes, they will see their instructor, preceptor, or another provider offer an alternative solution to a given situation that is the old way to do things. Be respectful of those who have gone before you. Just because it’s the old way doesn’t mean it’s wrong. Take the time to learn several methods for getting a job done. You will soon learn that every call, every patient, and every situation is different. Knowing two ways to, for example, splint a broken bone may save your butt someday. 10. Enjoy your first moments on the street. Make sure you remember how you felt on that first call, after that first successful IV, medication push, or radio consult. Try to keep some of that enthusiasm in your back pocket for those times later in your career when you’ve had a bad day. It will remind you of why you are doing this job and you’ll be thankful for it!
Starting IVs Most of us were taught to start our IVs bevel-up, but when you’re trying to thread a plastic catheter into a little vein, quite often the leading edge of your trocar pierces the opposite wall of the vein before you’re ready to advance the catheter. There you are, with needle in the vein and catheter still outside it. Perhaps you try to shallow the angle of your needle and advance a bit, and as often as not, you see the hematoma form at the same time you notice flashback in the catheter hub. If you’ve ever had that happen to you, try inserting your IV catheters bevel-down. Doing so will make the angle of insertion much more shallow, thus minimizing the chance of poking the very end of that needle through the opposite wall before the tip of your cannula enters the lumen of the vein. It takes some practice, and with certain types of protective IV catheters, more than a little gymnastics, but the technique can be mastered with all types of protective catheters. Or, if you prefer, keep a few of the old, non-protected IV catheters on hand especially for this purpose. If tiny veins in pediatric patients—or, for that matter, geriatric patients—always make you pause, consider using the bevel-down IV technique. If you have access to an IV therapy manikin, practice the technique on it. You may find it a useful trick one day. Treating Steakhouse syndrome
Steakhouse syndrome, otherwise known as an esophageal food bolus obstruction, is a medical emergency occurring when a foreign body becomes stuck in the esophagus. Standard treatment in-hospital includes endoscopy, digestive enzymes (such as papain), or glucagon. An interesting property of glucagon is that it has smooth muscle properties when given intravenously. A 1.0-mg glucagon slow IVP under medical direction may be an effective means of terminating any spasms and passing the obstruction. Glucagon could also be considered in the case of a recent clearing of a foreign body airway or esophageal obstruction with excessive coughing or spasms. Unfortunately, the use of glucagon in the field to treat true esophageal food bolus obstructions is limited by an inability to conduct radiological studies, so unless transport times are long or the EMS system rural, safe and expeditious transport should not be delayed.
Manageing the intubated patient End-tidal CO2 waveform capnography is truly a standard of care throughout the nation and is used to confirm and continually monitor intubated patients.2 A trick in limiting flexion and hyperextension of a patient’s neck and airway is to apply a cervical collar and immobile his or her head and spine to a long backboard after intubation. This process reduces movement on the obvious trauma patient and reduces movement in the intubated medical patient. This significantly reduces the possibility of the endotracheal tube from being dislodged during transport and patient movement.
More Tips and Tricks
When a patient is placed on a backboard (long spine board), take a blood pressure cuff and place the bladder under his or her lower back. Inflate the cuff until the patient feels comfort in the lumbar region of the back.
While extricating a patient down a flight of stairs using a stair chair who has an IV line in place, use a hemostat or karabiner; run it through the hole in the top of the IV bag and clip it onto your shirt lapel. This will keep the IV bag out of the way and keep the IV line flowing. When knocking on a door, make it a habit to stand to the side of the door. If you do it every time, you will instinctively do it on a call where it might save your life. Tape a soft-tip suction catheter to the laryngoscope blade. The catheter hole to control suction is taped to where your thumb is when holding the handle. During intubation, you can suction at the exact time and location needed to visualize the cords. Caution: You are going to need to work on how to tape the tube to the blade. Practice on a manikin to ensure your suction catheter and tape don’t block your vision; it took me a few tries during practice before I figured it out. A key to success is to put the catheter tube to the outside of the blade. Put the tape flat so it doesn’t cover your vision down the inside of the blade.
Needle decompression Attaching a stopcock to the end of the angiocatheter serves as a means to control the “venting” of the pneumothorax (by using a stopcock to shrink the size of the pneumothorax). Start with the pneumothorax venting to the outside air. Next, have the patient take a forceful breath out. This maximizes the intrathoracic pressure and vents the pneumothorax air out through the stopcock. Then close the stopcock. When the patient breathes in, the outside air can no longer be sucked back into the intrathoracic cavity. After several rounds of this timed inhalation-exhalation routine with the stopcock, your patient should feel significantly better.
