Like anything else in medicine, widespread utilization also comes with widespread misunderstanding. The SAMPLE history is an educational gold standard for a reason. It’s a very effective tool for remembering the major components of a medical history.  It’s also often misused and highly inadequate when taught and utilized at face value.

Let’s review the SAMPLE history and talk a bit about how to use it correctly to get all the juicy bits of medical history that you need when treating our patient.

First, to make sure we’re all on the same page, let’s review the SAMPLE acronym. SAMPLE is a six part subjective assessment that covers a good deal of critical information that is typically gathered in a basic subjective patient assessment. To review the difference between subjective and objective assessments, check out the SOAP reporting format. SAMPLE stands for:

S – Symptoms (Signs are important but they are objective.)

A – Allergies

M – Medications

P – Past Medical History

L – Last Oral Intake (Sometimes also Last Menstrual Cycle.)

E – Events Leading Up To Present Illness / Injury

That’s pretty straight forward. But let’s dive a little deeper. The first thing I’d like to emphasize before we jump into the questions in a little more detail is this – a SAMPLE history is not over in six questions. They are never complete in six questions.

I emphasize this because that isn’t the way we typically teach it in EMT class. You run your scenario and you say to your skills instructor, “I’d like to know about her signs and symptoms, allergies, medications, history, oral intake and prior events. And then the instructor dutifully rattles off a list of information. Do this over and over again and you may get the idea that your SAMPLE history will be six questions long and take approximately 2 minutes to complete.

In truth, the SAMPLE history, when done correctly, is a time consuming and detailed interview that may begin in the first few moments of patient care and continue until your walking through the doors at the emergency room. Good SAMPLE histories can be disorderly and divergent. They go off on tangents. They explore deeper than the basic questions. They encourage the patient to talk and elaborate (when the patient is able).

If you remember only one thing about this post when you show up to work tomorrow, remember this, a good SAMPLE history will take more than six questions to finish. If you accept the first detail that your patient volunteer and then move on to the next subject, you’re going to miss a bunch of stuff.

Let’s look at each question with a bit more detail. I’d like to identify many of the common ways that we can diverge from the basic question to get a better picture of our patient’s predicament.

Symptoms (And occasionally signs)

While the patient may report physical signs as their subjective complaints (i.e. My fingernails turned blue. I can’t move my legs.) for the most part, reported complaints are subjective in nature. I like to start my SAMPLE with a broad and open ended question like, “So what’s going on today?” or “Can you tell me what’s been bothering you today?”

For our injury patients, questions like, “What happened?” or the slightly less broad but time saving, “What exactly happened to you?” might be good starting points. Be ready to ask follow up and exploratory questions like, “What else happened?” or “What did you feel then?”

The good opening symptom question will encourage the patient to tell us, in their own words, what they are feeling and what physically happened to them. We may need to keep the patient from veering off to far into the events leading up to the illness or injury. If you feel like you have a handle on their specific complaints, let them diverge. You can always come back. But don’t be afraid to pull them back on topic until you have a good understanding of what they are experiencing right now.

Try to avoid long lists of closed ended questions like, “Do you feel chest pain?”, “Do you feel shortness of breath?”, “Do you feel dizzy?” You can spend a long time working through symptom checklists and never come anywhere near the true patient complaint. An earnest, “Tell me what you are feeling?” can get you to the point so much faster than a long list of closed ended questions.

Also know that you will frequently end up diverging into your full QPQRST before you move off of the “S” in SAMPLE. That’s OK. Go where you need to go. Another hint on OPQRST…it isn’t six questions either.

Allergies

“Have you ever had an allergic reaction?” is a good place to start with the allergies portion of your SAMPLE. This will often prompt the patient to begin by telling you about their most significant allergic episode. This may be medical or environmental. We often start with a medications specific question. I don’t think this is the best way to go. I’d prefer to start with the most significant allergy.

This also avoids glossing over significant allergies to bites, stings, latex, food or other, non-medication related stimuli. I also follow up with, “What other things have you been allergic too?” Keep going until the patient runs out of answers.

Medications

I know there are some providers who will probably disagree with me on this point but, for our patients with extensive medication lists, I don’t spend a bunch of time trying to get them to name all of their medications. If they can rattle off the list, I’ll certainly write it down, but few people who take more than three medications can list them off.

This is especially true for our patients who have their medications nearby. If we’ve found a big pile of medications, I’ll probably ask something like, “Are these all of your medications?” or “Where else do you keep your medications?” and then be done with it. I’d rather read the medication list and jump right into medical history instead.

There are a few more vital questions to ask before you move off of the medication list. One is, “Are you taking all of your medications?” I’ll usually follow this up with a few questions about how often the patient takes a prescription medication. “Mrs. Goldberg, how often are you supposed to take your Lisinopril?” The goal is to get an idea of how well versed the patient is in their medication dosing and frequency. If the patient struggles with the follow up questions, we need to consider that non-compliance (not taking prescribed meds as prescribed) may be an issue.

Another way to root out possible medication non-compliance is to ask, “Have you stopped taking any of your medications? You will often find that, due to unwanted side effects, many patients simply quit taking medicine that they have been prescribed. Not the medicines that have been discontinued and explore why the patient quit taking the medicine.

It’s also worthwhile to ask if there are any non-prescription medications that the patient takes. This includes over the counter medications, herbal medicines and alternative medications. You also want to ask about drugs and alcohol consumption. This is a good place to include that question.

Past Medical History

Once you have a good idea what medicines, the next are to move into is an exploration of why those medications are consumed. If I already have a makeshift list of medical ailments I may start by reviewing what I already know about the patient’s medical history. “So, Mr. Jones, it sounds to me like you have high blood pressure, high cholesterol and gout. Is that correct? What other medical conditions do you have?”

Be prepared for your initial assessment to be incorrect. Medications are often prescribed for multiple reasons. If the patient reports, “I don’t have gout.” follow up with a question about the medication that lead you to that assumption. “Why do you take Uloric?” The patient may only know that they take it for painful, swollen joints. Or you may learn about a new use for the medication in question.

After the patient is done with their full medical history, I often throw out one last question that can uncover hidden medical conditions. “Are there any other medical conditions that your doctor is concerned about?” Physicians will coach their patients about medical conditions that they are at risk for long before they make an official diagnosis. This question can give you great insight onto where the patient’s medical history is headed.

Last Oral Intake

I’ll admit it. For the first half of my medical career I almost completely ignored the patients last oral intake. With the exception of diabetics, I just didn’t see how the question could be useful to me. I was wrong.

