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Thread Title: When is Enough, Enough?
Created On Sun Jan 17, 2010 10:57 PM
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foxtrotdelta
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Sun Jan 17, 2010 10:57 PM

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I've got this EMT partner who picked up two of my shifts. Nicest guy on the planet and he tries real hard but I'm getting to the end of my rope.

It started with an arrest where he yanked out my IV. It was slim pickings which eventually forced me to EJ the guy. It chewed up time where I could be doing other things but fortunately the job ended up being a save.

During another arrest he extubated my patient while we were transporting. I ended up having to re-intubate which again killed a bunch of time. To make matters worse he pulled out my IV just as we arrived at the hospital. The ED staff had to dig and dig before they found another vein after 10 minutes which effectively destroyed the resuscitation. I was ready to choke him.

Today we're doing a nasty accident/arrest on a highway and we're having trouble intubating due to damaged anatomy. So his idea to help is to take the patient with a very high suspicion of spinal injury and pull him up by his shirt so his head flopped back. I gave him a verbal beating but it just didn't seem to sink in that what he did was ridiculously inappropriate.

I thought it might have been isolated incidents but clearly that's not the case.. he's showing me a track record of incompetence. I've been dropping hints that he needs to get off my shifts and keep away from ALS units but it hasn't worked. I'd hate to make an issue with management because it could easily cost him his job.

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HEWITTC4
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Sun Jan 17, 2010 11:21 PM

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First, stop dropping hints and be direct. Tell him that he needs to improve because he is dangerous. If those codes had a chance of success, his actions could be responsible for their deaths (even though they were most likely going to stay dead no matter what you did).

If that doesn't work, speak to the training coordinator and tell him what is happening and that this employee needs remediation. That is the TO's job. At that point, the TO will either get him to improve or take appropriate action.

In the mean time, make a conscious effort to direct his actions while on calls. Keep him where you want him and have him do what you tell him to do.

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 Murphy was an optimist.

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roblanious
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Mon Jan 18, 2010 3:09 AM

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How is he with other medics? Do they share the same concerns and problems? How long was his field training, or was he thrown to the trucks like many services do? Do you think he is trying too hard? Does he get excited on calls? Is he accident prone, absent minded or just acts compulsively before thinking?
Hewitt is right, but I wonder if there is something you can do by trying to target where he is going wrong and work with that. I also think there are people ideal for BLS transports only. I also believe there are people who should not be in EMS. But there are also people who just need a little more work, fine tuning or placed on the proper trucks.

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 Greatness is not standing above our fellows and ordering them around, it is standing with them and helping them to be all they can be.
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foxtrotdelta
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Mon Jan 18, 2010 10:22 AM

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I've thought long and hard about whether I was being unreasonable. I know that I am a very demanding person, I expect A LOT from myself and I worry obsessively about the smallest mistake I make. I had to consider whether or not I was translating my personal stricture to my partners and the verdict is, I don't believe I hold them to nearly the same standards.

I look for certain things:

- a strong BLS showing, I like to see them get a BP and baseline vitals as quickly as possible. He does this *most* of the time. What's becoming more common is that I have to tell him to do it. This last shift he was better.

- familiarity with ALS equipment, I'm not saying he needs to know the dose of Oxytocin but he should know what color the vial is and be able to grab it. Even simpler than that is to prep Epi in a burstajet during an arrest. He should be able to figure out what I used during a call and restock it without asking me. I did it for my partners when I was an EMT. Is this unreasonable? Its accepted in my system that the BLS partner restocks the ALS gear.

- decisiveness, which is something he most definitely does NOT have. Everything from where to park the ambulance at a scene to the order he does things in appears to be carefully debated. He'll drive past the scene... then back up... then spend 2 minutes parking. He operates in slow motion. If I miss a line and ask for another catheter, I can literally take the IV kit from him, get it myself and open it before his hands even move.

