Lessons for Paramedic Interns (Part 3)

Here is the third installment in my series on advice to paramedic students in their field internship. I’m thinking there will be one more after this one. You can find Part 1 here and Part 2 here. Thanks for reading!

9. Understand the hierarchy of rank in all public safety professions: When I started as an EMT in our county, I was fortunate to have a great mentor who’s dad was the Chief of a large fire department. In knowing this family, I learned the importance of being polite to those that I worked with as colleagues in the fire service and the police department. Even though my mentor was well known to almost everyone in every agency (his brother was a captain in a fire department also, after working for years on the ambulance), every time we got on scene, Mike would walk up to the highest ranking person on the call – typically the officer on the fire apparatus – and say, “Hi, Captain List, how are you today?” He did this every single time, even if he had grown up around the fire fighters. Why did he do this? Respect. It’s that simple. Respect and professionalism. It was amazing the effect that this had. In showing the respect that he did, he was always treated with equal respect. I was new to EMS, and I had no idea who to address and how to address them. I remember one day, I asked Mike to explain it all to me. He got a piece of paper and drew out the differences in badges, in lapel pins, in color of badges. I started paying much more attention to the people that I was interacting with. If I didn’t remember how to identify someone’s rank, I would just call them “Sir” or “Ma’am.” I would walk on scene of calls and say, “Hey there, Captain Rose, how are you? How can I help you guys today? I’m an intern, so anything I can do, I’d love to jump in.” When our county went to ALS fire, there was a lot of tension between the ambulance service and certain crews or departments from the fire agencies as people tried to figure out who was in charge on calls, when patient care needed to be transferred, and when fire medics would be required to ride to the hospital. Sometimes, it got really heated, almost turning to shouting and shoving matches. Every single time though, I would get on scene and start with my scripted greeting. “Hey there Captain, how are you today? How can I help you guys?” Even at the height of the tensions, I was offered to have free access to the fire stations, invited to dinner, made part of the family. The simple truth is, both as an intern and a paramedic, I was treated well as an intern as a team member and a student, I was able to be treated with respect, mitigated all of the tension, and all because I learned to be polite. A final thought on this: I think its important that, even when given permission to call an fire officer or ranked member of the police department by their first name, always refer to them by their rank and last name on scene. This might just be more my personal style, but I think that keeping someone as an absolute authority on scene is really important. I do this so that, if a patient or family wants to talk to a supervisor, I can refer to them to someone that I have already shown deference to. I’ll call them by their first name once we are back at the station talking, but on scene, I always address people by rank. Please don’t think that this makes me less of a leader on scene either. What I have learned though is that I don’t always need to posture and puff my chest. In fact, the opposite is true, and because of our collegial relationships and my respect, if I really need a fire crew or police officer to do something, they will most often listen and consider my position and defer to that. Again, the reason for this is simple respect. It goes such a long way, and can literally change how smoothly your calls run.
10. Don’t compare yourself to your preceptor or other experienced paramedics: My very first ride along with the paramedics was after I had been working as an EMT for about four months. It was a crazy call, and I knew that my life had changed. I knew I had seen something special with their scene management and patient care on a critical stabbing patient. All I knew is that I wanted to what they did, and to be that good at it. This started a journey to try to get to that place professionally. What I realized though as a student myself was that I would often put so much pressure on myself to render myself overwhelmed simply by my expectation of knowing what an experienced paramedic would do in a situation, and not being able to do the same. I couldn’t manage to string my history and physical together, to do the simple skills required of me. How did my preceptors do it? How did the paramedics I could do my ride-alongs with do it? And why couldn’t I? I didn’t realize how easy the answer was until I started teaching. While I always try to encourage my students to think of themselves not just as “interns” but as “Paramedics, with a capital P,” I also caution them to be aware that they are not me. Before I went to medic school, I worked as an EMT full-time for 14 months, and still managed to log 3,000 hours as a ride-along. I did paramedic school, 720 hours of field internship, and once I started working on my 21st birthday, I worked a lot. A LOT. I was averaging 96 hours a week for the first five years. By the time I had my first intern, I had probably run close to 30,000 911 calls, averaging 10-12 runs on 12-hour shifts, and 18-20 on 24-hour shifts. How is it fair to any student for me to have the expectation that they would have the same skill set and abilities that I did, as a 12-year paramedic in a super busy system? It’s not. What I learned to do was to remind my students constantly that it was also unfair of them to have those expectations for themselves. I love students passionately. When I choose an intern, one of the the things I look for is their drive, their willingness to be pushed hard and to push themselves hard. Our profession is hard, mentally, physically, and emotionally, so it’s important for me to find someone who embraces that and wants to succeed at a high level, and that’s all self-motivation on the student’s part. That’s a double-edged sword though, and they need to know when to be graceful with themselves. In my state, interns and preceptors grade every call on a variety of components on a 1-3 scale, with 1 being failure, and 3 being a skill that needs no rather improvement. I find my students often give themselves a lot of 1’s at the beginning of their internship. I give them more 2’s and 3’s. I do this not because they are doing things perfectly, but based on their experience and education, they are doing really well. This trend reverses itself later in the internship, where I will give more 1’s and 2’s, and the interns will grade themselves with more 2’s and 3’s. What they are learning is that they are transitioning appropriately from being students to being safe, new paramedics ready for independent practice. I really can’’t stress how important this is as a student to realize that you are on a continuum of education and experience. While you are new, push yourself hard. If you make dumb mistakes, own them. As a good Twitter friend just told me recently, in reminding me to do the same, there is also a time to be more gentle with yourself. In doing that, I would argue that you’ll actually become more effective as a student and intern, because there will be there will be a huge stress relief and self-doubt.

