The Power of Why

There are two big complaints from students and trainees that I hear fairly often.  The first is that their preceptor/trainers are inconsistent between each other.  One trainer says one thing and another says exactly the opposite.  The other complaint is that trainers are just plum mean – they seem to be trying to berate and belittle a student, rather than to teach them.  This happened to me, as well, until I figured out the answer.

When I started with my current employer, a part of the new hire academy was a day spent running scenarios at the SWAT team’s training house.  The house is a building that is made up to look like an apartment complex inside an old hangar.  The scenarios were fairly realistic, and were set up to give specific lessons that were important before your first day on the street.  All in all, it was a pretty fun day.  We no longer do it, but I was lucky enough to take part.

One of the scenarios was a narcotic overdose.  There was a bystander who was a friend of the victim who was mostly getting in the way.  Long story short, I pushed 0.5 milligrams of pretend Narcan and the preceptor said, “Nothing happened.”  Another half milligram: “Nothing happened.”  Another half milligram: “Okay, Greg, get him.”

Oh, damn.  Not words you want to hear.  The victim and bystander ganged up to put a whoopin’ into me.  I still have a faint scar on my arm.

The lesson from the scenario was to be able to make the right decision as to where to initiate treatment.  It was the lion cage theory: A lion tamer never enters the lion’s cage, where the cats eat and sleep.  The lion feels comfortable there and will eat the trainer.  Instead, the tamer moves the lion to the less familiar surroundings in the ring where the trainer is “at home” and more comfortable.  The lions are less comfortable and will perform the act.

A week or two later, when I was on the street working with a field trainer, I ran a narcotic overdose in an apartment.  I know! I know! Move him to the ambulance to wake him up!  It may have been the first thing on a call that I thought I knew the answer to.

After I voiced my move-to-the-ambulance plan, my field trainer said disgustedly, “What’s the matter with you?  Wake him up here!  Why would we move to the bus*?”  So I administered Narcan and woke the patient up in the apartment.  Huh.  Apparently the trainers in the academy were not in touch with the “real” way paramedicine was done.

The next narcotic overdose was a few weeks later.  When I asked for an IV line and Narcan, my field trainer was flabbergasted: “Are you crazy?  Move him to the bus and wake him up there!”

The third narcotic overdose was in the bathroom of a convenience store.  The unconscious patient still had a burnt spoon in his hand and a needle in his arm.  At this point, I had no idea where I was supposed to wake up junkies.  I did a mental coin flip and it apparently landed on its edge.  I split the difference: “Let me bag him up, I will get the line here, and we will give Narcan in the bus.”

My field trainer blew my mind: “Why would you go through all that work?  Just mainline the Narcan.”

“Mainline it?” I said.

“It’s Narcan.  It works IV, sub-q, IM, sublingual, whatever.  A blown mainline IV is just IM, right?  Mainline it and wake him up.” 

[Whatever you do, don’t do this.  We have other, safer ways to administer medications.  This was a long, long time ago.  As a matter of fact, on this call I pulled the Narcan needle out of the heroin addict’s vein and accidently stuck it directly into a firefighter’s leg.  You can’t do that with the intranasal atomizer.  Trust me, you don’t want to look down at the needle swinging from where it is buried in a thigh, look up to make horrified eye contact with an enraged firefighter, and then have to make the etiquette decision as to who should pull it out.  That’s one Miss Manners has never had to answer.]

See what I mean?  Inconsistency between field trainers and an apparent ability to make me feel small and stupid. 

Photo courtesy Intropin, Creative Commons License

What I discovered is that I was too unsophisticated to see what was obvious to experienced medics.  On the first street call, the patient was in a sixth story walk-up apartment.  My trainer wanted to wake him up and let him walk down, rather than carry him while he wasn’t breathing.  It is hard to bag someone being manhandled on stairs.  The second scene was unsafe, like the scenario house.  There were bystanders who would be likely to jump in on the patient’s behalf.  The third call: I have no idea why you would mainline Narcan.  It would be best if trainers and instructors could explain what the trainee is missing clearly without being asked.  But sometimes they don’t.

The answer to this problem is the ability to ask “Why?”  It has to be done in a collegial, non-argumentative way, however.  I have found that the best way is to compliment the trainer: “It seems to me that your experience is giving you clues that I don’t have.  What influenced you to make that decision?” 

You could even explain flat out what you are doing: “I don’t understand.  When I ask this, I am only trying to get the information so I can make the right decision later.  I mean no disrespect.  Why did you decide to do that?”

Usually the answer will enlighten you.  That is what you are being trained for, right?  In rare cases, the trainer will give you a flat wrong answer (mainlining Narcan).  But at least you know how he/she came to that decision.  Sometimes you will get two contrary answers and have to research which answer is right. 

Researching conflicting answers is important.  Research can mean asking people with more education than you have (your medical director or another physician), reviewing literature, or just thinking through the pathophysiology.  It is your practice.  You will have to make the choice when the situation repeats itself.  You will own that choice – your trainer won’t know all of the background you’ve been through.  You have to do what you think is right.  Wouldn’t you rather get in trouble for doing the right thing, rather than some guess as to what your trainer would want?  Do what you would be proud to defend.

One way or the other, it is important to ask “Why?” and get the information.  You are responsible for the choices that are made on a call.  So it is important to understand the factors that influence that decision.  There are no easy answers in EMS.  Everything is a grey area.  How can you expect yourself to operate in the grey if you don’t even know that influencing factors exist?

*Every system has its own vernacular.  Here, an ambulance is called the bus.  Not a rig, not a truck, not an ambo – a bus.