The Provider Type Grid

After an earlier post, I am getting the business at work about there only being four people that I will let attend.  That was a throwaway line, but there is a tiny kernel truth to it.  It isn’t necessarily up to me who sits where in the ambulance, but I am certainly most content when I’m attending to patient care instead of driving.  What makes for an attending partner with whom I am comfortable?  It got me to thinking about the best way to explain the attributes that make for someone I will “let attend.”

In my career, I have been able to work with dozens, if not hundreds of partners.  I have seen most variations on the EMS provider.  Some partners have been aggressive while some are more laid back.  I’ve worked with men and with women.  I’ve worked with medics on their first day with a cert and ancient medics who had experience with IC epi, full-time medics and part-time medics, medics who were long-time EMTs and “zero-to-hero” medics.  Some got their start in a city, some in more rural agencies.  Some began their EMS careers in other countries before immigrating to America. 

Medics I’ve worked with have become politicians, police officers, doctors, nurses, firefighters, engineers, physician assistants, teachers, lawyers, accountants, professors, horse masseuses (really), mercenaries, flight medics, soldiers, financial advisors, convicted criminals, and bureaucrats.  That list is way too short, but it is all I can come up with off the top of my head.

In the end, none of that matters.  What matters is how well they do their job.  Are they a good prehospital provider?

To me, I can best describe a good provider on a grid with two axes: smart and skilled.  Each provider can be ranked on a 0-10 scale for didactic knowledge (“smart”) and for their psychomotor skills (“skilled”).  Between those two, we can create a matrix:

A smart provider has the cognitive skills - book learnin’.  I have worked with partners that can draw and explain Starling curves, interpret ABGs, and have never met a home med they haven’t heard of.  Every ECG is correctly and thoroughly interpreted, every drip medication has the correct drip rate calculated, and the provider can explain Hashimoto’s thyroiditis*, CREST syndrome**, and Takutsubo cardiomyopathy***.  The opposite end of the smart scale is a tough one to name.  Dumb?  Too insulting.  Ignorant?  Too insulting again.  Hypocognitive?  Nice – there we go.  So you can grade a provider from a hypocognitive zero to a smart ten.

A skilled provider is one that can do the physical requirements of the job well.  They consistently hit IV lines, even the hard ones.  They are gunslingers with an endotracheal tube in their hand.  Skilled providers may not specifically know the medical reasons why a procedure is needed, but I’ll be damned if they don’t always know the exact moment a tube needs to be placed – and they get it.  But going even further, they are skilled at calming a chaotic scene, setting a patient and family members at ease, and making everyone feel like it is going to be okay.  The greatest part of a high ranking on the skilled axis is that it has nothing to do with your cert level.  Experienced EMTs can rank really highly on the skilled side. 

On the other end, we have all worked with partners who engender no confidence in their ability to complete tasks.  Once, I had a partner who was attending and I was driving, but I intubated three people that shift.  My partner did not have the skills to intubate patients so I had to do it.  Three times (the rare driving hat trick).  It can be exhausting to need to spend extra time on every scene before transporting, just in case I need to get their line for them.  Some unskilled providers are just plum asocial – they just have a knack for unintentionally pissing everyone off on a scene.  Patients don’t feel calm, family members complain, and other providers get upset.

The easiest way to think of it is to divide the results into four quadrants – smart/skilled, hypocognitive/skilled, smart/incapable, and dumb/incapable.  There are infinite variations actually possible, but the quadrant approach is easiest to understand for this model.

The partners I most enjoy to watch work are smart and skilled.  A dumb and incapable partner makes for an exceedingly long shift (and quiet thoughts of despair).  The other two choices are fine, and some of my favorite partners fall into the “skilled but hypocognitive” category. 

So these are my rankings of partners that I like to work with:

Smart-skilled: Smart and skilled is a great combination.  These medics know why they are doing what they’re doing, plus are good at it. 

Hypocognitive-skilled: Hypocognitive and skilled medics are just fine in my book.  A partner that may not know why s/he is intubating a patient, but knows that the tube is needed (or not) and hits it quickly is a fine partner.  These medics probably have the easiest time on the most critical patients – you can run unstable ventricular tachycardia just fine without needing to understand ejection fractions or minute volumes.  Keep in mind, most good EMTs fall into this category – they haven’t had a lot of school, but they can be really good at skills.  And there are EMTs that I really love to work with.

Smart-incapable: Now we're getting into partners that make for a long shift.  What good is it to be able to diagnose LVH via the Romhilt-Estes scoring system if you are irritating patients and need your partner to start all your lines?  I also find these medics to be really slow on scenes, have a tendency to overthink calls, and to not be able to accept the term “idiopathic.”

Dumb-incapable: Bad partner.  Long shift ahead.  Maybe we can get in a crash that is bad enough to get me sent home, but not bad enough to actually hurt me…

Nobody is 100% smart and nobody is 0% skilled.  So the patterns of where your coworkers fall on the chart probably looks more like a scatter plot:

The good news: A person’s spot on the chart isn’t genetically determined, or set in stone.  It is up to each of us to move upwards and to the right.  We can educate ourselves, and we can practice our skills.  Get a book.  Talk to people better educated than you are.  Go to a conference.  Find good continuing education.  Expand your comfort zone.  Improvement on both axes just requires conscious effort mixed with some hard-won experience.  Hopefully you feel like I do – our job is important enough to warrant the effort.

*Autoimmune disease that causes hypothyroidism with episodes of hyperthyroidism.
**Connective tissue disease: a group of symptoms seen in limited cutaneous systemic scleroderma.
***A type of non-ischemic cardiomyopathy caused by emotional distress.