Earning A Spot in the Pit

Once or twice a week I precept paramedic students in an emergency department for their clinical rotations.  We assess patients and discuss what the treatment in the field may be, listen to lungs, start IV’s, administer medications, and practice other skills under supervision.  It is my favorite part of the work week, and I love seeing the “ah ha!” moments when students make connections between something they see in class.   Our goals are to learn as much as possible from every patient who comes in, help the ED staff, and help patients get faster care.

I start each clinical shift with a discussion about expectations.   Everything we do at a clinical site is a privilege, which granted first by the ED staff and then by the patient.  We have to earn their trust, which requires a good attitude, being polite, appearing confident (but never arrogant), and expressing a desire to help.  We want the staff to like us being there, so we try to make their jobs easier while we learn.

I also explain that when a sick patient arrives, a crowd will gather in the room.  A few people will be allowed near the patient who are involved in patient care, and since we are in a teaching hospital, most people watch in the periphery.  Our goal is to earn enough trust in the staff to be in the pit near the patient, and actively participate in taking care of them.  In order to do that, we need to show the staff how professional we are and how fast we can move with the less sick patients.

I start each clinical shift by introducing the students to the staff members, tell them what skills the students are credentialed to do, ask if they need help with anything.  Then we hustle.  If we see an ED tech wheeling an EKG machine into a room, we offer to do it for them.  If a patient asks for a blanket, we get two out of the warmer.  If their spouse asks for a cup of coffee, we get it for them.  We also take patients for CT scans and X-rays if their nurses or techs are busy, and helped them change diapers.  In addition to helping the staff, these are great opportunities to learn how to talk to sick people and their families.

When a new patient arrives, we try to intercept them before they get to their room.  When appropriate, I challenge the student in charge  to get as much information as possible about what is wrong with them before we get there, and for them to think about which questions are most important.  Once they are in a room, but before the nurse comes in, our goal is to get the patient in a gown, get their vitals, attach them to the monitor, and get an ECG.  If the patients is likely to need an IV, I have the student who is up for the next one get their equipment ready.  This helps them learn how to work quickly as a team, and lets the staff know that we can be trusted to get things done.

After hustling with the less sick patients, on several occasions our students have earned the opportunity to practice skills on high acuity patients.  During cardiac arrests, we do most of the CPR and run pit-crew compressor changes.  The student doing the compressions knows to jump off as soon as the doctor asks for a rhythm check, and the next student knows to jump in his place to resume.  One student pulled back the ET tube of a right mainstem intubation, another gave epinephrine to an anaphylaxis patient, and another used the IO drill on a seizure patient.  Our students have also started IV’s and on a patient in V-Tach, a stroke patient who needed one for a CT scan, and a STEMI patient while the transport was ready to transfer them to a PCI center.  One even got an IV on a patient with a pneumothorax, who said he was so afraid of needles that he may not be able to control his arms or legs after getting stuck.  I am proud of my students when they succeed in these situations.  They earned these responsibilities, but I remind them that trust can be lost in a second.

Paramedic clinical time should be about more than tallying skills.  It is about learning as much as possible about how to be a good caregiver with each patient encounter.  It is an opportunity to learn assessments, communication skills, and teamwork – both with classmates and the ED staff.  The opportunity to care for the sickest patients in clinical is a privilege that must be earned, and achieved through professionalism and hustle.




  1. Shaun St.Germain says:

    This is gold. Thanks for posting.

  2. I love the metaphor of earning the opportunity to work in the pit. Well done!

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