How can you be sure a horse is just a horse?

[DwayneEMTP]

Capisce.

[Dustdevil]

I have never met a good female preceptor in my career. I've met some great female medics. But, unfortunately, the females frequently face the same kind of prejudice that she is giving you, and it colours their judgement in the long term. They end up with a chip on their shoulders for their entire career, and always feel like they have to prove something, as well as having to make sure that everybody else endures the same shyte they endured. The whole relationship becomes about them instead of the student, which is seriously counterproductive. No female preceptors in my system.

I'm not intimidated by her, but by her motivation to help me fail, as it reinforces her opinion that 'people like me' don't belong as medics. By not having street experience I give her a lot of latitude to steer me wrong, or make me look foolish to my peers, so I'm ever vigilant for signs of that.

Her job is to make sure you succeed. If you fail, SHE is a failure. Plain and simple, if she is worth a shit as a preceptor, then she should possess the ability to overcome any disadvantage she thinks you have from not having EMT experience. If she can't, then WTF is she doing precepting? While I do believe there is a time and place for "tough love," and pushing the student out of their comfort zone -- sometimes even by challenging them verbally -- it does not look like that is what she is doing. She's making this all about her instead of about you. Honestly, I am getting so pissed at this chick right now that firing is too good for her. She definitely needs to be on the carpet in front of her supervisor, her director, and your dean for incompetence and for creating a hostile environment that is counterproductive to her job and to your education.

As for the whole zebra thing, it doesn't sound to me like you are really having a problem with it. They always have to be in the back of your mind. And you have to rule them out. But you do not have to focus on them primarily. I don't see that you are putting an unreasonable focus on them. In order to rule them out, or to even suspect them seriously, you have to have all the relevant information available to you. That means a THOROUGH assessment on every patient. NO patient gets just enough evaluation to arrive at a primary impression, no matter how good you think you are. You may start interventions after that cursory evaluation, but the total assessment continues until the moment you turn that patient over to the hospital. If that woman had been hypoxic from pneumonia or carbon monoxide -- neither of which are zebras -- how stupid would you have looked for failing to check her pulse ox? It's all part of doing a complete assessment, which is expected on each and every patient. With all that information available to you, you can then consider your zebra differentials as you go. Usually, when you have ALL the necessary information, something will stick out from the rest and make you think, "Hmmm... something more is going on here." A fever. Tachycardia. Widening pulse pressure. Red or pale skin. No previous history. Something that just doesn't usually go along with the diagnosis you are currently working with, even though everything else does.

Example. Last month, I had a guy come in to me complaining of headache, dizziness, nausea & upset stomach, fever, chills, mild tachycardia, body aches, and just generally feeling like crapola. HEENT revealed an otitis media, which could by itself account for most all of those sx in extreme cases, but not usually in an adult. Chest was clear. No URI sx. He was well hydrated. I wrote the severity of the sx off to a combination of the OM and a viral illness, put him on antibiotics for the OM and sent him home. Twenty four hours later, he came in for a recheck feeling somewhat better, but now asking for something for his leg pain. What leg pain??? He hikes up his pant leg and there, bigger and hotter than hell, is a flaming cellulitis on his lower leg. That's where all those symptoms were coming from, not his ear! He had not said anything about leg pain the day before, but had I done a thorough assessment, I would have found it. No big deal though, right? Wrong. What if it had not been a cellulitis, but a DVT? The delay could have been catastrophic. I was lucky.

EVERYBODY gets a THOROUGH assessment! DO NOT STOP just because you found a problem. There are frequently other problems still to be found, and sometimes they are more serious than the one you found already. This is very basic stuff, if you think about it. It's like treating an entry wound without ever looking for an exit wound. It's a horribly stupid, and potentially fatal mistake. You are absolutely on the right track in your thinking and your practice, my friend. Don't let this bimbo intimidate you into being as crummy a medic as she is.

