The Terrible Twos

I’m sorry to be the one to let you in on a horrible secret, but here goes: Medics around their second year are hitting the nadir of their medical skills and knowledge. They are commonly terrible paramedics and terrible employees. I guess there is never a never and never an always, but it certainly happened to me, and it is a normal finding to watch happen with other medics. Sorry – but that is just the way it is. 

I think the reason is that paramedic school sends you out into the world on the high point of a pendulum swing. A brand-new medic just spent between six months and two years studying their chosen craft. In addition, they are probably just finishing up their field internship, with irritable medics evaluating their every move. All the little EMS facts and medical knowledge are fresh and accessible in their brains, and they have been studying like mad for the National Registry test. 

Career roller coaster is a metaphor that works too. This is what my coaster looks like...
Picture source

Immediately after that, in many cases, they are hired into a paramedic service and begin a field training process. Once again a grouch is watching and nagging about their every move. Between calls, trainee paramedics are quizzed. Situations that trip them up are found and corrected. Trainees spend time studying protocols and medications. They are constantly asked: Why did you do that? What did you think was going on with that patient? 

The skill and knowledge pendulum is pushed higher.

Then a new paramedic clears the field training process, wherever they are, and begin to work as an independent medic. All that career pressure, going all the way back at least to the start of paramedic school, is suddenly relaxed. Now is when the skill/knowledge pendulum swings back to the suck end of the scale – but it takes a little time. There is no longer an irritable trainer looking for mistakes to hammer. A medic finds that they can palpate blood pressures, rather than auscultate, and in most cases nobody will call them out on it. Physical exams become progressively lazier until the point that they may even be skipped altogether. If-then statements fill their day, without thought or reasoning. General work habits slowly decline, patient and citizen complaints increase, and (being that they are progressively more comfortable with the experience of driving an ambulance fast) crashes and near-miss crashes start to occur. As the pendulum keeps swinging back away from the peak of skill that they had, the rate of patient non-transport calls increases. Unnecessary refusals increase. The new medic gets more bitter and acts like a burnout. 

Don't be sad, little medic.  It happens to everyone... Picture source

At least, this is a pattern that I commonly see. I will admit it happened for me. Mostly what is happening is that the pendulum overshoots the mean and falls to the below average end of the scale. A medic, especially in a busy system, has seen a lot of patients and begins to feel comfortable with their job. Ninety percent of patient presentations present no challenge to them. Unfortunately, these two-year medics think 100% of presentations present no challenge to their skills and knowledge. The gap between 90% and 100% is where problems arise.

I think it is related to the Dunning-Kruger Effect. This psychological finding is a failure of metacognition described by David Dunning and Justin Kruger in 1999.* What it describes is that relatively new or unskilled people experience “illusory superiority” and cannot correctly place their skill level into context. A person doesn’t know enough to accurately assess if they know enough. They don’t know enough about the scale to precisely place themselves on it. They don’t miss on the low side, though. Like an underheight middle schooler who thinks the NBA is in their future, the cognitive failure is to evaluate their skill level too highly. (On the other side, though, high skill individuals may underestimate their relative level of competence, thinking that tasks, which are easy for them, should be easy for others. But that is a topic for a later discussion.)

Looking back, I can completely see that I felt this way. I had two years in a high-volume system under my belt. I had run enough calls to get comfortable. I was good at my job, but I thought I was excellent at my job. I thought I was an incredible medic without even having to work at it. I was a prodigy medic, in my own head. I was lucky that I had a call or two that scared me without harming anyone. Looking stupid is better than causing harm. Even more beneficial to me was when I got to see a twenty-year medic work at full speed. Not work fast; work at their full speed. A salty old street dog doesn’t often feel the need to work as fast as he or she can – it only happens once or twice a year. Watching that, I went from feeling like I was a bad-assed über-medic to sitting in the captain’s chair with my mouth open, gobsmacked, wondering why I sucked so bad. 

Those near-miss calls and incredible partners were enough to wake me up and start the pendulum swinging back the other way, away from lazy and dumb. I’m glad that my poor skill level didn’t affect anyone else. 

For me, the pendulum swings got smaller and smaller, until it essentially stopped altogether. There wasn’t a whole lot of variability from day to day or week to week in my job performance. At this point, a great medic would push the pendulum to the skill end of its arc, and kept on pushing without letting it swing back to the lazy end. Keep pushing for excellence, not comfort. Reset the pendulum’s range. For the rest of their career, they would keep pushing to expand the length of the skilled side of the pendulum’s range.

