October 24, 2013

Third Rider Introductions

My first third-ride, as a part of my initial EMT class in 1994, was with a private ambulance in the suburbs.  There are four things that I specifically remember about that shift.  First, 21-year old me had a really hard time coming up with blue pants and a plain white shirt.  I mean, who owns clothes like that?  The only white shirt I had was a concert tee that said Ozzy on it.  I had to go buy a white polo and blue pants.  Second, I realized that this ambulance crew went to a lot of nursing homes.  I didn’t realize there were that many nursing homes in the state, let alone in one town.  Third, I remember a head-on crash at highway speeds.  There must have been close to 100 mph combined impact.  What I remember most was that the surviving driver’s lower leg wrapped around the brake pedal so that he was looking at the sole of his foot.  Nasty and cool all at the same time to 21-year old me.  And finally, I remember what the paramedic told me when I started the ride: “Sit on your hands.  If I don’t see your hands all shift, you will pass.  If I see your hands, I will take you back to your car and end your shift.”  I didn’t want to tell him that he had nothing to do with some imaginary pass-fail ride grade.  Ass.

My current introduction to third riders is a little different from that one.  I also include the fact that I shouldn’t ever hear a rider.  Just kidding.

At my agency, we have riders along for shifts for a lot of reasons: EMT students, paramedic students, new hire EMTs and paramedics, military trainees, resident physicians, medical students, and so on.  It is a rare shift that I don’t have a rider along during some parts of the year.  My introduction to riders is always about the same:

  • Introductions
  • Welcome
  • Shift goals
  • Safety
  • Dispatch number
  • Complaining
  • Crew status
  • What they’re bad/good at

I start with who my partner is and who I am.  I make sure that they get our names, and I also talk about what our respective positions in the agency are.  Who’s a medic, who’s an EMT, how long we have been there, that kind of thing.  The name thing is more important than most people realize – a new rider’s head is spinning with excitement and new facts aren’t necessarily being laid down into their memory banks.  Make sure they get your name.

I ask them who they are, and make an actual effort to remember their name.  It is embarrassing to call out “Hey, uh, dude, need a bathroom or anything?” to the back of the ambulance all shift.  I’m also interested in finding out what experience they have in medicine and in the prehospital setting, whether and where they are currently working, and generally get them to tell me a little about themselves.

There is a scandalous rumor that my affect makes me seem as though I am not the most warm and welcoming person.  So I need to make a specific effort to make sure the rider knows that they are welcome.  I’m glad to have riders, I love to teach, and if they have any questions they should never be embarrassed to ask.  They are completely free to ask whatever they like, wonder about anything, and ask me to explain what I'm doing.  I probably had questions on that first third ride but was concentrating too hard on keeping my palms clamped to my butt cheeks to ask.

I ask riders why they are riding.  What do they need to get out of being with me on the shift and what are they hoping to get out of the ride?  There is a difference.  Most rides are just being on the ambulance for 10 hours, but riders have aspirations and hopes of what they will see and what they will be able to do.  I can do a better job teaching if I know that the rider is an EMT student versus a third year emergency medicine resident.  I have different things to show them and different expectations of them.  Some riders plan to work on an ambulance and some would like to work in an ED.  With residents, I need to make sure they are getting the non medical EMS operations picture – I don’t need to teach them how to read an ECG, but they do need to hear about our protocols, our pharmacopeia, plus any safety and system issues that come up.  I really want EMT students to perform a real exam on a live patient, I want paramedic students to start to use the knowledge that was just jammed into their heads, and I want residents to get an appreciation for the difficulty of information gathering without testing and imaging.  If you don’t know what they want to learn and at which level they should be expected to perform, then how can you successfully teach?

Next I move into the safety portion of the introduction.  There are just a couple of main points.  First, a rider should not get involved in anything in which they don’t understand completely.   Don’t lift a pram you don’t understand.  Don’t dive into a wrestling match if you don’t understand what you’re needed to do and where you should be positioned.  Don’t even spike a blood pump for me unless you are sure you know how.  This is safety for the rider, me, my partner, the patient, and everyone else on scene.  I need a rider lifting the business end of a pram for the first time with grandma on it like I need a hole in the head.  And I don’t know what kind of worker’s compensation an EMT student has, but blowing out their back lifting a big patient improperly is probably bad juju.  Riders need to be told that I don’t need their help.  My partner and I would handle the situation as a pair if the rider weren’t there, so the rider being there is superfluous.  Don't let a rider get involved if they don’t know what they are expected to be doing and are comfortable doing it.

Second in regards to safety is to stay with me: “Don't wander off with the shady stranger into the basement cause he ‘needs to show you something.’  Don’t let the police block you out of the scene thinking you are a nosy bystander.  You can’t really be too close to me, and if you are a little too close, I will tell you.”  I don't want to have to divide my attention between the patient and wondering where my rider wandered off to.