A good example of this, my last shift I had a guy who fell down 3 or 4 steps with an OBVIOUSLY fractured lower leg. Walking in the door, this is an easy, bread and butter BLS call. I manually stabilized the leg and told him to grab the splints and some triangles from the bus. I chatted with the guy to get his mind off the leg and we actually finished an entire conversation when I realized my partner was still missing. I had to send the police officer on scene outside to find him and ask what the hell was taking so long.

- independence, I'm not sure that micro-managing a BLS partner is a good use of time. Should I have to tell him where to park? Should I have to tell him to get another catheter if I miss an IV? Should I have to tell him to start CPR at a cardiac arrest?

My organization is supposed to run a special class to help Medics and Basics work together and it used to be required before EMT's could work ALS shifts. However, when manpower is short or when it ends up getting lax, people breeze past and pick up 9-1-1 ALS. I spoke to the ALS QA supervisor and he wasn't sure if he had ever been trained. He also suggested it was my responsibility to work with him. I'm not sure if this is a workable issue or if his capacity is just below what's necessary.

Does he get excited on calls? Its hard to tell but his performance seems to suffer on more demanding or more severe calls, which would indicate yes. He doesn't seem to have the lay of the steps that need to occur for any significant emergency.

I did speak to several other Medics and every one basically said "the guy is a slow poke and has no clue, but he's a very nice person." One of these was even a supervisor and she made it clear that she felt I should speak to the BLS QA.

The problem is that most people don't complain about him because he's so nice. So by me speaking up, I feel like I'm the first one. Not only that but I'm jeopardizing the job of a genuinely nice guy. By the same token, he's so bad at times that if I don't keep my thumb on him, he's jeopardizing my job. I'm ultimately responsible for the stupid things he is doing and I'm far less effective as a medic if I have to micro-manage him or re-do something he has undone with carelessness.

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TRAININGATOEMS
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Mon Jan 18, 2010 12:34 PM

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First, I agree with everything HEWITTC4 said. Additionally, it sounds as if this guy is lazy and just doesn't want to do the job. I worked with someone like that once. The guy had the knowledge, but he didn't like the job, he was very lazy and just didn't want to work. He was an extremely nice person otherwise and when not on calls, we got along very well.

Bottom line: The way this guy is behaving now, would you want him working on you or on a member of your family?

If you answered "no", then it is time to take HEWITTC4's advice.

Peace,
RG

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Zorfox
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Mon Jan 18, 2010 2:50 PM

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What would you do as a supervisor to a medic that posted what you have?

Dealing with “genuinely nice” people is hard at times. If he has done the things you say, he shouldn't continue doing the job he currently has. It's that simple. Don't feel like your throwing him under the bus. Your position is not only about making appropriate patient care decisions. You also have to manage subordinates as difficult as it may be. You're not a bad person for feeling guilty. If you ignore a problem and let it jeopardize patients and other employees, then there is a problem with your own actions or lack of them. Think about it.

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PARAMEDICMIKE
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Mon Jan 18, 2010 3:59 PM

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Originally posted by: HEWITTC4
First, stop dropping hints and be direct. Tell him that he needs to improve because he is dangerous. If those codes had a chance of success, his actions could be responsible for their deaths (even though they were most likely going to stay dead no matter what you did).

If that doesn't work, speak to the training coordinator and tell him what is happening and that this employee needs remediation. That is the TO's job. At that point, the TO will either get him to improve or take appropriate action.

In the mean time, make a conscious effort to direct his actions while on calls. Keep him where you want him and have him do what you tell him to do.


I think this is as close to perfect an answer as you're going to get.

Good luck!

-be safe

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"There is an incessant influx of novelty into the world, and yet we tolerate incredible dullness."
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ESPARKS
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Mon Jan 18, 2010 10:48 PM

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The first question that comes to mind is :
How long has he been in the business, & how much exposure has he had to 911 ALS calls?
If he is not a noobie and just doesn't get it , then remediation is probably not going to work.
If he's had no exposure to what you expect from your partner ,then maybe a few minutes talking him through what he needs to do to step up to the plate might work.
If all else fails then a sit down and come to Jesus meeting with his supervisor may be needed.