I figured out that I was wrong when I finally started asking the question. Suddenly, I found a wealth of information about the patient’s appetite, social and daily activity, life stressors, questionable food intake and changes in diet regimen. The patient’s ability to eat, desire to eat and volume of food intake can give you great insight into what their life has been like in the 24 hours prior to the 911 call.

I also like to know what it was that the patient last ate and, if you can find a diplomatic way to ask, how much. When the patient tells me what they ate, I can often get a feel for how much they ate by asking, “Was it good?” What I really want to know is, how has their appetite been? I’d also like to know if they are newly dieting. I probe this by asking if they’ve had any recent changes in their dietary patterns.

If the patient’s symptoms are GI related I may tangent off into the quality of the food. Was any of their food intake in the last 24 hours sketchy? Was it prepared outside of the home? Did anyone else eat the same thing and, if so, are any of them feeling sick?

Events Leading Up To Present Illness or Injury

You may find that you end up covering some of the events leading up to patients 911 call when you ask about the patients symptoms. What the patient has been feeling tends to get twisted up with what the patient has been doing. If you diverge into OPQRST you will inevitably run up against the patients activities prior to their symptoms when you ask about provoking factors and symptom onset.

This is your opportunity to probe the patient’s recent activities a little further. Have they been active of static? Was there an emotional component to what was happening in the patients life at the time the symptoms began? Many of our patients’ are more prone to recognize symptoms when they are already upset about something else and some of our patient’s complaints can have a specific emotional component to them.

With trauma, we can get caught up in the details of the event itself and leave out one crucial detail, was there a medical symptom prior to the accident? When the patient describes a traumatic event, don’t forget to ask, “What made you (insert event here).” “Mr. Jones, What made you drive off the road?”, “Mrs. Sims, what made you fall down?”. When discussing the event, always consider a medical precipitating factor and adjust your questions accordingly.

When you’re versed in the different variations of the SAMPLE history and you stay focused on the global meaning behind the questions, you can feel free to let the questioning drift off on tangents. Take the questions to where they lead you. Return your patient back to the path when you’ve found all you can or strayed too far off topic. The SAMPLE technique is a well-worn trail, but it has lots side paths. Good subjective history takers are masters at exploring the side paths and always finding their way back to the main trail.

1) Start Checking Out Your Rig Each Morning

Most organizations have a policy in place that states that oncoming EMS crews should complete a thorough checkout process. The reality is that very few of us check out our rig at the beginning of each shift with the proper attention that the task deserves. We know we should, but we get caught up. The signs of an incomplete rig checker are subtle but recognizable. If you open your cabinet or kit on a call and note (for the first time) that you are low or absent a needed supply, you’re not checking out your rig well enough. If you need to look in two or three paces to find what you are looking for, you aren’t checking out your rig well enough.

When you complete a detailed rig inventory, you aren’t just confirming that everything that is supposed to be there is still there. You are hard-wiring into your brain the exact location of everything that you might need. Once you’ve done this over and over again, you’ll find that you are able to collect necessary equipment in a fraction of the time. When you can grab equipment without even looking, your patient care efficiency will go way up. You’ll become a better caregiver. So grab that list and open those cabinets.

2) Look -Up Every Prescription Medication That You Don’t Recognize

The patient’s medication list is a wealth of information about their medical history. It contains vital information about possible causes of the their current condition. It hides details about how the patient will respond to acute medical conditions and it gives clues to how they will respond to your subsequent treatments. If you don’t understand what those medicines are and what they do…you’ll miss all of it.

If you’re caring for folks and you don’t understand the medications on their med list, you might as well wear a blindfold. You’re missing that much.

In today’s information age, there’s no excuse to not have some sort of medication reference in your phone or in your pocket or in your work bag. Carry it and use it. Every time you sit down to write a trip report and you write a medication down that you aren’t completely familiar with, look it up…right then. Don’t wait till later. Just pull out your reference and learn the medication. Google it if you need to. Once you start this habit, you’ll be surprised by how quickly you start to understand these lists in a much more detailed way.

3) Stand Up and Claim Your Mistakes

This can be one of the hardest new habits to learn. Partly because we’re all so afraid of admitting that we made an error. Winston Churchill once said that success was the ability to go from mistake to mistake without losing our enthusiasm. It’s absolutely true in medicine. We can’t grow as patient care providers without making errors. In 2012 commit to avoiding errors whenever possible and owning every error that you make. Be brave. Be fearless. (But don’t be reckless.)

4) Learn Every Patients Name and Use It for the Duration of Your Care

In all but a few rare exceptions, asking your patient’s name is an excellent first step in your patient assessment. Airway, breathing, circulation and a large majority of the cranial nerves can be assessed by simply taking your patient by the wrist and asking their name.

Once they say their name, the next step is a little harder. Remember their name. This takes a conscious effort at first. Once you get in the habit, it’s easier. Now that you remember their name, use it. I think you’ll find that your patient rapport increases dramatically (almost effortlessly) once you stop calling your patient honey, sweetie, dear, sirs, ma’am, pal, friend or partner, and start calling them by their name.

5) Learn Your Protocols

I mean better than you already do. When I was an EMT-Basic, I all but ignored my county protocols. I figured protocols were things that paramedics needed to worry about. Once I became a paramedic and started reading my protocols I realized that I should have read most of them back when I was an EMT.

Your protocols are the rule book. I’m not an advocate of always following the rules, but before you can break the rules properly, you need to know the rules. Learn them. Know them. Then you can start refining your care around them.

6) Pay Attention to Research

I already mentioned that this was the information age. There’s really no excuse to be ignorant of current research in EMS. If you don’t know where to start, start with the research section of EMS World. Then check out the news and features at EMS1. Keep an eye on podcasts like The EMS Educast and The Research Podcast. When you’re ready for the big leagues, check out Rogue Medic’s blog. (Wear your seatbelt.)

Half a dozen things you’re doing right now will change in the next five years. Want to know which six things are going to be obsolete? Start paying attention to research.

7) Develop a Specialty

Think of the most talented, well respected EMS practitioner you know. I’ll bet I know something about them, even though I’ve never met them. I’ll bet that they’ve taken their knowledge in at least one area of medicine far beyond the expectations of their job.  Think I’m wrong? Ask them.

Sooner or later, every EMS caregiver who’s eager to learn and improve will find some area of medicine that interests them to a degree that they seek out more information. Once they tap into the subject they’re compelled to keep going. They become specialists.