Finally, it is conceivable that a rider could get left somewhere between calls.  This has never happened to me in 15+ years, but if they are in the 7-Eleven bathroom when a cop is shot two blocks away we may need to leave without the rider.  It is also conceivable that I am not paying attention, don’t know that the rider is still inside dealing with last night’s Mexican dinner, and go on the next call.  They need to know that it is not the end of the world if it happens.  I will know where I left them and someone will soon be by to get them.  Just hang out and read magazines or something for a few minutes and I will buy a meal to make up for it (if it is my fault).  This is the point that I make sure they have dispatch’s nonemergency phone number in their cell phone.  They can call dispatch to make sure someone is coming for them if it makes them feel better.

I give them dispatch’s number for another reason, which I try to clearly explain to them.  If they want to complain about me, or let a supervisor know about something I did, they just need to call dispatch and ask for a field supervisor.  I tell them this flat out.  There could be situations that can be misinterpreted – searching a patient’s bag can look like stealing to the uninitiated.  Restraining a combative patient can look like battery if you don’t understand what’s going on.  I know that I am never doing anything wrong, so I don’t mind if they tell my supe what happened.  I would certainly prefer that the rider asks me about it so I can explain, but if they are not comfortable with that they have my express permission to call the supervisor directly.  To me, it is important that a rider has a mechanism to bring his/her concerns to my boss.  Not one rider has ever taken me up on it.

Two final points.  First, I make sure they understand they are like a full-fledged member of the crew when it comes to things like bathrooms, food, and climate controls.  If the rider is cold, they need to speak up.  If they need to pee, they should say something (or at least keep making a whimpering noise).  We’ll get it taken care of.  Importantly, if they have an important piece of information about the patient or the situation that I seem to have missed, they need to tell me – just like a full-on crew member.

Finally, I ask them what they are bad at and need to work on.  What have other preceptors said that they need to work on?  This way I can focus on those lessons.  If they have a hard time with hearing blood pressures, I can give them a lot of practice with blood pressures.  If they are an IV student, I don’t want to be snaking their IVs.  If they have never performed CPR, I will make sure to get them on a chest if the situation arises.  If this was covered during the shift goal section, I will occasionally skip it.  But I try to finish the introductions on a positive note by asking them what they are good at.  Everyone is good at something, and I want them to tell me what they are good at.  It starts the shift off well.

Then we go have a good, productive shift.I know this seems like a lot, but it takes less than 5 minutes to talk out.  I promise, it took you longer to read this than it would to speak it.  There is a lot of reasoning and explanation in this post so the actual talk is much faster.  The main points are introductions, welcome, shift goals, safety, dispatch number, complaining, full partner status, and what they’re bad/good at.  That’s all it takes to set someone at ease, gain information that will enhance their ride, keep everyone safer, start to know a person who may be interesting, and be a better teacher for the shift.

And you won’t have a rider 20 years from now telling stories on the Internet about what an asshole you were…

Is there anything important I left off?  Let us know in the post comments if you have a rider checklist that includes other points.


paramedoc said...

Awesome post. Your best yet.

I also think students should be prepped in advance about their rides better than they are. Particularly med students and resident physicians.

I wish they knew in advance:

1. EMS is highly regional and provincial; resist the temptation to pass judgement based on your rides.

2. Experienced EMS providers are formulating an impression, implementing a treatment plan, and attempting treatment in a short amount of time with limited resources.

3. If your ride is on board a fire engine, you are not likely getting a true sense of how EMS is done.

4. Don't call us ambulance drivers. It's pejorative and a medical student should know better.

5. Be prepared. If you are on my car, I will expect that you are able to take and record vital signs, listen to breath sounds, formulate a differential, etc.

6. Under some unusual situations, you might get left behind. It's unlikely, but if it happens, stay where you are. I will send someone to get you.

7. You engender good will when you stay to the end of the shift. I will think less of you of you leave while my partner clean up and restock.

8. Have fun. But remember our job is more than going the wrong way down a one way street with lights and siren.

Unknown said...

Good points, paramedoc.

I also left off two safety points: Wear your seatbelt and listen for any exit instructions when we arrive to a scene. The seatbelt thing is self-explanatory. The exit instructions are for when it would be dangerous to exit the side door and I want them to go out the back door.

Kent said...

Love this line-There is a scandalous rumor that my affect makes me seem as though I am not the most warm and welcoming person.

Said the man who has the scandalous moniker in his email address?

I love ya

Kent said...

Best line of all?

There is a scandalous rumor that my affect makes me seem as though I am not the most warm and welcoming person.

Said the man who has an angry moniker as part of his email?

Oh, and you might want to mention something about modeling, so as to not give the impression it is ok to stalk across the garage whilst, in a harsh tone asking about the F@%king efficacy of some procedure that another paramedic thought made sense at the time..

In all seriousness, PLEASE, PLEASE, PLEASE get the message out to your peers that enquiring about patient care issues (dockside counseling) is perfectly fine, as long as you don't act as described about and you really want to stimulate conversation and though...

Who Loves ya?