Don't give up without knowing whether there is a reason for his actions/ inactions.

Ed

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foxtrotdelta
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Tue Jan 19, 2010 8:41 AM

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I don't believe its for a lack of experience. He's been around awhile and worked ALS before. I spoke to 3 or 4 other medics and they all basically said the same thing. He's done 3 cardiac arrests with me alone in the last month, by the 3rd time I would think it would be smooth.

The guy is in nursing school and he's starting to get ballsy because he believes that what he has learned in nursing directly applies to EMS on the street. He's improperly applying things he's read to what we do daily and its just not adding up to success or efficient EMS.

The bottom line is I'm going to have to speak to the BLS QA and get him off the shift.

Edited: Tue Jan 19, 2010 at 8:42 AM by foxtrotdelta

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roblanious
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Tue Jan 19, 2010 11:00 PM

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Hewitt wrapped it up well.
I tend to believe that what is learned in nursing CAN be applied in the streets, but EMS providers have the ambulance driver tradition instilled in them that everyone who calls for an ambulance should be transported expiditiously. Spending an hour with a hypoglycemic patient and then getting a refusal is counter to what EMS has been taught, but may be best for certain patients overall. I wish medics had similar intense training and education as a standard. It would revolutionize our profession. However, in this situation, this guy sounds like he will be perfect for floor nursing, especially in a nursing facility. He does not sound like someone who should be in EMS, at least not on an emergency truck. Do you guys have trucks designated for NETS or BLS calls? That would be ideal for him.
I am not sure I agree with RG that he is lazy. Maybe he is. I think it is his lack of exposure to emergency calls, and he does not have the decisiveness to think and act quickly, and effectively. I am not sure if this can be taught effectively well in a short amount of time, if at all.

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 Greatness is not standing above our fellows and ordering them around, it is standing with them and helping them to be all they can be.
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foxtrotdelta
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Tue Jan 19, 2010 11:21 PM

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We do have dedicated transport and BLS 9-1-1 units which is where all EMT's start when they climb their way up (some choose to never try and that's perfectly fine.) In fact when I started with my organization as a Basic, I worked with him on BLS 9-1-1 once or twice. He did strange things too back then but it wasn't as relevant because we didn't do any serious calls those particular shifts. And I hate to say it but a lot of the Basics are strange or poor performers at that level. They used to have an entry exam and minimum standards but when they got rid of that and the state started recruiting EMT's from the projects, we got this huge influx of people who were off-the-wall or not at all interested in actual EMS. It just beat the pay at McDonalds by a few bucks.

I can't say its laziness, because he tries. It has to be a combination of him not being from this country initially hence a moderate language issue and his personality which does not function well under pressure.

When I cited his being a nursing student, I was referring more to him referencing drugs we don't carry and justifying actions with irrelevant nursing practices. When he extubated my arrest, he argued with a supervisor for a full 10 minutes about how he was suctioning the lungs because the fluid was a different consistency. I think both the supervisor and myself were mystified as to what point he was actually trying to make, but he kept referencing nursing school as the source of his information. We both tried to explain that he had actually dislodged the ETT and was suctioning the esophagus but he was adamant that it didn't happen that way.

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roblanious
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Tue Jan 19, 2010 11:43 PM

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Originally posted by: foxtrotdelta
We do have dedicated transport and BLS 9-1-1 units which is where all EMT's start when they climb their way up (some choose to never try and that's perfectly fine.) In fact when I started with my organization as a Basic, I worked with him on BLS 9-1-1 once or twice. He did strange things too back then but it wasn't as relevant because we didn't do any serious calls those particular shifts. And I hate to say it but a lot of the Basics are strange or poor performers at that level.