It could be cardiology and it could be limb splinting. It could be airway management and it could be extrication. The subject isn’t that important, the idea that your knowledge does not need to be limited by your scope of practice is critical. Find an area of medicine that fascinates you and dive in. Don’t worry about whether or not the information is applicable to your patient care. Learn for the sake of learning.

Before you know it, you’ll be a specialist.

8.) Use the Information in This Blog (Or Stop Reading It)

Yes, you read that correctly. This might be the only time you’ve ever heard a blogger tell you to stop reading his or her blog, but I’m serious. If you’ve been reading my blog for a while and you still haven’t encountered anything that you can take to work and use to your benefit, stop reading.

I’m not writing this stuff for my own information. I’m writing it for you. If you don’t actually use any of it in practice, then it’s worthless. You can stop reading…I won’t take it personally.

If you aren’t using and applying the information you see here your wasting our time. Find those useful little gems that resonate with you and go to work and actually try to be a better EMT. Or find someone else’s blog to read who might be more useful to you.

9) Listen to (At Least) One Podcast in Your Rig While Posting (Or On Duty)

There are so many awesome podcasts out there in our field. If you have an iPod or an MP3 player or any other device that plays digital audio, you have no excuse to not listen. Download a few and see what you like. Make that down time useful.

You can hear some of the most lucid thinkers in EMS talk about the latest issues that affect you and your industry if you simply tune in. I recommend The EMS Garage, The EMS Educast, The EMS Leadership Podcast, EMS Office Hours, and Confessions of An EMS Newbie. They’re all awesome.

You can learn a bunch from regularly listening to any one of them. In the age of MP3 Players, Ipods and smart phones, there are no longer any excuses for wasting your time in your car listening to commercials on the radio. Pick a podcast you like and start listening. You won’t believe how much good information you’ll have packed into your brain by next year.

10) Start Teaching Something

It’s time. If you already teach a class, such as Red Cross First Aid or AHA CPR, great. You can skip this one. But if you haven’t taken the time to give back to the community by teaching the EMS information you already know, 2012 is your year.

It’s hard to describe how much teaching can expand your knowledge and experience. Once you know that other people are going to learn vital skills based on your knowledge you will feel compelled, like you never have been before, to dial in your own knowledge.

Teaching opportunities are everywhere. Hopefully you can find a way to teach your specialty to other people. Educators like Mike Smith and Tom Dick have built their careers on finding something they are passionate about, becoming the leading authority on the topic and then teaching it to other people.

Maybe in 2013 I’ll see you on the speakers list for EMS World or EMS Today.

11) Bring Yourself to Work

You might be thinking, “Steve, I’m required to show up at work.” True. That’s not what I mean. I mean that this year is the year for you to find that unique contribution that only you can make to the world of EMS. When you begin your career, you mostly copy the styles and techniques of your preferred instructors. You do what you can to be like them.

Now it’s time to break that mold and ask yourself what your style is going to be. What are your techniques? How can you make this job uniquely your own. What can you do to make the people you work with think to themselves, “Wow, I’ve never seen anyone do it like that before.”

There is a unique something that you were meant to bring to the world of prehospital emergency care. No one can tell you what it is. You have to figure it out on your own. When you find it, don’t tell anyone…just show them.

12) Start Doing Full Head-to-Toe Patient Assessments

I know you’ve been faking it. I know this because most EMT’s fake it. Regardless of how good or talented they are, most EMTs don’t have a good, smooth, thorough head-to-toe assessment that they can perform with confidence in front of other people.

And the really sad thing is that it isn’t that hard to do. You just have to start doing it. Do it and then do it again and then do it again. As you practice detailed head-to-toe assessments again and again you will quickly reach a level of proficiency that far exceeds that of the vast majority of your colleagues.

More importantly, you’ll become a better caregiver to your patients. Commit right now to making 2012 the year when you quit faking it and start doing solid patient assessments

13) Learn a Thorough Neurological Assessment And Do It Whenever It’s Appropriate

You can add this one to your new-found head-to-toe assessment when the need arises. A neurological assessment is how we figure out if the patient’s body is talking to the patient’s brain correctly. Just like a physical assessment, it starts and the head and ends at the feet. A good neurological assessment includes motor, sensory and cognitive assessments. If your assessment includes questions like, “Can you feel me touching here?” or “Squeeze my hand.” or “Where are you right now?”, you’re already doing some neurological assessments.

Once you have a systematic, head-to-toe, neurological assessment, do it on every potential spinal injury, stroke, overdose, poisoning and head injury patient. (That’s a good start.) I’ve never seen two caregivers who use the exact same neurological assessment. Develop your own. It will get better over time. Do it often. It will help define you as a quality caregiver in 2012.

14) Find One Glaring Mistake or Outdated Treatment in Your Protocols and Vow to Violate It

I know this one is going to be a little controversial. I’m not telling you to give inappropriate care to your patient. I’m also not giving you a license to not know your protocols. (See number five.) But I can guarantee, beyond doubt, that there are some things in your protocols that are out of date, useless and possibly harmful to your patients. Find one of those things and commit to not doing it in 2012. Make sure to write a variance report when you’re done.

15) Stop Eating Roadside Junk Food

It’s killing you. Just stop. This year, start bringing your food in a little cooler. As an industry tasked with protecting the health and safety of others, we are ridiculously fat and out of shape. Don’t be the next post-difficult-call-cardiac-arrest story in the national news. Drop the trans-fat and eat an apple.

16) Stop Having Tantrums On Your Way To Calls

Yes, you do. We all do it. The dispatch happens and we immediately start rationalizing why this shouldn’t be our call. “Isn’t Medic 36 closer to this? Are they still out at the hospital. Those guys spend way too long at the hospital. This nursing home calls for the dumbest reasons. Why can’t PD transport their own drunks?” When we’d rather be doing something else, there’s always a reason why we shouldn’t have to run the call we’ve been assigned.

Just decide to commit yourself to the call from the moment that you are dispatched. You can’t feel good about the job you do if every time you get assigned a call you go into angry / frustrated mode. You’d be surprised how much energy you can expend with these habitual negative tantrums. Let go of it. Shrug it off like a heavy weight. If the job is worth doing then decide to just do it. You’ll be amazed at how much better you feel.

So that’s it. There’s your recipe for how to have an awesome 2012. We’re just far enough into 2012 to have abandoned all of those ridiculous resolutions that we committed to on January 1st. Now you can make some real worthwhile commitments. Pick a few and get started.

