You’re Not Going to Be Good. Advanced Tips for Paramedic Interns

A supine simulator.
File Photo.

Congrats! You’ve completed a large portion of paramedic school. You’ve endured hundreds of hours of classroom learning, endless hours at hospitals, and now you’re ready to hit the road. You’ve just got to get that pesky internship out of the way. The standard advice applies: be early, wear a clean uniform, bring food, be ready to help out in ways not directly related to education, don’t take pictures, and be respectful. You already know all that though. Here are some things you might not have heard or might not be aware of.

Manage Your Expectations of Yourself

You’re not going to start off good. You’ll probably be pretty bad, actually. Paramedic school gets you ready to start your internship, not complete it. If you are already working in the field, you have the advantage of being comfortable with the expectations and flow of calls, however you’re going to need to break some of your old habits. If you’ve never worked in the field and are coming in as a completely blank slate, there are going to be some very steep educational and cultural challenges to overcome. It can definitely be done, and I know many fine medics that went the “zero to hero” route, but they will all tell you that it was hard. Be patient with yourself. There is a reason internships are so long.

There is a theory of adult education called the Hierarchy of Competence.1 This theory describes the process a student takes when learning a new skill. It starts with unconscious incompetence. You’ve just successfully completed several major parts of your paramedic education and you’re feeling smart and ready. But you don’t know what you don’t know. It usually takes students several days to several weeks to realize that they’re not ready, and then we move into conscious incompetence. There is usually a crisis involved here.

More from the Author

Students typically say things like “This is way harder than I thought,” or “I didn’t learn any of this in school,” along with a look of dismay. But don’t be discouraged! This is a necessary and expected stage of your education. You are now aware of what you need to learn and study to bring you to the next phase, which is conscious competence. You know what you need to know and you’re confident in the knowledge. You probably won’t get here by the time you’re done, but it should be on the horizon. Typically medic students start getting their real confidence after a year or so working in the field. The last step is unconscious competence, where you aren’t even aware of how skilled you are. EMS is now second nature and you’re confident on virtually any call. This is truly rare air, and you’ll know these medics when you work with them.

Don’t Make Excuses

You’re going to make mistakes. How you handle those mistakes are up to you. You can make excuses about how you didn’t get the correct information, or you couldn’t have known something. Many terrible medics brush off mistakes as one-off events they weren’t responsible for and there was no way to anticipate. Instead of that, take responsibility. Find the gaps in your knowledge and address them.

Mistakes are a great opportunity to learn and shouldn’t be passed up. When your preceptor or another provider takes the time to correct you on something or give you advice the best response is gratitude and an earnest desire to do better.

Be Assertive

When you get on scene there may already be providers on scene. Get in there and make yourself known. Most crews will be more than happy to turn over patient care to a student. Remember, the medic on scene was once in your shoes. This tends to be a sticking point for people with EMT experience who are used to hanging back and doing tasks as assigned. The primary skill of a paramedic is leadership. If the person in charge is calm and confident, any scene can be managed. So, get in there and start bossing people around. Delegate tasks. Be like a duck – calm and composed above the water but paddling like crazy underneath.

People Have Several Things Wrong with Them. Prepare for Ambiguity

Paramedic education is typically taught in a way that presents one disease process per patient with the associated findings that lead the student towards that conclusion. This presents a good method for practicing differential diagnosis and simple assessments, but sadly does not translate well to the field. Patients frequently do not present classically and may have complaints that do not align with physical findings. Don’t get caught up trying to figure out what is medically wrong with the patient before initiating treatment. Treat symptoms as you find them and if you come to a working diagnosis, great! If not – it isn’t required.

What If I Don’t Get Along with My Preceptor?

Ideally, the school internship coordinator will work with the agency you are interning with and find a preceptor that will be a good match for your learning style. This doesn’t always happen though. If there is really a huge conflict that you can’t see yourself tolerating for several hundred hours, reach out to your school and let them know. This is pretty rare, though. You can keep this relationship about work. It’s easier if you get along well, but not required. If you can just do it the way your preceptor wants until you’re done, then you can develop your own style.

Prepare For a Very Poor Work-Life Balance

Paramedic school is rough. By the time you get to internship you are probably tired, frustrated and burnt out. Well, it’s going to get worse. During internship you’re likely going to be working full time for free, and still doing clinical rotations and classroom work. I’ve seen people work not at all or part time and be poor, or work full time while interning full time and have money but be miserable. It’s awful either way. If you can mitigate these options ahead of time you really should. Can you save up enough money to not work for a few months? Maybe move in with the parents for a while?

If you’re lucky enough that money isn’t a problem during internship, you’re still going to have not much of a social life. You almost have to eat, breathe, and sleep EMS during paramedic school if you want to do well. Tell your friends ahead of time that the 3 a.m. late night bar and pool nights are on hold, not canceled.

Learn the Local Protocols for Where You Are Interning

You were likely taught a generic national curriculum at school, which is perfect. Schools don’t know where you are going to end up, and it would be silly to teach specific protocols. Schools often send people out of county, state, or even country for their internships. Once you find out where you are going, find their EMS protocols and start studying.

Yes, you may be doing a lot of memorizing for something you will only use for a few months, but few things will annoy your preceptor more than not knowing how to function in the system you are in. It’s amazing that you want to give diltiazem for this rapid afib, but we don’t carry that. Now what? If you don’t know what you’re supposed to be doing in that system, it’s going to be the first thing you are assigned and you’ll be starting behind.