Auscultation of Lung sounds Prehospital providers seem to have trouble listening to lung sounds. Many instructors have told me that this is an “art form.” Here are a couple of useful tricks to help reduce external noise. First, place your stethoscope in the axilla of the armpit, and then have the patient cover it with his or her arm. This will reduce almost all of the external noise.
Intubation Tip 1: Grip site along laryngoscope handle. Variable force is necessary to lift the tongue and pharyngeal soft tissue anteriorly in order to visualize the vocal cords during intubation. For patients with excessive neck soft tissue, a large tongue, or trismus, the operator may need to exert significant force to obtain an unobstructed view. To minimize exertional trembling by the hand holding the laryngoscope, grasp the laryngoscope handle as close to the blade as possible. This gives you the greatest control and strength. Tip 2: Endotracheal tube lubrication. Occasionally, the endotracheal tube may become “caught up” along a floppy epiglottis. Because it is difficult to predict when this may happen, prelubricate the tube tip with a thin layer of water-soluble lubricant, such as K-Y jelly. This lubricant can also minimize the degree of surface trauma to the trachea and tracheal rings as the tube passes through the vocal cords.
Prehospital ethical issues The single most important question a paramedic has to answer when faced with an ethical challenge is: What is in the patient’s best interest? Over the past 30 years, the field of prehospital medicine has undergone impressive growth. As the body of knowledge continues to grow, as more technology is introduced, and as research defines and refines the uniqueness of prehospital emergency medical care, the challenges of the prehospital setting are becoming more than operational and medical. Efficient response, appropriate care, and safe, expeditious transport are the expectant fundamental components of prehospital care. However, more and more prehospital providers are facing challenging ethical dilemmas.
The prehospital provider must frequently interact and negotiate with reluctant patients; counsel those patients who ask for advice or refuse care; address requests for limitation of resuscitation; assume some degree of personal risk in the care of agitated, uncooperative, or infectious patients; deal with social and psychiatric challenges; and respond to a variety of unusual requests that may not be medical in nature. Each of these situations presents potential ethical conflicts. Formal training alone does not prepare the prehospital provider to deal with ethical situations. Many learn by experience, whereas some are guided by well-defined policy. Appropriate resolution of ethical dilemmas in prehospital care is promoted when those who provide and those who direct prehospital care are educated and sensitive to ethical conflicts that may arise.
Resuscitation Efforts EMS should be available to all persons in need, including terminally ill patients who need to be transported to the hospital for palliative care. Prehospital care providers require a means to honor patient directives to limit intubation and avoid application of cardiopulmonary resuscitation (CPR). This issue often presents a complex problem. Requests to limit resuscitation will confront the provider in many forms. Written Do-Not-Resuscitate (DNR) orders, living wills, clear and unequivocal family requests, and a relative’s impulsively expressed reservations about life support will be encountered. Acceptable directives must guarantee that withholding resuscitation would reflect the informed wishes of competent patients. Reliable mechanisms have been developed by some EMS systems to identify patients in the prehospital setting who do not want to be resuscitated. These items allow recognizable, consistent, legally accepted written statements to be used as valid indication that the patient wishes to have no CPR or intubation at the time of cardiac arrest. The goal is to minimize ambiguity and maximize patient autonomy. Such documents must be familiar to the EMT or paramedic, be easily recognizable, and be specific in regard to the interventions to be withheld. Extensive written lists should be avoided, since the time to read, interpret, determine the applicability, and decide on a course of action threaten appropriate care. There can be no delay or question when such directives are presented. Some states have passed statutes to authorize prehospital orders to limit resuscitation. Verbal requests by relatives cannot be accepted. When ordinary verbal requests are made, it is not clear that they represent the informed decision of the patient. An exception to this rule exists when the relative holds a durable power of attorney to make healthcare decisions. The person who holds power of attorney for healthcare decisions has a duty to base decisions on the patient’s values and wishes; the decision-maker must assess what the patient would have wanted. As a legally recognized proxy decision-maker for the patient, this person may request that resuscitation be withheld. Based on this direction, resuscitation ethically can be withheld. This might present confusion for prehospital care providers who have little experience in dealing with these situations or who may be unsure whether the decision has been well thought out. Even a legally designated proxy decision-maker may make impulsive requests that are not carefully thought through. Prehospital care providers should not enter into what may be a complicated and uncomfortable discussion regarding healthcare options and questions of the legitimacy of withholding resuscitation. At the time of crisis in the prehospital setting, such discussions are not appropriate. If there is any doubt about the legitimacy or authority of a request to withhold resuscitation, appropriate resuscitation maneuvers must be initiated. If the authority is clear and the EMS acknowledges such directives, there is no ethical reason that they could not be accepted. Optimal communication is facilitated through a written “no CPR/no intubation” order that is familiar and acceptable to the prehospital care provider.