Your time with her is very definitely not wasted though. You are learning at least two very important lessons here. First, you are learning how NOT to be a crappy preceptor. But more important, you are learning how NOT to be a crappy medic.

I am positive that you are going to be somebody’s Medic Of The Year early in your career. And, unlike her, you won’t need knee pads to do it.

[Doczilla]

Dust: Vivi is a lucky woman.

Dwayne: If you knew how to sort out the horses from the zebras, then you could teach at the medical school. This is a skill that is virtually impossible to teach. Medical intuition comes, as others have said, from experience. There are subconscious cues that we pick up on that tell us someone is sick. Most of those cues we haven't yet identified. Some folks approach it one way, by treating the most likely cause of the patient's illness, leaving the zebras to settle out once intitial treatment has failed. Others shotgun lab everyone and admit everything because they lack confidence in their ability to sort these out.

Some folks decide on a diagnosis, then continue to believe in that diagnosis despite emerging evidence from the patient that it might be wrong. This is where people run into real trouble. The correct diagnosis may become clear to the outside observer as the patient condition changes (and would have been clear to the provider had he seen the patient this way initially), but because the provider has essentially settled the question in his mind, the right answer eludes him.

Zebras are just that: rare. Most of the patients which make us scratch our heads are uncommon presentations of common illnesses, rather than presentations of obscure illnesses. I agree completely with Dust on doing a thorough assessment. A good rule for your medical practice as well as for testing: if anything changes, if something isn't working, if you still don't know, then reassess.

Until you have your own jedi sense of sick people, you have to be more conservative in your approach, i.e., overtreat and overmanage. Treat what is most likely, but always keep the zebras in the back of your mind and have a tactical plan to deal with them. If the patient isn't quite what you expect, or if he isn't responding the way you think he should, then reexamine your initial impression and consider other possibilities. Don't get locked in by your preliminary diagnosis. Folks who never think of zebras will get blindsided by them on a regular basis.

The above is why PAs and NPs will never truly take the place of physicians. Their training is in the "most common" and "most likely", whereas the physician also has training in those obscure diagnoses that elude most midlevel providers.

And Dust, you must have had a good run of bad luck, because I've had plenty of female preceptors- medics, nurses, and physicians- who were excellent teachers and helped me develop skills (MEDICAL skills, you pervert) that I will keep for the rest of my life. Come up this way and I will introduce you to some of them.

'zilla

[chbare]

Sounds like a bad situation. I had to deal with a nursing instructor that had a chip on her shoulder when I was a first year nursing student. Sometimes the old saying "cooperate to graduate" can apply. However, if she is precepting students and advocating incomplete and lazy assessments, then perhaps the problem should be addressed.

Regardless of horse versus zebra, pulse oximetry monitoring is quite simple, non invasive, and many people consider it part of a vital sign assessment. What do you think would happen if I quit monitoring pulse oximetry on every non critical ER patient just to save a little money?

Give you self some time and experience to develop your sixth sense as others have already stated. Keep at it and you will get through.

Take care,

chbare.

[DwayneEMTP]

What a gift you all are.

I agree that if I fail, she fails as a teacher as well, though now that it's become obvious teaching is not her main motivation I'm committed to making the most out of the experience with the tools I have available.

Being exposed to you guys, with your expectations, it just came as a shock to find that many of of the professionals I've been exposed to seem to fall short of a professional standard. I didn't expect that attempting to be an ambassador of your attitudes would put me in a minority.

ER docs seem to be a glaring exception. They seem to love to teach, and truly seem to rejoice in the intelligence of those around them, be it nurses, other docs, or the lowly medic student.

One of the high points of my rotation so far followed us bringing in a CHF pt having an MI (undiagnosed in the field) that they decided to RSI. While waiting the few seconds for the paralytics to take effect, with the RT standing by, the Dr. says “Hey, hotshot medic student, what does PEEP stand for?” Though it seemed a simple question, when given the correct answer he, the RT and several nurses started to laugh and applaud!