“Wait!” you say… “You promised us 17 ways to become awesome.” Indeed I did. You’ll have to wait until next time to get the 17th tidbit. It’s just good enough to warrant its own post. …And you can find it right here.

]]> http://theemtspot.com/2012/02/26/17-ways-to-become-an-awesome-emt-in-2011/feed/ 22 http://theemtspot.com/2011/12/01/what-is-the-parkland-formula/ http://theemtspot.com/2011/12/01/what-is-the-parkland-formula/#comments Fri, 02 Dec 2011 00:18:55 +0000 administrator http://theemtspot.com/?p=4671 Here’s a (fairly) simple calculation that you can use to figure out just how much fluid you should be giving to your burn patient. The Parkland formula is both simple and useful. It not only gives us a good general idea how fast we should administer that first bag of saline enroute to the E.R., it’s also a great reminder of an important fact of burn care:

Burn patient’s need lots of fluid. …How much?

Let’s review the Parkland Formula and figure it out.

The Parkland Formula was born in 1968 when emergency room physician Charles Baxter realized that his critical burn patients needed massive amounts of fluid in the first 24 hours of treatment to remain hemodynamically stable. Working out of Parkland Memorial Hospital in Dallas, Texas, he and his fellow physicians began experimenting to figure out a fast way to know just how much fluid was enough.

The result was the Parkland Formula. Used today almost universally, in burn centers across America and around the world, it has become a standard of critical burn care. And, yes, you can do it too. Don’t get nervous about your protocols, your local E.R. physician knows the formula.

The Parkland formula begins with a rough calculation of the patients total body surface area burned. That is to say, what percentage of the patients total body surface area is involved in the burn? To come up with that number we can use a few techniques. There’s the palm rule (or palmar rule) and the rule of nines. Feel free to brush up on both. We’ll wait.

OK, now that we know the total body surface area burned (TBSA) we also need to estimate the patient’s body weight in kilos. This is a relatively simple matter for just about everyone in the entire industrialized world…except within the United States. Here in the states we insist on teaching, learning and using the English standard system of measurement, which gives all of us in the medical field fits. There are a few good techniques for learning to estimate body weight in kilograms. You may want to review those too.

Now back to our Formula.

With the Parkland Formula, we’re only estimating second and third degree burn involvement. First degree burns don’t tend to create the massive fluid shifts that we see in second and third degree burns so we don’t administer fluids to them nearly as aggressively as we do for our more significant burn patients.

With that said, let’s take a look at the formula and then let’s use it in a couple of real burn scenarios. The calculation looks like this:

(4 * Patient’s weight in kilos * Percent of body area with second and third degree burns) = Amount of fluid to administer in the first 24 hours after burn injury.

Fluid to administer in first 24 hours divided by 2 = fluid to administer in first 8 hours

Finally, if we divide the final number by 8, we’ll know about how much fluid our patient should receive from us before we reach the hospital (in most urban EMS systems).

Don’t panic, it isn’t as complicated as it sounds. Let’s try it out.

A 220 pound male has second and third degree burns on his whole chest and abdomen, the front of both legs and the front of his right arm. Using the rule of nines we determine that the patient has approximately 40% of his total body surface area involved in the burn.

Chest + abdomen = 18%, whole leg = 18%, half of one arm = 4.5%. 18+18+4.5= 40.5%

We also calculate that his 220 lbs. puts him at exactly 100 kg. 220/2.2=100.

For this patient, our Parkland calculation would look like this: 4*100*40=16,000.

This patient will need 16,000 ccs of fluid, or 16 one liter bags in the first 24 hours of care. Divided that in half and we see that we’ll need to administer 8 liter bags in the first 8 hours. This patient needs a bag of fluid for ever hour of care that we provide.

Start your time calculation at the estimated time of the burn injury.

Do you feel like you have a handle on that one? Let’s take it up a notch.

This time lets take a 138 pound female with second degree circumferential burns to both her legs. Let’s also include her full back and the back of her head in the affected burn area. That would be 57.5% of her total body surface area.

Upper and lower back = 18%, Left whole leg = 18%, Right whole leg = 18%, back half of the head 4.5%. 18+18+18+4.5 = 58.5%

Now let’s convert her body weight to kilograms. 138 / 2.2= 62 kilos (more or less).

Now we’re ready to do our Parkland formula. 4*58*62= 14,384. With our first patient, many of us could manage the math in our heads. For our second patient, most of us would prefer a calculator near by.  Luckily, most of us carry a cell phone with a calculator function in our pockets. Make good use of it.

Our burned female will need about 14 litters of fluid in the first 24 hours of care with 7 coming in the first 8 hours. Between 800 and 900 ccs will do her just fine in transport.

We can see a few good uses for the Parkland formula. First, by playing with the calculation now, on hypothetical patients, we remind ourself of an important fact of burn care. Burned patients need a lot of fluid. Second, if we’re nervous about opening up that IV bag during transport, it’s simple enough to be used right there in the back of the medic unit to make a quick guess about how much fluid we should be giving enroute to the ER.

It’s important to note that the Parkland formula isn’t the last word in a burn patients fluid resuscitation. The formula is a fast way to develop a good idea just how much fluid a patient will ultimately need. As patient treatment progresses, unine output and vital signs will give care givers more accurate information about the effectiveness of the ongoing fluid resuscitation efforts. Retrospectively, the formula tends to be accurate in 70-80% of cases. Others will need adjustments along the way.

There you have it. Play with the Parkland formula and let me know what you think.

The question: What can EMS providers really do to reduce mortality rates in sepsis patients?

The answer is here:

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Here’s a quick rundown of what EMS folks should know about this new and growing trend in street pharmacology.

Synthetic cannabis products have a variety of street names including Spice, K2, Herbal Incense, Potpourri, Barely Legal and Kronic. It is frequently sold under the classification of an “herbal smoking blend” and some head shops and online retailers have attempted to skirt the ongoing tide of new regulations by selling the products as legitimate potpourri or plant food with the warning, “Not for human consumption.”

What is it really?

These products are all various dried organic (plant) compounds that are laced with a synthetic cannabinoid chemical that is designed to mimic the effects of cannabis in the body. Many of the products claim that they are a natural blend of legal herbs and spices that combine to give the user a legal and cannabis free high. Investigations into the contents of the products reveal that most of the herbs listed on the product packaging are not truly present in the product and that the often unidentified organic material in the product is laced with one of five common synthetic cannabinoids. (While there are over a hundred known synthetic chemical cannabinoids, these products tend to contain cannabicyclohexanol, JWH-018, JWH-073,  CP-47,497 or HU-210.)