“Dead on arrival” (DOA) policies specify those patients who should not undergo resuscitation attempts, because the effort would be futile. Although the medical criteria that define futility must be discussed from a scientific point of view, the ethical implications are evident.
Prehospital care providers may be biased regarding age, underlying illness, or other factors that may or may not suggest futility. In general, age, medical history, social position, or patient vices should not determine whether resuscitation is initiated. The values and attitudes of the paramedic must not enter into such decisions. The decision to determine that a patient is “dead on arrival” must be made on the basis of firm scientific grounds. In those medical conditions that have been scientifically accepted as futile, resuscitation should not be performed. Strict criteria, education, and appropriate supervision and review must be part of a DOA policy. Examples include extreme dependent lividity, tissue decomposition, rigor mortis, decapitation, or similarly mortal injuries.
Patient Confidentially When should providers speak with the press? Should they speak with police regarding intoxicated patients? Should they ever be concerned about broadcasting names over radiofrequencies that can be monitored by the public? Are prehospital care providers appropriately sensitive regarding the confidentiality of a patient’s medical diagnoses? Numerous threats to patient confidentiality exist in the routine of prehospital care. In a very short time, prehospital care providers become privileged to sensitive information. Indiscriminate discussion or inappropriate release of the information could present both ethical and legal threats. All information that is encountered by prehospital personnel must be considered privileged and treated as confidential. Information should be communicated only to those who are assuming direct care of the patient and who have similar obligations of confidentiality. The only information that should be discussed over the radio is that which is necessary to provide for optimal care of the patient.
Casual conversations should be avoided with parties uninvolved in the care of the patient. Discussion of cases that do not identify the patient and are used for educational purposes present no ethical conflict. Clear policy and appropriate education are important to promote the highest standards of prehospital care.
The Bad-News Bearer, the Toughest Job in EMS Despite that death is a basic truth of our profession, we are usually woefully unprepared to explain it to those left behind. Regardless of how peaceful or traumatic the circumstance, I do not know of anyone who enjoys doing a death notification. They get the heck out of Dodge; that’s the deeply rooted sense of emotional self-preservation that wants us to avoid being snarled in whatever the grief-laden aftermath is going to be. Did you know that more than 43,000 people die in the United States from motor vehicle crashes each year? That more than 35,000 people commit suicide? That more than 16,000 die from falls? That more than 17,000 die by homicide? Together, more than 150,000 North Americans die each year as a result of sudden, violent death. Oh yeah, did I mention cardiovascular disease? 1,000,000 people each year.
Death is never easy, but for families and friends affected by sudden death, grief is especially traumatic. Deaths caused by accidents, homicide, and suicide typically seem premature, unjust, and very, very wrong. Obsessive thoughts and feelings about what the death must have been like for the person who died and what might have been done to prevent it often color the grief process. Strong feelings of anger and regret are also common. Understanding and expressing these feelings helps survivors; over time and with the support of others, they come to reconcile their loss. Although awareness of the necessity of death notification education has increased, it has yet to be translated into a readily available curriculum. That does not mean we should remain ignorant of the impact we can have upon the survivors of loss. With a little education and some insight, there are definitive steps you can take in your approach that can help at least mitigate some of the emotional devastation and shock you are otherwise taking part in delivering. Remember that the deceased is not your only patient; in fact, he or she is no longer the priority. The loved ones at the scene are also your responsibility, and your choice of words and actions will leave an irrevocable mark on their memory.