It wasn't until that moment that I realize how much the constant nagging, insulting and effort to find error where it might or might not exist was taking a toll on my attitude and self confidence. It forced me to the conclusion that it was time to choose my own path on this clinical instead of continuing to hope that things would work out. In that one 'teaching moment' the Dr. reminded me that learning is about celebrating small successes and improvement, that learning is, or at least should be a positive, building endeavor, not one of fear.

My reason for telling that story (obviously knowing what PEEP stands for is no great accomplishment) is to try and explain why you all are so important to those of us trying to find our way.

I wonder sometimes if you know how important it is for us to have a place to come where it's understood that sometimes we just need the truth! Thank you for making me see that I'm being an idiot, or not. That things were unfair, or that I was simply whining. That I might be good, but I can be better, and this is how. That's such a gift. I know you have better things to do with your time, but this time WILL change the future of EMS...It changed my path, and continues to throw flares along my future path that I don't have the experience to see, but need to find, to end up where I'd like to be. A peer.

I'm just an old, fat, not so bright medic student. Why do Dr.s and nurses and medics smarter than I ever hope to be take time to care about that? I don't know...but I'm grateful.

Ok, I always feel like a dork when I write these things, and I know it has nothing to do with the topic, but I'd hate to go out today and get hit by a bus and have it left unsaid.

Thanks for all that you do for us here.

Dwayne

[DwayneEMTP]

Ooops. Back on topic.

Thank your all for your advice. I can't take the "looks" , criticisms, and personal uncertainties as long as I know I'm on the right track to doing good medicine.

So I will continue to do what feels right for my assessments. And will continue to treat horses, yet watch closely for zebras while I wait for my own 'gut' instincts to develop and mature.

Thanks again.

Dwayne

[Dustdevil]

I know you have better things to do with your time

LOL... I'm afraid your instincts failed you on that one, Bro.

If it weren't for EMT City, I'd be asleep at my desk all day long.

[Freaknuggetz_chick]

So I will continue to do what feels right for my assessments. And will continue to treat horses, yet watch closely for zebras while I wait for my own 'gut' instincts to develop and mature.

Thanks again.

Dwayne

no patient could ask for anything more than that. be thorough, be confident. take 'zilla's advice and KNOW that even a crappy preceptor can teach you, even if only it's how NOT to be.

its true, the world is full of horses, but the zebras do sneak up and bite us in butt if we dont keep them in mind!!

Right now i am precepting for my first time. I'm still a student technically (I have my diploma, only 5 courses left for degree), and hope that i never have the arrogance of your Ice Queen!! part of the reason why i love this profession so much is that there are always opportunites to learn....new techniques, new research, new tools...

Keep at it! you said nothing in your original post that would make me doubt your assessment. I am surprised that there is a charge for sPO2, but i am also a canadian medic, and not involed in billing! up here, every pt. gets sPO2 checked, and i would also check that ladies BGL too.

Dust: sorry you've never met a decent female preceptor. They do exist.

[DwayneEMTP]

I can't take the "looks" , criticisms, and personal uncertainties as long as I know I'm on the right track to doing good medicine.

Ooops again. Hopefully it was obvious I meant "can" instead of "can't." :oops:

Thanks all!

Dwayne

[toutdoors]

I agree with you. When I was in intermediate, every pt we had in class was an IV candidate. Now every pt in medic class a candidate for intubation, the monitor, RSI, a needle decompression, some type of medication, pacing, cardioversion, god the list goes on. I too have been trying to "find" a reason to do more than vitals and maybe a little O2 on a good number of pt's during my ride time. It seems frustrating that when I am working I see truly sick or injured pt's, and when I ride, they simple need a white taxi to the ER. I have been involved in this field of work for almost 15 years and do know this, as your experience base broadens, your intuition becomes much more keen. Good luck in your ride time, and know that you are not alone in the corral.