The synthetic cannabinoid chemical is sprayed on to the product and then dried. When the user smokes the product these chemicals bind with cannabinoid receptors in the body, producing a similar euphoria and psychoactive experience to THC ingestion. (THC is the active cannabinoid in marijuana.) By this method, users are getting a comparable marijuana high while doing an end run around traditional marijuana laws.

This creates a few new issues for the user and for EMS workers as well. First, while the long term effects of marijuana on the human body are well known, nobody is really sure what the long term effects of synthetic marijuana will bring. There may be a host of chronic ailments waiting to emerge in our traditional pot-smoking patient group. Second, legal or illegal, there is now a new, independent source of cannabis-like drugs to supply this drug-user group without the traditional problems associated with marijuana growth, cultivation and acquisition. Nobody really knows how big this new drug will get, but it has the potential to be huge.

So far, traditional marijuana drug tests have been unreliable at detecting the use of synthetic cannabinoid metabolites. With multiple synthetic compounds in existence and more on the way, it may be hard for reliable blood and urinalysis tests to keep up with the chemical tide. Since most drug users don’t want their drug use known or detectable, the medical community may struggle to find tests that can help them determine when synthetic cannabis has played a role in a given patients presentation.

Is this stuff really legal?

Yes, it was.  For a while anyway. First marketed as Spice in the UK in 2004, these drugs were available on the internet for almost four years before they really spiked the radar of regulatory agencies like the FDA. That is, until their popularity surged in 2008 and the media started to take notice. Then local counties and individual states began banning the products sale and possession. Several European countries banned the products. In the US, Kansas was the first state to enact legislation outlawing the products.

In November of 2010, using rare “emergency powers”, the United States D.E.A. announced that the five most popular  found in synthetic cannabis would be classified as schedule I drugs. This move makes them illegal to possess or distribute anywhere in the United States.

What are the actions of synthetic cannabis on the body?

While little is known about the real effects of these chemical compounds, some early research suggests that they could be more damaging in both the short term and long term than traditional marijuana.

Canabinoid receptors in the body perform several vital functions including regulating body temperature and heart rate, memory use, advanced cognition, immune system funtion and hunger control. Marijuana only partially binds to cannabinoid receptors so most of these functions remain intact (though sometimes altered). Synthetic cannabinoids bind completely to the receptor sites. What that means is that the underlying bodily function is more completely blocked, causing some physical reactions that are not typical in marijuana users.

These reactions can include dramatically increased heart rate and blood pressure, sleeplessness, paranoia, dehydration, nightmares and immune system dysfunction. That’s not all. The effects of these synthetic drugs can be substantially longer than that of traditional pot. Users report ill effects days and even weeks after use.

And, lastly, the synthetic cannabinoids may have bridged the withdrawal gap as well. What I mean by that is that users actually have physical withdrawl symptoms. Most marijuana users are well aware that the long term addictive affects of marijuana are primarily or completely psycological. Even after long term use, the body never really experiences any physical withdrawls after the user quits using. Not so with synthetics. Researches are seeing true physical withdrawl symptoms even after reletively short term use. This suggests that the long term addictive properties of synthetic cannabis may make it a more widespread and troublesome problem for the drug control community than it’s parent drug, marijuana ever was.

How should we respond to the potential synthetic cannabis user?

Like most drug related responses, the treatment of the synthetic cannabis user is primarily supportive. Support the airway with oxygenation and suctioning as needed. Be prepared for vomiting at higher cannabinoid doses. Restain potentially violent patients and interact with the patient in a calming and supportive manner.

When available, consider the use of benzodiazapines for extreme agitation and anti-emetics for nausea and vomiting control. Fluid may be indicated if signs of dehydration are present.

Trend the patient’s vital signs and watch closely for changes in mood, behavior or level of consciousness and airway control.

Drug users can be highly unpredictable. Be safe on scene and in the back of the rig. Remember your safety is paramount. When you are done dropping your patient off at the hospital, be sure to come back to The EMT Spot and tell the readers about your experience with this new drug in our comments section below. We’d love to learn a little something from you too.

Yeah, It’s been a ride…
I guess I had to go to that place to get to this one
Now some of you might still be in that place
If you’re trying to get out, just follow me
I’ll get you there

- Rapper Eminem, I’m Not Afraid, Recovery

I’ve been there.

Sure, I’d like to say that I was always a positive, proactive and optimistic EMS employee but that isn’t the case. I’ve been through periods of burnout. More than once to tell you the truth.

I know what it’s like to dread getting up in the morning and going to work. I also know what it’s like to feel like you aren’t valued by your employer. I’ve been through phases where I just didn’t care about the service that I worked for or the quality of the care that I provided. If they don’t care, why should I…right? I know what it feels like to be a cog in the machine, replaceable and unimportant.

I’ve been to those places and I’ve come back. I’ve come back stronger than I was before.

If you’re in that place right now, first let me say a heartfelt, “I’m sorry.” I know where you’re at. I’ve felt the disillusionment and frustration. Hang in there. EMS still needs you. You still have something meaningful to contribute.

Now let me give you a few ideas for how you might get back to where you need to me.

1) Stop working overtime shifts. (Refuse if necessary.)

One of the unfortunate side affects of burnout is that it often comes coupled with a belief that the solution lies in working more shifts. For some individuals, their non-stop work ethic may have been a major contributing factor to their burnout in the first place. For others, the overtime may be a way of hiding from the reality of their situation.

Our tendency to drive our EMS workforce to its limit is one of the naughty little secrets of EMS that we tend to hide from outsiders. We avoid talking about it in management circles. When vehicle accidents and clinical errors rear their ugly heads, there’s an unspoken rule that fatigue and burnout shouldn’t be considered as possible contributing factors. If you name the ugly truth you might bring the whole system to a halt.

Your employer may have designed a system that will allow you to work yourself to death (if you are willing). You need to say no. When you say no to non-stop shift work, you say yes to your life, your friends and your family.

Let go of the idea that you need to work 90 hours a week in order to have all the stuff you want. You don’t need nearly as much stuff as you think you do. Convince yourself that your life is far more important that your stuff. Your time is the most valuable thing you own. Spend it well.

2) Reconnect with old friends.