11. Stay as long as possible: This one is controversial for students to hear. In my state, field internships can last between 480-720 hours, and when I take an intern, I tell them that I expect that they will stay for the entire 720 hours. Often, this is met with disappointment, and then bargaining. (I think they skip the anger because they want to have the internship position!) I’m pretty firm about this. This has nothing to do with their capability and nothing to do with how they come prepared to the internship. I choose to do this because I feel that there is just so much information and knowledge required now. I think that for the most part, especially in college-based EMS programs, we do a really good job overall preparing students to start their internship. However, even with that preparation and skills labs, everything changes when the environment is real-world calls, stress of taking care of real people who can have poor reactions to bad treatment decisions, the unpredictable and dynamic nature of of interacting with patients who don’t know how they are supposed to react, who have never read the books so that their presentation matches their pathology, and where there is so much sensory stimulation. All of these factors mean that for almost every single paramedic intern, it feels like a giant step back in performance on day one of field internships. The teaching that takes place during the internship adds even more time that needs to be committed to the process. With all of these learning challenges, I have yet to graduate an intern at less than 680 hours. In retrospect, all of my interns are grateful to have the extra time to put all the moving pieces together. It’s a grind for them, thinking about three months working 24-hour shifts, but when they graduate, they know that they are more well prepared and more confident than they were if I had kicked them loose at the 480 hour mark. My final thought for this: I hope that as a profession nationally, we spend more time with our students. I hope that this changes as EMS leaders push for more standardized training, skills, knowledge, and mandated degree programs. I sincerely think that we will be more valued by the public and by our healthcare colleagues if we train harder and more, owning our pre-hospital world, but in a way that brings us closer to the level of training and experience like our nurses do.

12. Cultivate relationships with other public safety providers and hospital staff: I absolutely love this idea, and again, its one I stumbled on in my own internship, and one that took years to solidify into a practice that I basically mandate with my interns. I found in the high pressure environment of my internship, that there were always a few nurses that looked out for me. They would be the ones during a handoff at the hospital that would ask me a pointed question to remind me to include something that I may have forgotten to ask or communicate. They would also be the ones who could tell I was having a rough shift and tell my preceptors that they had “one more question” to ask me, and really, it was just a ploy on their part to get me away from my instructors and ask how I was, give me a hug, and tell me it was going to be alright. (And there is nothing wrong with someone doing that when things seem like they are falling apart!) In the fire station that was in our first in area, we would go and visit once a set and have dinner with the crew, or try to. When we made it, they would ask me to help cook and set the table while my preceptors sat in the other room and talked and laughed and watched TV. This was another not-so-subtle effort to give me a break from being a student, and instead treat me like part of the team. It felt so good to be included in the laughing and joking. It felt better when one of the senior guys who was the station’s best cook would grab me and take me out to the porch, just to check in and see how I was holding up. Dave was doing his role as the senior man in the station, checking on the new kid, which if you’re not familiar with the role’s and responsibility of the senior man (I use the term man, because that’s how they refer to it at FDNY who does it better than most, but can absolutely apply to the senior non-officer in any firehouse, regardless of gender), its a tradition where you are the voice of wisdom, the chief instructor, the confidant, the mediator, and a person of authority. It’s a tradition that I love. You are also the nurturer of the new guys, when the time is appropriate. Dave not only looked after me, but he made relationships possible with the other members of the crew at this station. This also paid off in the same way my relationships with the nurses did. I would be running a code, and one of the firefighters who had been a medic previously, would ask me, “Hey, Tim, what do you think about another round of meds?” Or Ken would pretend to lean over to grab a blood pressure cuff and remind me to slow my breathing down, and that they were watching over me and wouldn’t let anything bad happen. I cannot even begin to tell you how reassuring and confidence boosting that was for a shy, somewhat awkward kid learning how to fit into a world of alpha-types, who was scared out of his mind. These nurses and firefighters also introduced me to others that they knew, physicians, respiratory therapists, police officers, and chiefs. As my world expanded, so did my knowledge. When I didn’t know the answer to a question, I could answer – as every good intern should – “I don’t know the answer to that question, but I’ll find out and get back to you on that,” and I knew whom I could call and ask. I shadowed physicians. I did ride-alongs with the police. I learned everything I could from everyone I came in contact with, all because of these wise, compassionate people who looked after me. I will say this, too, in fairness to the experience: They all made a lot of fun of me. A LOT. I knew though that it was good natured, and I knew that they liked me. I had been around the people in this profession enough to know that they only tease the ones they really like. Even today, 21 years later, there are things that I did in my internship that a few people still remember and tease me about. I wouldn’t change that teasing, mentorship, and friendship for anything in the world, and while it certainly made me a better intern, it absolutely made me a better paramedic and preceptor. I know take those lessons and make my interns find a nurse mentor for them at a hospital we visit often. I also take my interns to various fire stations with crews I know they connect with, and let them go inside and visit, while I sit in the ambulance and “make a phone call.” Half the time, I’m just listening to music and playing on my phone. The real gift is for them to have time away from me to create and nurture these relationships on their own, during their internship, because these will have long lasting benefits for them, just as it did for me.

Thanks for reading the third in this series! There will be one more, but later this week, I’m going to publish something based on an episode of The MedicMindset Podcast by Ginger Locke, when she interviewed Dr. Tania Glenn for the second time. In light of the mass shootings recently, I again just wanted to talk about mental health, and how Dr. Glenn read my freaking mind. Stay safe out there! ~ Tim

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