It appears he may not have been right for the job to begin with, but the BLS trucks is where he needs to be. Hopefully he will finish nursing school and be out of your hair (that's if he makes it through the clinicals-and I doubt he will).
Quote
They used to have an entry exam and minimum standards but when they got rid of that and the state started recruiting EMT's from the projects, we got this huge influx of people who were off-the-wall or not at all interested in actual EMS. It just beat the pay at McDonalds by a few bucks.

Ah, the municipal politics and EMS. Compromise good patient care for affirmative action. We see this all over, I guess.
I worked with a guy once that could not pass his NREMT-P practical. I precepted him and found him just like the guy you stated. In short, we all gave up on him, but after a couple of years, he persevered, and finally passed his practical. You know the type. You just described him, but imagine him being a medic. Somehow, the City just hired him as a medic two years ago, and they regretted it. He didn't change. Hell of a nice guy though.

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I can't say its laziness, because he tries. It has to be a combination of him not being from this country initially hence a moderate language issue and his personality which does not function well under pressure.

Yup. This is one of those I have seen that I feel just does not have the mental capacity to function in an emergency setting. I just can't see this guy making it through nursing school, but I know a few nurses that make me scratch my head and wonder.

Quote
When I cited his being a nursing student, I was referring more to him referencing drugs we don't carry and justifying actions with irrelevant nursing practices. When he extubated my arrest, he argued with a supervisor for a full 10 minutes about how he was suctioning the lungs because the fluid was a different consistency. I think both the supervisor and myself were mystified as to what point he was actually trying to make, but he kept referencing nursing school as the source of his information. We both tried to explain that he had actually dislodged the ETT and was suctioning the esophagus but he was adamant that it didn't happen that way.

I think he was making this up. I cannot imagine a nursing school teaching this, but then, I can be wrong.

So, again, Hewitt had the best advice. He will only make your job harder and compromise good patient care, and worse hurt someone and/or become a liability to you and the company.



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 Greatness is not standing above our fellows and ordering them around, it is standing with them and helping them to be all they can be.
G.Arthur Keough (1909-1989) Educator

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golfr1
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Tue Jan 26, 2010 9:20 AM

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There are these type of people in all areas of work. It is usually the very funny, very nice and accomodating person that has lots of friends, but are totally irresponsible. We really like them as people but I wouldn't trust them to follow through on anything. It is very frustrating, and usually they end up getting canned and not realizing why, even though the friends at work 'hinted' because they didnt want him to lose his job. He is also the person that would blame it on something or someone else, and never realize. He needs a good jolt before he is let go.

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foxtrotdelta
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So to update, I ended up reporting him. They're attempting to pull him off ALS 9-1-1, but since its a union outfit, they have to go through all the channels. He's also supposed to be remanded to retake the "Working with Medics" class.

As of right now, he's still on my shifts which is a bummer but we'll see what happens. I wish him the best, I just can't do this crap anymore. I need someone who either knows what they're doing or who I can train to know what they're doing.

Edited: Wed Feb 03, 2010 at 5:54 PM by foxtrotdelta

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roblanious
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It is easy for me sittling so distant to tell you to take on the responsibility of training him while you have him, but I do understand that some people just cannot be trained, at least not that easily, and some just don't want to listen or change. Some just have their head so far up their...Anyway, try to work with him.

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 Greatness is not standing above our fellows and ordering them around, it is standing with them and helping them to be all they can be.
G.Arthur Keough (1909-1989) Educator

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foxtrotdelta
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Thu Feb 04, 2010 7:59 AM

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About the time he started arguing with me over my instructions is about the time I gave up. A combination of that and a lack of common sense means I was probably engaging in a futile effort. There were areas where he improved but areas where he can't seem to make any progress.

