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
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?
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.”