With a little more time on your hands you may want to find those people who used to fulfill and enrich your life before you became an EMS zombie. You can probably think of one or two folks who you let sip away over the past few years. Maybe you’re embarrassed to talk to them now because you’ve ignored them for so long. They would love to hear from you.

Quit reading their Facebook updates and actually reach out and connect with them instead. Make some plans. Share your life.

Old friends have a unique quality that coworkers and associates just can’t replace. Your old friends know you differently. The not only know who you are, they know who you’ve been. Because of that, they can see who you are trying to become. Old friends can help give you a unique perspective on your life. Value them; they’re worth it.

3) Have a mentor outside of EMS.

I emphasized this in my e-book, The Non-Conformist’s Guide to EMS Success. I’m sure a bunch of readers didn’t really get it at the time. But from a place of burnout it will probably make much more sense.

Mentors are important, but a mentor inside your workplace is only going to mentor you about your work. Find someone with the life that you want and have them be your life mentor. (And there needs to be something in it for them too.) This person should be someone who knows nothing about EMS. I’m serious. The more they know about EMS, the more inclined you will be to discuss your job with them and not talk about the really important things in your life.

Your mentor shouldn’t be asking you questions about how well you’re doing in your ACLS class. They should be asking you questions about what’s happening in your life. How does this new thing fit into your overall life goals? Are you doing the right things to get to where you want to be in five years? If you’re burned out, it may be time to find a new mentor.

4) Spend time with your family.

If you have a mother and father, brothers and sisters, wife and children, you may need to reconnect with them as well. They may need some time to get reaquainted with your non-zombie self. They’ve undoubtedly been affected by your burnout and there are a few things you need to say to them. Go have those conversations. Start with something like this, “I know that I haven’t been as available as I should have been for the past few months (years?) but I’m going to start changing that right now and I hope you’ll help me.”

Sometimes, life is about having difficult conversations. You need to go have those conversations with the people you love.

5) Go on a mission trip.

This seems rather specific, but nothing has ever done more for my basic appreciation of my life than going on a mission trip and helping impoverished people in another country. It should be a mandatory experience on everyone’s bucket list. There are countless lessons that you’ll learn if you decide to pack up and go build houses or perform basic medicine in a third world country. Here are a few:

• You’ll recognize that your problems aren’t nearly as significant as you might think.
• You’ll learn (or relearn) the restorative power of helping others.
• You’ll see your life from a larger perspective
• You’ll make new connections with amazing people.
• You’ll remind yourself that your organization doesn’t collapse if you don’t show up to work every day.

6) Exercise.

Another unfortunate side effect of burnout is that we tend to move our bodies less as we feel the exhaustion of burnout. Eating Twinkies at the corner Quickie-Mart at 2:00 AM isn’t going to help your mood. Moving your body will.

There’s an old parenting trick to stop your children from crying when the are hurt or sad. You stand them up and ask them to look up at you. Then you ask, “What’s wrong?” The child will undoubtedly try to look down when they begin to answer, but you remind them, “Hey, look up here at me. What’s wrong?”

Have you ever noticed how hard it is to cry while you’re looking up? Try it sometime. Your body position has a huge effect on your mood. You can change your mood right now by simply forcing yourself to sit up strait and look forward.

Moving your body is essential to improving your mood. If you feel like you can’t bear to show up for another shift on your ambulance, schedule a workout before your next shift. Nothing huge. Don’t go crazy. Just move your body.

7) Avoid other burned out people.

Burned out people attract each other like magnets. They make little burnout clubs and they validate each others burnout. They talk about burned out stuff and they agree with each other about how much everything sucks. Nobody in your burnout club is ever going to help you feel less burned out. They need you to keep feeling just as burned out as you are right now so they can feel better about themselves and their burned out state.

If you want to get back to a place of fulfillment, you’re going to need to cancel your membership in the burnout club.

Focus your time and energy on people who are doing good things. They are the ones that you want to align yourself

8 ) Play.

If you’re burned out, your first reaction may be, “But I don’t feel like playing.” Feelings follow actions. Play first. Then feel.

Do whatever it is you do when you play. You know what it is. Do it whether you feel like doing it or not.

9) Leave.

This idea seems to give people such anxiety. The idea of simply moving on is so terrifying to some folks that they are willing to endure all kinds of misery instead of just moving on to something else. There are thousands of EMT and paramedic jobs across the country.

Opportunities for EMS personal rain from the sky. If you’re willing to seek additional training, you can earn decent money. If you’re willing to travel internationally, you could bring in some serious cash and see some parts of the world most folks will never encounter.

Leave doesn’t necessarily mean quit. Take a vacation. Go on a sabbatical. Switch to another division or operation. Request  a voluntary six month furlough. Take on a new position. Just do something to get out of the work situation you’re in right now. It isn’t a failure to realize that you are in a situation that you didn’t want to be in and something isn’t working. the only real failure is showing up to work every day, doing the exact same thing, thinking the exact same thoughts and expecting to eventually feel differently about it.

Life is change, whether you like it or not. You can choose to take charge of that change, or you can be at the mercy of it.

I’ve been bugging Sean to write a guest post for the blog for a few years now. I don’t usually harass my friends about writing content, but Sean is so enthusiast about his work that I just couldn’t help myself. As a first year paramedic, Sean has a unique perspective on what it takes to make the transition from EMT certification to paramedic. In this post, he shares with you five things that can make the difference between success and failure.

Sean is a graduate of Regis University and a Firefighter / Paramedic for The South Metro Fire Rescue Authority. He lives in Denver, Colorado with his lovely wife Oz and their two sons Jonas and Axel. If you’re considering making the jump from EMT certification to paramedic practice, you won’t find better advice anywhere.

Steve and I have been discussing the possibility of my writing a guest post for The EMT Spot for a couple years now. So, after paramedic school and clearing as a new paramedic were done, he proposed that now was a great time to stop backpedaling and get on it. I’ve been accused of dragging my feet on getting this done. Shooting topics back and forth, we came to the obvious conclusion that an article discussing five tips for new or perspective students would be far more uplifting than the pediatric death and dying discussions that I’ve been having with the current paramedic school students.

With that said, here are my top five  tips for fledgling paramedic school students.

Tip #1: Get Ready for Paramedic School

Let’s start with the question I’ve heard prospective and new paramedic school students ask over and over again, “What do I need to read to ensure that I’m ready for paramedic school?”