“Life is a fatal condition, with a 100% chance of mortality.” —Anonymous
Notification of Death Notification of death presents unique difficulties for both paramedic personnel and survivors. Both notifying and being notified of the death of a loved one are most often painful and extremely traumatic experiences. Although there is no “good” way to notify survivors of a sudden and unexpected death, the compassionate expression of dignity and respect will result in proper notification that will help survivors cope with their great loss. It is recommended that paramedics, preferably those involved in the care, notify the next of kin of the death. At no time should survivors be notified of the death by telephone. It is further suggested that agencies utilize two EMS personnel to effectuate the in-person notification function, and that they be in uniform. Although some survivors have asserted that the appearance of a uniformed individual at their home caused trauma, the uniform itself is an identification that will prevent confusion. Thus, the survivors will be more likely to be put at ease. Also, there are other advantages in utilizing two EMS personnel to extend a death notification. One medic should communicate the information while the other carefully observes the reactions of the survivors. Individuals react to death in various and often unexpected ways. Some may suffer physical reactions that may require emergency care, whereas others may become violent or aggressive, which may require their being physically restrained from harming themselves or others. In addition, it may be advantageous to notify two or more survivors separately, especially in instances that may require them to provide law enforcement officers with investigative information.
“I’ve learned that people will forget what you said, people will forget what you did, but people will never forget how you made them feel.” —Dr. Maya Angelou
If possible, the notifying EMS personnel should obtain pertinent medical information about the survivors prior to making the notification. This will allow the notifying paramedics to respond more properly to the immediate needs of those who suffer chronic medical problems such as heart disease, hypertension, etc. When speaking to the patient’s survivors, the medics should introduce themselves and politely request that any children be brought into a different room. The medics should attempt to seat the survivors and ensure that the notification be made to the appropriate individuals. The medics should inform the survivors of the death simply and directly and answer their questions tactfully but honestly. They should provide as much information as possible. The paramedics should ask the survivors if they would like to have family or friends contacted to assist them. Under no circumstances should the medics depart the residence of a survivor who resides alone until a designated friend or relative arrives.
HELPFUL PHRASES
After the survivors have recovered from the initial shock of learning of the loss of a loved one, the medics should explain what can be expected of them in the immediate future. The survivors should be informed that it may be necessary for them to identify the deceased. If so, EMS should transport or arrange the transportation of the survivors to and from the hospital or morgue through the use of law enforcement. Survivors should also be informed that certain laws may require that an autopsy be performed to establish the exact cause of death. If it appears likely that survivors will have to be questioned by law enforcement personnel, they should be so informed. Notification should be conducted with compassion. Prior to departing the residence, the medics should provide the next of kin any telephone numbers so that additional questions can be answered and further assistance rendered, if necessary. When a critically injured person is transported to a hospital, it is recommended that the hospital staff promptly notify the appropriate law enforcement agency. Generally, if the injured person dies shortly after arriving at the hospital, the investigating law enforcement officers should assume responsibility for notifying the survivors of the death.
This is the most difficult part of being a paramedic, hands down. So what do we do? How do we prepare? And why don’t we have formal training in this subject?
Have a Plan It’s awkward to be in a position of authority on a scene and not be able to answer questions. Know what your agency protocols are for out-of-hospital death and have a general idea of what your regional policies are for what comes next. Do the police come? Is there an investigation? Who moves the body? Where is the morgue or funeral home? In New York (Suffolk County to be specific), if a paramedic determines the patient meets the criteria for obvious death, then the police officer on-scene will make the notification to the medical examiner. The medical examiner will respond and confirm the death, whether it is due to an illness or by criminal means. The patient is then transported to the medical examiner’s office (morgue) by that division. Paramedics technically do not pronounce; we make a presumptive diagnosis of death. Ultimately, the doctor signing the death certificate is the person who makes the absolute decision of death. One way to alleviate some of the family’s anguish and eliminate the process of going to the morgue is if a patient has an extensive medical history and the police do not find any obvious signs of foul play, the police will contact the patient’s primary physician. If the physician agrees to accept the responsibility of signing the death certificate, then the officer will make a verbal agreement with that physician to sign the certificate of death. In turn, the patient’s family can then arrange for a funeral home to pick the body up. Thus, it is extremely important to understand these policies when dealing with “DOA” calls.
Introduce Yourself Introducing yourself rehumanizes the uniform, serving as a small buffer to the information you’re about to deliver. It also validates your information as coming from someone in authority, as well as giving the recipient a focal point for questions.