*Kruger J, Dunning D. Unskilled and unaware of it: How difficulties in recognizing one’s own incompetence lead to inflated self-assessments. J Personality Social Psych. 1999; 77(6): 1121-34.

Old Incident Reports, Part One

I was going through an old folder found in a desk drawer in my office and found a bunch of old incident reports. When I say old, I mean at least 10 years old. I opened the folder and blew dust off it like Indiana Jones. Old. Reading some of the reports put a smile on my face and reading others made me embarrassed. Deeply embarrassed, as a matter of fact. Reading some of those reports now, I feel like I’m lucky to still have a job.

One of the reports is my description of an ambulance crash. If I remember correctly, it is my most recent crash. I can't think of another, more recent one. Let’s pause a second and acknowledge that it’s pretty impressive, considering my last grinder was in 2003 or so, huh? I used to think occasional crashes were “just part of the job.” I was involved in a crash per year or thereabouts. I mean, when a medic drives x-thousand of miles per year, sometimes the dice come up with an unlucky number. Impossible to avoid, right? Nowadays I think occasional crashes may have been related to me driving like an asshat. But then I came across the report for this crash. It doesn’t seem to have been especially avoidable, so I don't know what to think. Maybe I have been lucky for the last decade.

Way, way, way back in the day, I was stoked to be working with one of my favorite partners. This was in 2003 or so. Early in the shift, we were assigned to a report of chest pain. I was driving and I flipped on the lights and siren. We were rolling on a huge four-lane road (four lanes northbound and four lanes southbound). I approached an intersection where I wanted to turn left. The light was red and there were cars in the number 1, 2, and 4 lanes. The three lane was open. I came up to the intersection, stopped (mostly), ensured the intersection was clear, and made my left turn through the red light from the three lane.

Crunch.

Yep. Ambulance crash. But it is not what you think. What happened was that the guy in the number one lane waited until I was in front of him before running the red to crash into the side of my bus. He up and plum rammed me. For no reason. Nobody has any idea why he did it. Including him – he said so to the police officer and to my supervisor. I have to admit – he was cool about it. It is nice when the other dude says the crash was his fault, in those words. He took all the blame. I mean, it was his fault and all, but a ton of other drivers would try to make excuses or stretch the truth. So good on him.

The worst part of the crash wasn’t the crash itself. I wasn’t at fault, the damage was minor, and nobody was hurt. The worst part is that they put my partner on another car while I was getting the crash investigated. When all of the investigation and paperwork got done and I swapped out ambulances into an uncrashed bus, I got a new partner! No! Crap! My dream of a cool shift with the partner I liked was dead! The partner I wanted to work with was across the city in another unit. Sadness…

At least crashing meant I could attend the rest of the shift. 

So it is possible that some accidents are unavoidable. It could be that all of my crashes are secretly, quietly unavoidable. Even the one where I hit a curb going about 40mph in the snow and got all the wheels to point in different directions. Even the one where I backed into a fence – completely unavoidable, right? After pondering it, I think many “unavoidable” crashes are due to poor choices and aggressive driving. There are certainly some ambulance accidents like the one described above that are accidental, but there are others resulting from a string of suboptimal choices with a crash at the end. 

I don’t know. I need to think about this some more.

Another Problem, Part II

In yesterday's case, I told you the story of how my partner and I were running an unresponsive gent with a believable report of seizure, obvious evidence of frank GI bleeding, hypotension, tachypnea, and hyperglycemia. I ran a 12-lead before departing to the hospital:

By ArcGenus41 (CC BY-SA 3.0, via Wikimedia Commons). Click to enlarge

When I saw it, I said aloud: “Oh, that’s good. Just what he needs. Another problem.” My partner glanced up from taping down the IV line and immediately saw the relevant ECG finding, as well. Did you see what we saw?

Hypothermia.