One of the supervisors who was hot to the problem started responding to my jobs to watch him. He has this habit of asking people for their insurance information at VERY inappropriate times. I told him 3 or 4 times I don't care about insurance info, if I never get it, I still don't care so stop asking for it. The supervisor caught him doing it and told him not to do it again. Then he did it yet again and when I approached him for 3rd time on it, he argued back. What do you do with that?

I hear you rob about training and teaching him but I'm not sure that's feasible anymore. They won't fire him unless he pitches a fit but they'll stick him back into BLS where he probably should be for now. He'll be a RN in a couple years and then I'm sure he'll move on anyhow.

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TRAININGATOEMS
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What it comes down to is that as an EMT, he needs to realize that on an ALS truck the person with the highest certification is in charge and he needs to follow that person's lead. I've always encouraged new EMTs to ask me questions and learn as much as they can, but, in the end, it is the paramedic who is in charge of the call and the patient and until he gets that EMT-P patch on his shoulder, he needs to realize that and do what he is told to do.


Peace,
RG

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roblanious
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That is part of the problem. He can't follow instructions of the medic in charge. I knew many EMTs like that, but this guy has more of an issue of not following instructions. I just can't see this guy making it through nursing school. Not at all.

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 Greatness is not standing above our fellows and ordering them around, it is standing with them and helping them to be all they can be.
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foxtrotdelta
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I have no doubt he will be an RN, he'll churn through the RN factory and get spat out into the field... and he'll end up in some nursing home (he was a nursing assistant previous to becoming an EMT) where he'll do what all nursing home RN's do.. kill people with neglect or ignorance.

That was a little rough but I've almost never had a positive experience with nursing home RN's.. they generally seem to be 2nd or 3rd tier, as in they couldn't make it in a hospital setting and ended up there.

Not to get off subject but one told me the other day, "All chest pain is the same." Word for word.

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roblanious
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RNs who work at nursing homes are generally very good nurses. Unless you do a shift or two of nursing home clinical, you cannot appreciate their specialty. They are better at caring for these patients than your average acute care RN. Nursing is not just acute care, but wholeness care, including spiritual, physical and emotional wellbeing. The nursing home RNs are not good at unexpected emergencies like EMS and ER nurses are. Leave a suddenly critical patient to a nursing home nurse, and she will end up killing the patient. Now let's flip it. Now you are in charge for a day for a wing of chronic care patients, ensuring they are all tossed and turned, ROM exercises, they are all bathed and cleaned, proper skin care done, proper feeding, ensuring the patients have the appropriate diet, ensuring the patients have the appropriate restraint or supervision, ensuring the pt.'s are receiving adequate emotional and spiritual stimulation, etc. I can alsmost guarantee you and I would kill a patient or leave a patient to become contracted, or with huge bedsores. Of course we all know of nursing homes where we the care in that regard is also substandard.
I admit, nursing home nurses should be better prepared for acute emergencies, but perhaps a training session by your EMS service would be nice. A few services do that here.

I am not sure how nursing schools are there, but around here, they are still not real easy. Around here, people continue to get washted out of the schools at faster rates than those do from paramedic training. I can assure you, this person would not last in one of the schools here. He may make it through the first or second semester, but that is about it.


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 Greatness is not standing above our fellows and ordering them around, it is standing with them and helping them to be all they can be.
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TRAININGATOEMS
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I have to disagree with you there, Rob. A good CNA could do all the care you mention except for medication administration.

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RG

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roblanious
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CNAs are not taught ROM exercises, pathophysiology, and certainly not pharmacology. The medications are an important part. What medications can go through tube feedings? With all the medications the patients take, considerations need to be made with interactions, appropriate times of administration, and the pharmokinetics. Are the CNAs able to determine what skin lesions or rashes or bumbs are benign or what needed addressed? I will say though, good CNAs do most of the necessary skills, and a CNA can make or break a nurse.