Don’t worry, everything you need to read to be ready for paramedic school is in your EMT-Basic book. There’s a reason every EMS class and every EMS book you’ll come across stresses the ABCs; these are the basic essentials that we use to evaluate and treat every patient. These are the basics we need to be prepared to treat and have within normal limits before we move forward with our patient assessment. These are also what you should fall back on when your advanced interventions aren’t working or cannot be performed for any reason.

It sounds trite, but every good paramedic begins as a good basic. Without good assessment skills and the ability to use your five senses, instead of your machines that go ping, it will be an uphill battle to work up your patients. To re-emphasize that point, you should have a systematic approach to your physical assessment of patients when you’re arriving at the door of paramedic school. This systematic approach will save you time and again. It’s your job to find out what is wrong today, not theirs to tell you. Quite often, they can’t or won’t tell you.

Your EMT-Basic book also teaches basic anatomy/physiology, patient presentation, and how to address insults to the ABCs. All of these are foundations to what you will begin building upon as a paramedic student.

Tip #2: Learn From Your Mistakes

One of the most important lessons you can learn early on in paramedic school (if you haven’t already learned it as a basic) is to learn from your mistakes. Mistakes are inevitable, they’re going to happen. No one is perfect. Perfection doesn’t exist in medicine. (Hence the practice of medicine.) There’s a learning point to every call, rookie or vet. Learning from your mistakes means recognizing where you’ve gone wrong, and likely 90% of the time you’ll realize it as you’re making the mistake, or soon there after The other 10% your preceptor will let you know. Then you can mentally bookmark what you did, why it was wrong, how to correct it in the future. Then move on and don’t dwell on it. Go on to your next call in two minutes or two hours with a clear head and treat the next patient.

Learning how to move on, so that you’re not dwelling on the mistakes you’ve made, will help you continue moving forward and learning, so that you can competently listen to and treat your patients appropriately. Dwelling complicates things, muddies your thoughts, and doesn’t allow you to learn from the mistake. It usually stems from that nagging need to be perfect. Again, remember that perfection doesn’t exist in medicine. It’s an environment where we’re constantly learning and can always strive to do better at something every day.

In addition, there will be numerous subtleties that you likely won’t clue in to yet, with regards to patient presentation.   Don’t beat yourself up over this – it is normal during school. The purpose of your clinical rotations and field rides is to reinforce pattern recognition and patient presentation; this is where you start learning the subtleties. This is why, when you watch your preceptors run calls, they may only ask a handful of pointed questions and seem to be confident in the direction they’re heading with treatment, while you’re still trying to figure out why the patient called 911 today.

Medicine has numerous shades of gray and you’ll learn that what was right to treat one patient may not be right with another of similar presentation due to subtleties of their disease process/injury.

Tip #3: Communicate Effectively and With Confidence

In order to begin running calls in any capacity (Meaning you begin, then your preceptor takes over or you run a call from initial contact to the final destination.) you will need to be able to talk effectively to your patients. This skill doesn’t come easy for every one and usually isn’t seamless early on in your clinical experience, but this is another skill that your clinical rotations and field rides will reinforce again and again.

Steve wrote a post around a year ago about how, if you actively listen to your patient after asking a question, you’ll likely hear some of the answers you were looking for. However, when your head is overloaded with material from class and your desire to find answers outweighs your patience to listen, you won’t hear this information.

Instead, after you ask a question, you’ll likely be distracted from the patient’s answer because you’re thinking of the next one you’d like to ask, and then as soon as they stop talking, you repeat the cycle again. This rapid fire questioning and not listening is very common during some portion of paramedic school for most people. Frustrating as it is, it will pass.

One of my partners described the paramedics who could seamlessly transition between different populations and have similarly good patient interactions with them all. (A social chameleon.) Eventually you’ll need to be able to speak competently, without jargon, to people of any age group, income or education level. Your ability to cultivate this skill directly correlates with how quickly and effectively you gain patient trust and build a rapport. Strong rapport is built quickly. Patients observe how you carry yourself, the respect with which you speak to them and others, the confidence that you convey, how you discuss their current situation, how you would like to remedy it and the calm manner of your delivery.

Rapport cannot be underestimated. Without it, calls tend to run with more difficulty and patients do not have as much trust in you or your skills.

Tip#4: Your Habits and Attitude Will Make or Break You

Your attitude can make or break your paramedic school experience. A positive attitude, a clean uniform and respect for your preceptor, your patients and the hospital staff will go a long way toward ensuring that your reputation is a good one. Along with the previously mentioned items, a strong work ethic and the realization that you don’t know everything will further cement that good reputation for you. This is a good mantra: work harder everyday than you did the day before. Whatever reputation you have, good or bad, everyone at the agencies where you’re doing your clinicals and rides will know that reputation before they know you. Reputations precede and follow you everywhere you go. A bad reputation is exceedingly hard to get away from.

Part of your strong work ethic should include learning the par levels and location of all of the equipment (on the ambulances you’ll be working on) as early as possible. It’s your job as a student to know where everything is. Your preceptors already know this stuff.

Another aspect of illustrating a good work ethic is a dedication to studying your classroom material. Bring your books on rides for slow times. Be cautious with reading them during clinicals, because there’s almost always something you can be doing instead of reading when you’re in the hospital. (The OR rotation might be an exception) You don’t need 100% on all of your exams, but you should be able to discuss and apply all of the material appropriately. Remember, your patients won’t care what your grades were; they will care that you can treat them with a solid, common sense approach.

The key to studying well is finding out how you learn most effectively and using this approach consistently throughout school. In addition, ensure that you budget your time wisely with regard to studying and scheduling your clinical hours. If you get behind in either one you will quickly feel overwhelmed. Then that focus on a positive attitude will suffer (as will your work ethic) because you have diverted your energies elsewhere.

Tip #5: Take Care of Your Family, Your Friends and Yourself

Lastly, all of the above things don’t matter if you don’t take care of yourself and your family. Though I just stressed the importance of vigilant studying, learning from mistakes, learning to talk with others, attitude, work ethic, and all, none of it matters if you’re a hermit with failing relationships due to stress and exhaustion.

You should have days where you put down your books and go out with your family and friends and decompress. You’re going to need it. One of my friends told me just prior to school that I should put my books in a box on those days, because he knew if I could see them I’d be inclined to open them. You’re also going to reach a point where you’ve studied enough and further studying will only stress you out instead of reinforcing the material. It took me a while to realize when I had reached that point. As time went on, I could feel it and I would walk away, go for a run, go out for dinner with my wife, get ice cream with my kids, even do house chores.