Specifically, we noted Osborn waves in pretty much every lead. The end of the QRS (or the beginning of the ST segment, depending on how you look at it) gets a sharp waveform that some people compare to a fishhook. I don’t see the fishhook shape, but I can see Osborn waves. Here are some more examples that I found online*:

By Jer5150 (CC BY-SA 3.0, via Wikimedia Commons) Source

By WikiSysop (CC BY 3.0, via Wikimedia Commons) Source

The height of Osborn waves are supposedly proportional to the degree of hypothermia, but I've not seen a solid study to back that statement up, so I take that little factoid with a grain of salt. Life In the Fast Lane has some illustrations of worsening Osborn waves, though. According to a brief article in the journal Circulation, hypothermia is initially associated with sinus tachycardia. As the core temperature drops below 32.2°C (normal body temp being 37.0°C or thereabouts), sinus bradycardia is more common. In addition to the bradycardia, all intervals commonly lengthen. As the temperature continues to fall to the range of 30.0°C and below, atrial ectopy and atrial rhythms like AFib can appear. “At this level of hypothermia [<30.0°C], 80% of patients have Osborn waves…”  

Keep in mind that ECG findings aren’t the best way to measure a patient’s temperature, just like ECGs are sub-optimal for searching out electrolyte findings. The best way to find a temperature is with a thermometer. But recognizing ECG findings can put you onto a differential diagnosis that you may not have thought of otherwise. Like in the case we were discussing here…

My experience with hypothermia is usually generally similar to this case, in that this fellow wasn’t in a cold environment. The take-home point is that hypothermia is less common during raging blizzards than it is in settings in which you wouldn’t necessarily expect cold - like seizing indoors. Even the worst urban outdoorsman usually finds shelter when it gets hard-core cold. But I have seen hypothermia in early September when a college student got a little drunk and passed out in a park. The sprinklers turned on, he got wet, and then he got cold. Another guy tried to cross a river and got wet. The coldest patient I have ever been involved in resuscitating had a core temp in the teens (I want to say 17°C, but 14°C sounds right too). He had gotten intoxicated and fell asleep in an alley. In that case, the night was admittedly pretty cold but he was well-dressed for it. He lived, by the way. 

The patient in this case study had a core temperature of 28.4°C. He died in the hospital the next day. His medical issues were complex and interrelated. 


* You should also do an image search on the Google machine for Osborn wave and check out a ton of examples that I don't have permission to share.

Just What He Needs. Another Problem...

A few years ago, my partner and I were sent on a non-emergency response to a cheap residential hotel-apartment-type place on the report of a seizure. In my system, when a patient has a history of seizures but has stopped seizing it is not usually an emergency response. In any case, we arrived and were met by the building manager. On the way to the third floor of the other side of the building (because of course that is where the call is), the manager explained that he had let himself into our patient’s room to do some maintenance. He found the patient on the floor having a seizure. (This is the kind of place where one could reasonably expect the manager to be able to recognize a seizure. This wasn't his first rodeo.) The manager’s description of the activity certainly made it sound like a generalized seizure.

We arrived to find that the patient’s room was big enough for a bed, a television, and a hotplate. There were a pile of clothes in one corner and a pile of empty liquor bottles in another. Let's just say the maid hadn’t been to this room in a while. The patient was a male in his late thirties, but looked like he was older. He was supine on the wood floor, and he had indeed stopped seizing. His eyes were open, but he was unresponsive to any stimuli. His skin was pale but dry. There was circumoral blood and an old puddle of bloody vomit next to him. There was also bloody diarrhea in his drawers. After checking for other clues in the apartment (I found a half-full bottle of Seroquel and no other meds), I got to work setting up extrication (a probable hassle due to the previously mentioned frankly bloody diarrhea) and my partner palpated a quick set of vitals: 80/p, with a heart rate of 80 and a deep, sonorous respiratory rate of 22. We placed a nasal trumpet to stop the snoring (successful), moved the patient to the pram without getting anything on me (successful), and moved to the ambulance (also successful).

So where were we? Seizure, check. Gastrointestinal bleeding, check. Hypotensive, check. Unresponsive, check.

In the ambulance, my partner began working on an IV line while I placed a 12-lead and pulse oximetry. During the IV placement, my partner checked the patient’s blood sugar and found it to be 488. I didn’t find any sign in his room that dude was a diabetic. Another issue for the patient to overcome, check.

The patient was satting at 100% via the non-rebreather mask and the NPA and I got this 12-lead:

The quality is not good on this ECG, but you can still see what you need to see.  Click to enlarge

When I saw it, I said aloud: “Oh, that’s good. Just what he needs. Another problem.” My partner glanced up from taping down the IV line and recognized the significant finding, as well. 

Do you see it?