5 Things I learned in Medical School I wish I’d learned in EMT School

Granted, it’s been 10+ years since I went through EMT school, but I still remember the gist of it. I remember often thinking the course was being dumbed down – taught to the lowest common educational denominator, which at least in the State of VA can be a GED. I actually think that’s fine – someone with a GED can do a great H&P, start CPR when needed and fashion a pretty good sling out of cravats. But EMT class is often the entry point for many folks with capability and ambitions to continue well-beyond the EMT level. I’m a firm believer in setting expectations high – assume your students want to learn as much as possible, and believe that they can. Don’t assume that they can’t understand why. Looking back on medical school and a year of Emergency Medicine Residency, I’ve complied a few things I wish I had known earlier.

1. Appendicitis pain presents around the belly button for a reason

As an EMT, I never understood why appendicitis often presented as periumbillical pain. Understanding things helps me remember better than mere memorization – that’s true for many people.  The classic presentation (50-60% of patients) for appendicitis is pain that starts near the belly button and migrates to the right lower quadrant. To understand this migration, you just need to know a bit about how the abdomen is innervated. When the appendix first gets inflamed, it’s still small and isn’t pushing against other structures. The pain one feels is deep, visceral pain (think “gut”), which happens to follow a course along the midline of the abdomen, known as the splanchnic nerves. This is why patients perceive pain in the middle of their abdomen even though the appendix is located in the right lower quadrant.  As the inflammation and infection worsen, the appendix swells and begins to irritate the muscle and tissues of the abdominal wall, producing pain in the right lower quadrant.

2. Vitals really are as important as everyone says they are

15700449761_a5a063f9c7_b
Abby Hoobler, EMT-E auscultates to determine heart rate

I will concede that my EMT instructors definitely tried to tell us this. Often though, vitals are taught in the second lesson in EMT class, just after the chapter on consent and other medical-legal issues. It’s taught up front in a focused lesson, but really should be a longitudinal study. We spend much more time up front focusing on how to take those vitals, and less time as we go along learning how to interpret and act on those vitals.  Ask yourself – how long is your differential diagnosis for hypotension?  Bradycardia?

indexcards-planning
Vital Sign DDx Carry Cards

If you’re struggling for more than 5, try this: at the top of an index card, write “hypotension.”  List all the diagnoses you can.  Now make similar cards for hypertension, bradycardia, tachycardia, respiratory depression, tachypnea, hypothermia and hyperthermia.  Carry the cards with you on shift.  Ask colleagues to help expand your list.  Pay attention to which conditions appear on multiple cards.  You’ll be surprised how much you can learn.  And next time you feel like you are doing EMT-B&%$# work by taking vitals, you’ll realize you’re probably the most important person on scene.

3. If you communicate well, doctors and nurses WILL listen to your turnover

We want to hear your turnover, if nothing else because you’ve probably asked 70% of what we will, and that will save us time. Being assertive, confident and organized in your presentations is 99% of the battle. Believe it or not, we also really really wish we could have access to the patient care report you wrote. Those initial vital signs and early medication administrations can affect medical decision-making downstream, especially if your patient gets admitted.

4. Stomas, Fistulas, Ports & Other Medical Devices

The EMT curriculum fails to educate providers about common medical procedures and indwelling devices. I never learned about the pieces and parts of a foley, colostomy, mediport or dialysis fistula, yet in any given day, 40-50% of EMS calls can be to Specialized Nursing Facilities (SNFs) where patients have problems with any or all of these devices. We do an ok job with complex devices like LVADs, but there are tremendous gaps otherwise.  Here’s one to start:

Stoma – Any man-made hole through skin or tissue that connects a normally internal structure to the outside world. So, the hole in someone with a trach is a “tracheostomy;” the bag attached to the hole coming out of someone’s abdomen and intestines is a “colostomy,” just like the drain in the head of a kid with hydrocephalus is a “ventriculostomy.” If you want to know the grossest thing on the planet regarding stomas, look up “Philadelphia Sidecar” on UrbanDictionary.  Yes, it’s a thing.

5. Normal Values for Basic Labs

Along the same lines as above, many patients are sent to the ED by a doctor due to an abnormal lab value.  Arguably, if the lab is concerning enough that the doctor wants the patient seen emergently in the ED, then you should probably know the normal range for that value, and what to expect if it’s high or low.  If you responded to an urgent care center for a potassium of 8.2, would you think to call a Paramedic?  I know I wouldn’t have 5 years ago.  Turns out hyperkalemia can kill you, but you don’t get to learn that until Paramedic School.  Whenever I need something complex explained eloquently, I always turn to my friends at KahnAcademy.

Familiarize yourself with the components of a Basic metabolic Panel (BMP) and a Complete Blood Count (CBC) and you’ll be 95% of the way there.

Check out the follow-up to this post, written by my husband, Amir: “5 things I learned in EMT School that I wish I learned in Medical School.”

~Steph

1929583_22597559544_7910_n
Oceanfront Sunrise, Virginia Beach, VA

8 thoughts on “5 Things I learned in Medical School I wish I’d learned in EMT School”

      1. Very thoughtful and insightful. My Dad (a physician) always said “the 2nd year of medschool is wasted on med students”. Thats the year you typically learn about pertinent pathophysiology, but at that point of training you have no idea what to focus on as important. It would be great to go back now and hear those lectures again. -I know I would focus on different things. This piece you wrote is much in the same vein of thought. Its noble of you to ‘give back’ by trying to explain and teach what is “important” now. Thanks. Great read…

        Like

  1. I love your blog!!! I am a Va Beach resident too, I am a former EMT and I am currently pre-med. I’m your new biggest fan 😉

    Like

    1. Jamie that’s great news! Medicine is extremely rewarding, as I’m sure you already discovered from your time in EMS. I’m always happy to answer any questions you may have.

      Like

  2. Thank you for this. As a basic I often berated and chastised by fellow emt basic and sometimes even medics for wanting the greater explanation of things and for voicing and trying to share the knowledge I have gained. I can only hope that your message has not fallen on deaf ears and you inspired people to “go above and beyond” just learning basics. Too many times even the basic are disregarded. So thank you, you made me feel like I’m on the right track and not like a ‘know it all’ or even more so when I’m told I take my job too seriously. Worst is “you’re just a basic, you don’t need to know that stuff”. Thank you, seriously, thank you.

    Liked by 1 person

    1. Thanks for your comment Charmaine – I agree, I hate it when people say “I’m just a ______” whether it’s basic, medic, medical student, Intern, nurse… no one is just an anything. If the job role weren’t important, it wouldn’t wouldn’t exist.

      Like

Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out / Change )

Twitter picture

You are commenting using your Twitter account. Log Out / Change )

Facebook photo

You are commenting using your Facebook account. Log Out / Change )

Google+ photo

You are commenting using your Google+ account. Log Out / Change )

Connecting to %s