Identify the Key Players Figure out the relationship of those present to the deceased. If possible, try to give the same information to all the adults present at the same time; it will simplify things for them later. Consider segregating small children before speaking; their needs are different and are usually better met through adult family members. When asking the question “Are you the parents/husband/wife of so and so?” always use the present tense. Referring to the deceased in the past tense can incite confusion and even anger; the information is just too new and has not been processed yet.
Fire the Warning Shot This is called the “prep statement.” It gives the person time to prepare, even on a subconscious level, for the bad news that is coming. In many instances, the person already knows on some level what you are about to say but has not acknowledged it as reality yet. Giving the person a brief review of events gives his or her psyche a moment or two in which to take that proverbial deep breath and prepare itself to process what you’re about to say. If you are doing a field pronouncement post-care, an example might be, “We arrived to find your father unconscious. He was not breathing, and there was no pulse, so we immediately began CPR.” Do not include large amounts of detail; they will simply not be processed.
Get to the Point This is called the “core statement.” Make the information simple, keep it direct, and try to deliver it with compassion. Using the word “died” or “dead” is important; there is a certainty to the terminology that helps survivors recognize what’s going on. You may have to repeat things a few times. The person’s psyche will filter out what he or she can’t handle; it may take several attempts to get through.
Express Empathy Empathy is a powerful communication skill that is often misunderstood and underused. Initially, empathy was referred to as “bedside manner”; now, however, educators consider empathetic communication a teachable, learnable skill that has perceptible benefits for both paramedic and patient: Appropriate use of empathy as a communication tool facilitates the interview, increases the efficiency of gathering information, and honors the patient, whether they are alive or dead. Avoid the use of euphemisms. They can confuse and even anger stressed family members.
Don’t say, “He’s in a better place,” because you don’t know that. Don’t say, “I know how you feel,” because you don’t. Remember that sometimes, less is more. HARMFUL PHRASES: BASIC INSENSITIVITY
You have no way of knowing what somebody’s grief response might be, and there is no hard and fast rule saying what it should be. You may find that they accept the information tearfully, but rationally, or they may begin rending their shirts, pulling their hair, and keening in ululations of grief. Some may need their hands held; some may need to be pulled away from the deceased. Remember that we are an increasingly diverse society, and although some of this reaction is certainly emotional, there may be a cultural component as well. In some instances, there may be a significant physiologic reaction. You may be suddenly faced with a person suffering a syncopal episode or other clinical expressions of stress, such as chest pain or respiratory distress. Just because the cause is emotional does not mean it cannot cause the body to go into shock—that is something to keep in the back of your mind as you’re tending to the family on scene.
Answer Honestly This is neither the time nor the place to play crime scene investigator. Don’t assume or surmise on facts surrounding the death unless you are certain of the answer and will not be contradicted later on. A dishonest answer on scene may be revealed in other venues, for example, via autopsy, investigations, or future court proceedings. It not only damages your credibility but can cause irreparable harm to the family and shake their faith in the entire agency you represent.
Give Real Information Know or at least have an idea of what happens next in the process. After survivors weather the first emotional barrage, there are plenty more to come, and often they frankly just don’t know what to do next. This is where you can be of enormous help. Just by outlining what the next few steps typically are, you will give them some sort of structure within which to function while trying to sort everything out. If your department supports it, give out supplemental information on support groups or hotlines for grief counseling. Someone may pick up that slip of paper a week later and be grateful for somewhere to turn.
Turn Care Over to Someone Else of Authority We are just the first in a long line of authority figures survivors will have to deal with. Very often we are the only anchors they can rely on while they try to find some immediate footing. However, we are not designed to be there long term. When you’ve finished with your role and it’s time to leave, make sure you do not leave them without a next contact point. This may be the police officers on the scene or a hospice worker or staff nurse at an extended-care facility, but give them a source for additional questions. Do not leave them without someone to turn to. Here are a few additional points to consider: Be sensitive and open to families and allow them to express grief and anger. However, be sure to protect your personal safety at all times. I have always taught providers to keep a two-arms-length distance when delivering the news. Expect many, many questions. If you don’t know the answers to all of them, it’s perfectly correct to say, “I don’t know, but I will try to get you an answer.” It’s imperative that you do not speculate on any answers whatsoever. Offer simple gestures to the family, such as making any needed phone calls, transporting them to the hospital, or helping to arrange any immediate childcare. Be sensitive to the diversity of family structures and the different ways certain cultures choose to express their grief. Individuals need to be treated with dignity and respect regardless of their family structure (domestic partner, common-law spouse, etc.) or culture.
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