Hopefully, your family supports your decision to go to paramedic school and understands that you will be intermittently absent both mentally and physically. You will have periods where you can’t get away from school, be it clinicals or studying, and they may resent this from time to time. In those times, seeing the end goal is huge for all involved, even though, yes, the short term can suck. As your family supports you during school, you should support them. Let them know that you appreciate their love and support. Let none of it go unnoticed, no matter how exhausted or stressed you are.

The other crucial part to taking care of yourself (and I fully admit it doesn’t happen all the time) is ensuring you sleep, eat, and rest as best you can. My mantra became, “Sleep, eat, rest, repeat.” and when you can’t, stock up on your migraine meds. I refilled my Imitrex and Phenergan prescriptions a few times during school.

For all you’ll hear about paramedic school, including it being one of the most stressful times of your life, it’s entirely what you make of it. I had numerous migraines. (All atypical presentations and a handful during my clinicals and rides.) I slept anywhere between one and eight hours a night, but generally less than four. I frequently didn’t eat or drink during field rides. I often went what seemed like a week without seeing my family. I studied all of the time and increased my already elevated coffee intake exponentially higher.

Through it all, I smiled just about all day long during every clinical and every field ride. I made some great friends. I learned to stop over thinking my calls and I learned how to feel good standing at the front and walking into the call. I learned more than I ever thought I could file way in my head and competently use when needed. I found dozens of good and cheap Mexican food stands throughout the city of Denver. I enjoyed myself immensely and I had a great time.

In hindsight it’s a bit like high school. Would I do it again? …Not if I didn’t have to, but damn it was fun.

Here are a few things to consider before you run your next obstetrical call.

1) At full term, pregnant females have a heart rate 10-15 beats per minute faster than when they were prepartum. (Psst…Before they were pregnant.) They also have 25%-30% higher stroke volume and 30%-50% higher cardiac output.

2) Pregnant females will tolerate significant blood loss before they become symptomatic. Once they are symptomatic, they will decompensate rapidly.

3) The official obstetrical term for the mother’s water breaking is “rupture of membranes”. It can be documented with the abbreviation ROM.

4) Unlike the Glasgow Coma Score, you can’t just guess that a healthy baby gets an automatic 10 on the APGAR score. Most healthy babies are born with a score between 8 and 10. In some regions of the United States very few babies are ever scored a 10 at birth.

5) You won’t remember the APGAR score when you’re holding a newborn baby in your hands. Write it on your OB kit.

6) All things considered, moms tends to be the best judge of when labor is eminent.

7) In your EMT class we drilled on the idea that mom should be laid on her left side. More recent research has indicated that getting mom on her side is the important part. Whether she’s on her left side or right side makes no real difference.

8.) Designate the person with the least to do as the official time keeper. Make sure they have access to the most accurate clock available.

9) 600 ccs of blood pass between mom and baby every minute. Mom can loose 1,000-1,500 ccs of blood before she becomes symptomatic. Typical postpartum hemorrhage should be in the neighborhood of 500 ccs.

10) Delay transport if delivery is eminent. Don’t delay transport for delivery of the placenta. It can take hours. Once baby is out, package for transport.

11) Aggressive (uncomfortable) fundus massage is still the best method to slow postpartum hemorrhage.

12) Cut the cord between the clamps. (Seriously…it happens.)

13) When delivering twins, both babies will deliver first. Both placentas will deliver after. Any other ordering is an obstetrical emergency.

14) Fetal trauma cannot be ruled out in the prehospital setting. Lack of vaginal bleeding or pain on palpation does not rule out fetal trauma. Pregnant mothers who have suffered any significant mechanism to the abdomen should be transported for evaluation. (They will typically be observed for 12-24 hours.)

15) Don’t forget to prepare for two patients.

Now it’s your turn: What OB tips would you add to the list?

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Four Steps to Moving Past Medical Mistakes

“It’s the space between the bars that holds the tiger.”

-Zen Koan

How does anyone become really good at what they do? Is there a magic recipe?

From the opposite side of the bars, an adult Bengal tiger studied me from his resting spot. He was big, topping out just over five-hundred pounds. He was also strong. Pound for pound a tiger is four times stronger than a man.  Our guide explained this to me while she pointed out some of the finer elements of the great cats stalking behaviors.

The Feline Conservation Center in Rosamond, California, isn’t like a typical zoo. There are few barriers that prevent guest from reaching inside the cages if they chose to be so foolish. Hence our watchful guide. At the observation end of the enclosure, thirteen bars kept me from becoming tiger lunch. Once the great cat fixed on me, they seemed hardly adequate.

In truth, they weren’t. Bunch them all close together and the tiger would surely escape. Space them randomly across the gap and you’d get the same result. In fact, even the slightest alteration in the spacing between the bars would produce the same result. Free tiger.

While we tend to pay attention to the bars, it is the space between them that contains the power of the tiger.

If you’d asked me what saved me from becoming a tiger snack, I would have undoubtedly pointed at the bars. We tend to focus on what we can see. We are drawn to the obvious. The necessary perfection of the spacing would have never crossed my mind. And so it is with our job skills.

If you told me about an EMT that you know who is really good at what they do, undoubtedly, you would tell me about how they perform on calls. You would tell me stories about their great patient assessment skills or their ability to ask that just-right question in that just-right moment to bring the whole call together. You might discus the way the interact with people or their superior clinical skills.

You would point to the things they do from the time the call drops to the time they place the patient in a hospital bed.

Hard evidence. Strong proof.

You would point to the bars.

While it is their performance during a call that defines them as great, it is what they do in between the calls that makes them great. We tend to pay attention to what they do during the calls. It’s what they do between the calls that contains the power of their skill set.

The next time you have an opportunity to work with someone you feel is really good at what they do, pay attention to how they use the space between their working time.

Notice if they leave the hospital room immediately after giving a report  or if they linger and listen to the questions the hospital staff ask and talk with the doctor about their impression of the patient.

Notice how they check out their rig before their shift.

Notice how they respond when they encounter information that they are unfamiliar with.

Notice what they do when they make a mistake. (Yes, they do make mistakes.)

Notice if they spend time on continuing education, or research.

Notice the million little things that they do to prepare themselves for the next call.

What they do on the next call will be the thing that people talk about. What they do before the next call is every bit as essential. I imagine it’s the same for just about anything.

What about you? What do you do with the space between?