Once you understand the protocol / skill connection you might come to see a
host of problems with the way we develop, use and teach our protocols. I’d like to tell you about two biggies.
As we explained in the protocol / skill connection, we are dependent on our protocols to different degrees at different levels of skill development. This is defined by the Dreyfus model of skill acquisition. Misunderstanding this concept leads to some predictable problems.
The problem with our protocols is that they were written with the expectation that everyone would use them the same way.
The problem with our field education is that proficient and expert field providers teach novice and advanced beginner students. These two groups think differently about their protocols.
Let’s look at both of these problems a little more closely.
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If you’ve ever grown plants in pots you know that selecting the right size pot for the plant is essential. Put a plant in a pot that’s too large for it and 
the new life will struggle to find water and nutrients. Place the same plant in a pot that’s too small and it will struggle to find space to grow.
Such is the nature of growing things.
It works the same way with you and your skills and your protocols. Your relationship with your protocols is going to change as your knowledge and skill grow. It’s going to happen. This isn’t my opinion. It’s called the Dreyfus model of skill acquisition. And when you understand how it relates to you and your medical skills, you’re bound to have one of those ah-ha moments. Here’s how it works.
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Part 2: The Blood Pressure
I love teaching each new EMT class cycle how to take a blood pressure. It’s fairly simple and strait-forward, but there’s also a real art to it. Folks who are good at it wield their 
blood pressure cuff like a teppanyaki chef wields his knife. You can tell they’re good by watching the confidence in their movements, the order that they perform the steps, and the attention they give to the details.
There’s a big difference between the guy who chops vegetables down at the local Denny’s and the chef at the Benihana. Same tools, different level of skill. You see what I mean right? If your blood pressure skills are still somewhere in between the short order cook and the teppanyaki chef, here are some tips to getting better.
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It’s never comfortable to be placed under a microscope. Especially when the dude looking through the microscope is The Rogue Medic, Tim Noonan. Tim’s a great dude, but he’s not the guy you want picking through your knowledge sock drawer. He’s thorough, he’s smart and he’s willing to analyze the details long after you and I have gone to bed.
If you don’t already read Tim’s blog you should. He’s a fantastic EMS blogger. That being said, I wasn’t terribly excited when he posted a comment on my post “I’m Only An EMT Basic” announcing that his comments on the piece could be found over at Rogue Medic headquarters.
For the record, my piece received nothing but kind handling by Tim. The question he chose to focus his lens on? Are lung sounds a part of the EMT scope of practice?
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Part two of a two part series on scene presence. Part one is here.
While we’re talking about scene presence, I think it’s important to bring this one up. I’ve hesitated to talk about the illusion of control on the blog even though it’s a learning point that I invariably discuss with new students on the rig in the first one or two shifts. The illusion of control is deeply
applicable to learning scene presence, but, quite frankly, it contradicts something I’ve preached here on The Spot for some time.
It contradicts my advice to always be authentic. When it comes to authenticity, the illusion of control is the exception to the rule. I suspect that some of my regular readers may have take issue with that. It’s OK, I’m a big boy. I can handle it.
In the world of scene management and scene control, the illusion of control is a metaphor for how we should respond when things don’t go the way we planned.
There is an awkward and embarrassing moment that we all have to deal with while running calls. It helps to think it over before it happens. If you’ve been in EMS for any length of time, it’s already happened to you. So let’s talk about it now. How do you react when you make a mistake during a call? What do you do when things don’t go as planned? How do you respond when you make an outright flub, guffaw or blatant error right there for everyone to see?
My answer, “The illusion of control.” Allow me to explain.
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Fast or Slow, Strong or Weak, Regular or Irregular
I’d like to teach you how to take a pulse in three seconds or less. Yes it’s possible.
I am, quite possibly, about to contradict everything you learned about taking a patients pulse in your EMT class. Hear me out on this one.
In general, I think we overemphasize the importance of coming up with a set of numbers that represent the patients vital signs and we underemphasized the importance of placing the patients vitals in context for their condition. The pulse is a prime example of this dynamic at work.
The patients pulse holds a wealth of clinically significant information. The exact heart rate isn’t one of them. Sometimes, we get this misconception lodged in our brain that the purpose of feeling the patients pulse is to determine how many times their heart is beating each minute. We will dutifully devote 15 seconds, 30 seconds … yes some even advocate taking a full minute to make sure this number is perfectly accurate.
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Ahhh the embattled sternal rub. Revered, reviled … the sternal rub is the Ann Coulter of medical interventions. Abrasive, annoying, loved by many, hated by many more. The subject of the usefulness of the sternal rub is bound to cause controversy in any EMS forum.
In other words … it’s a great subject for The Spot.
Like many controversial assessments and treatments, the sternal rub (sometimes referred to as the sternum rub) got its bad-boy reputation more from its misuse than from its own shortcomings. Never-the-less, the technique does have its shortcomings.
Like so many other tools, it has its place when used appropriately and it has its potential for misuse. So let’s make sure you understand its uses and limitations.
If you’ve never encountered this technique, the sternal rub is a test for unconsciousness. It’s a popular form of painful or noxious stimuli designed to illicit a response from a conscious or semi-conscious person. Establishing an unresponsive patients ability to respond and remove noxious stimuli is perfectly medically appropriate.
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I get a bunch of E-mails from people just starting their EMT education who want advice on how to excel in their programs. “How should I prepare? What books do you recommend?” The questions vary but their is always the familiar flavor of enthusiasm and the same basic question, “How do I do this well?”
Success in this field is fairly predictable. Use the right recipe and you’ll get there. I think the hierarchy of EMS success looks like this:
1.) Attitude
2.) Motivation
3.) Tolerance for repetition
4.) Goal orientation
5.) Strategy and tactics
6.) Performance
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I’m blessed with two kids. They are amazing. My kids changed my whole perspective on the world. They re-framed my purpose. It’s wonderful, the way a few minutes with your kids can put an entire bad day in perspective. They also force you to evaluate some of your own behaviors. (If you’re lucky.)
Here are a few of the more valuable lessons I’ve learned from my kids.
1.) Test Your Limits.
Kids know this instinctively. The moment you create a boundary they begin testing it. There is no running in this area. How fast is running? Can we just walk really fast? What about jogging? It’s like they just instinctively know that life is more fun when you’re testing the limits.
Sure there are boundaries that we all have to live within but when was the last time you gave them a little test or maybe tried to actively redefine them? “OK, are you saying that I can’t attend this training or that you’re not willing to pay for me to attend this training? So are you saying we can’t use the conference room for an EMS journal club or we can’t use it during business hours?”
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After my post/rant about the overuse and misuse of the DCAP BTLS TIC acronym in EMS education, I was asked the question, ” Well, are there any acronyms that you do find useful?” And the answer is an
emphatic yes. Some acronyms make for useful mnemonic devices to help us recall needed information in stressful situations. Despite my strongly worded warning about the use of acronyms, I think there are several good ones that have valid clinical uses.
For sure one of the more useful acronyms I’ve learned is OPQRST. I learned it back in EMT school in 1989 and I’ve been using it ever since. I can’t imagine how many times I’ve gone through these letters in my mind while meandering through a subjective assessment with a patient.
This is an acronym that has stood the test of time, which is saying a lot in the word of emergency medicine. Considering everything that has come and gone in the last three decades of EMS evolution, the most remarkable thing we can say about OPQRST is that it has endured.
Today lets dive a little deeper into the nature of OPQRST questioning. What does OPQRST mean? When should we use it? What kinds of questions should you be asking to get the information we’re looking for and where does the OPQRST standard fall short of providing us with a complete picture of a patients pain.
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