Not Everything Is a Cardiac Problem

You receive a basic level of knowledge across a broad range of medical ailments in paramedic school. We respond to all complaints, and so we must be a jack of all trades. Prehospital interventions are particularly important for cardiac issues and that is where lives can be saved and our education reflects that. An inordinate amount of time is spent on cardiology and EKGs. When you finish school you’ve got a toolbox full of pretty average screwdrivers, and one really nice hammer.

Resist the urge to see every problem as a nail. Many of our patients have abnormal EKGs at baseline. Consider an elderly patient with a rapid atrial fibrillation and low blood pressure. You’d be tempted to think “Ah, yes. This is a cardiac problem. I need to fix this rhythm.” Many people have afib, and when they are tachycardic for whatever reason (hypovolemia, for example) they have a rapid afib.

Bradycardia also trips people up. Bradycardia only becomes symptomatic by way of hypotension. If their blood pressure is normal or high, leave it alone. Bradycardia can be compensatory for increased intracranial pressure and you really don’t want to be increasing that by “fixing” their bradycardia. Consider underlying causes. Don’t fix what isn’t broken.

The Hard Calls Aren’t What You Think

You’ve studied and practiced intensely on cardiac arrest, stroke, sepsis, severe trauma, and any number of other topics. How much time was spent on ground level falls? A geriatric syncope with a ground level fall could be almost anything, and you’ll run this call all the time. You will have to use almost everything you’ve learned and do some keen detective work to figure these out.

You’ll have to get used to working through multiple disease processes and using several protocols at once. These ambiguous calls will truly test your abilities. It’s a surprise and relief when patients present with clear and classic symptoms of a particular disease process, so don’t expect it.

Some Calls Hit Close to Home

Everyone has calls that they don’t like running. For a lot of people, it is pediatrics. It is car accidents for others. If you’ve had a personal trauma in your life, you will probably not like going on calls that are similar to your experience. A lot of times this is anticipation. You’re afraid you’re going to freeze up. You won’t. You’re going to get through the call just fine. After you’ve done enough of them the stress level will go down. It may never go away entirely, but it will be better.

It’s Mostly Talking

You know how to start IVs, intubate, calculate drips, and any other number of skills. The reality is that you won’t be using these skills much. Most people just need a ride to the hospital and some conversation. Even in a busy urban system, I have gone days without using a single piece of equipment other than some ECG leads and glucose strips. The so-called “soft skills” of assessment and conversation will be your most used interventions. And they are indeed skills. If you are not good at small talk by nature, it is a skill you can develop.

Just getting a description of what is actually wrong and a medical history can be an exercise is verbal gymnastics with certain patients. In general, patients love to talk about themselves and their medical problems, which is great because that’s exactly what you want them to talk about. I’ll usually take a look around their house and pick out a thing or two that’s interesting to talk to them about if we run out of medical topics. How much you want to share is up to you, but in general avoid topics about where you live and your family.

Embrace It

Your internship is going to be hard. It will challenge you intellectually, physically, financially, and possibly spiritually. You’ve got to go into it with the attitude that you can keep fighting even when you’re down. Adapt and overcome. If this was a comfortable experience you wouldn’t be learning what you need to learn. If you need to lean on your family or friends for support, or even a hot meal, do so. Keep pushing. You’ve got this.

Beyond the Internship

You’re done! Now what? It’s time to get to work. It can be a jarring change. You’re used to having an experienced provider watching your every move and making sure you’re not doing anything wrong, and then all of a sudden it is just you with a patient and no supervision. Trust yourself, and never stop learning.

I often tell interns that their real field education is their first year on their own, and their patients will be the teachers. Just make sure you’re paying attention to the lessons. Protocols and best practices change significantly and often. Your education is a three-ring binder, not a textbook. You’ll need to disregard things you learned in school and adjust your practice often. Always keep learning!

Quick Tips

Don’t try to impress your preceptor. They won’t be impressed by the crazy call you ran at your volunteer job.

Don’t try to be friends with your preceptor. That may develop over time, but while the possibility of failing you is looming they can’t be your buddy.

Do bring snacks for your agency on your first day if you have the financial means. Doughnuts are usually appreciated.

Don’t ask your preceptor about their worst calls. You’re making them relive something they’ve probably spent some effort getting past.

If you had a good experience on your internship, write a nice thank you note. I’ve kept every one I’ve ever received.

If you’re working on an ambulance that posts on street corners, use the bathroom at the hospitals if you even remotely need to go. You never know when your next chance will be.

Bring enough food for the day. You might not have a chance to pick any up.

The author would like to thank his steadfast partner Eve Hatfield and his most recent student victim Nicholas Hayes for their contributions to this article.

Reference

1. Broadwell, Martin M. (20 February 1969). “Teaching for learning (XVI)”. http://www.wordsfitlyspoken.org/gospel_guardian/v20/v20n41p1-3a.html . The Gospel Guardian. (But better explained and expanded here.

Upstate NY Weighs New Ambulance; Will It Help or Hurt?

In a contentious public forum Tuesday night, Northstar Health Alliance proposed launching a new ambulance service to transport patients between medical facilities.

OH Gunman Kills One, Injures Five in Industrial Park

A gunman shot six people in a New Albany commercial building Tuesday, killing one person and injuring five others. The city said police responded at…