Sunday, January 18, 2009

Paramedic Clinicals

So Friday was the first of many clinical shifts (500 hours total) I will be doing as a Paramedic student. My patients ranged in age from 11 to 92, with problems ranging from fractures to overdoses to a suspected DVT. I triaged patients, assessed vitals, started IV's, pushed medications, wiped asses, and did everything else I could find to do.

One aspect of our clinical time is a state requirement that we accomplish a given number of procedures. This is both a good and a bad thing. You want your certified Paramedics to be useful when they get their card. You also want your new Paramedics to be more than just some monkey starting your IV. But when you take those requirements and add to it a finite amount of patients and a finite amount of clinical time, an obvious problem is created. Any economist will tell you that the students will apply game theory to patient care, asking the question, "what interventions can I use," rather than, "what interventions, if any, are appropriate".

More players enter the game when you show your preceptor the clinical guidelines which include these requirements. Suddenly, you have a proxy, rummaging through charts looking for flags indicating a required intervention! This isn't necessarily a bad thing, I obviously need to be competent at starting IV's, administering medication, birthing children, et cetera. I just should not be particularly concerned about only having 500 hours to accomplish X number of IV starts, Y medication administrations, Z child births, et cetera ad nauseam.

The state clinical requirements should make the student more concerned with the academic approach, starting with patient assessment and ending with a clear and organized treatment plan. It shouldn't matter if I'm the one providing any required interventions, just that I'm able to provide any appropriate intervention when required.

So you can see why I'd find it funny that my first IV stick as a medic student was a heavily tattooed habitual IV drug user requiring cardiac blood labs. He was nearly devoid of useful veins and definately required blood drawn. A disgustingly green paramedic student tends to fall towards the bottom of the list of people you'd like performing this procedure. But not being one to avoid a challenge, I tried to follow some scar tissue to what felt like a vein, but my angle of attack was too high and I nicked and rolled it.

Swiiing and a miss.

Even with a little extra traction and some fancy needle movement I couldn't establish a patent line. The patient wisely asked that the nurse try the next stick, due to that being the only vein we could find sans a vein running along his thumb. I'm sure the fact that my shirt said EMS Intern on it played no small role in his decision to ask that somebody else make the try.

My mind is still debating if there was more learned attempting his IV or reading his ECG.