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 Greatness is not standing above our fellows and ordering them around, it is standing with them and helping them to be all they can be.
G.Arthur Keough (1909-1989) Educator

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missclampett
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I have to disagree with some of you... I dont think this guy has any business on an ALS OR BLS rig. Why is it ok for him to work BLS when he is demonstrating the characteristics delta has described? Just because he wouldnt be handling medications or IVs? Nonsense. He sounds like his issues are way worse than that, especially if he cant even get a splint and cravat from the rig. I would say if he has been around BLS that long and he is that incompetent, he doesnt belong in EMS at all. Period.
Isnt there a saying something like, 95% of ALS is BLS? In that case, he's going to kill someone doing BLS.
I know I'm a noob, but that's just my opinion.

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roblanious
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I was giving the benefit of the doubt and hate to see someone lose a job for something like this. I figured there is something he could do, however, you are right Sarah, he should not be involved in healthcare period. He should be a fireman.

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 Greatness is not standing above our fellows and ordering them around, it is standing with them and helping them to be all they can be.
G.Arthur Keough (1909-1989) Educator

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jayffemt
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Several years ago, I was helping evaluate a practical exam for an EMT-B class. The instructor of the class told me to keep an eye on one student that he didn't feel should be working EMS because he just couldn't get it. He barely passed the class's practical, and the written test, but failed the national registry.

The instructors are pressured to pass students to keep class size "appropriate". Those who should have flunked the class and been told, "Maybe EMS just isn't for you", go on to become EMTs who fill the "warm body" requirement.

In many occupations, it is a matter of pride that not all who start training succeed. Those tend to attract better people because of that high standard. EMS needs to put out licenses by quality, not quantity.

BTW Rob, I don't want anyone with a total lack of situational awareness next to me on a hose either. (But I appreciate the humor)

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foxtrotdelta
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Its a good point.. there are heavy pressures to fill out numbers. A lot of programs face termination if they don't pass 'X' number of people.

The medic program I attended has just made the requirement for Anatomy & Physiology I/II a thing of the past. Most of the people I spoke to said they wouldn't be half the medic they are if they had not taken those classes. I agree. More than that A&P was a major obstacle for a lot of poor medic candidates. I know at least 5 people admitted to not advancing because they couldn't pass it and in every case, that was a good thing. One person admitted to trying 3 times before giving up.

They used to require at least 3 years of 'high volume' 9-1-1 EMS experience. They reduced that to 300 hours and eventually to 300 hours of ANY EMS experience followed by no requirement at all. You get guys who still have ink wet on their Basic cards who have no real world experience to relate to.

Its a disturbing trend. Medics who graduated from my program were proud because it was notoriously difficult and had the reputation for producing top notch medics. I don't believe that's true anymore. I can only wonder how bad it will get.

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missclampett
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Delta... OMG! You are kidding me! No A & P???
What state are you in?
That blows my mind. Here, all paramedic schools are two-year degree programs with pretty much identical course requirements as the RN programs.

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HEWITTC4
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The current requirement is that all paramedic schools either require A&P as a prerequisite or teach the A&P as part of the curriculum. The problem with having it as part of the curriculum is that you are having paramedics teach a course they never took themselves.

I've taken A&P 3 times, once 10 years ago when I first started considering EMS, second was taught as before but part of my paramedic class, and finally a few years ago as part of my degree. I probably have more A&P education than any of the medics on this site and I think I would benefit from another class.

-------------------------
 Murphy was an optimist.

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TRAININGATOEMS
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Posts: 3254
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Thu Feb 11, 2010 12:25 PM

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That is interesting. Our state has pretty much always required A&P in associate degree programs and it is now a requirement in all certificate programs as well. I remember that we had two semesters of A&P, and both were taught by doctoral level instructors. But, our program also required microbiology, something not a lot of other programs require.

So, what's currently happening with your not-so-great partner?

Peace,
RG

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foxtrotdelta
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Thu Feb 11, 2010 2:47 PM

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That's actually what I heard they will be doing, teaching a "blow-through" version during the class itself which I believe is a big, big mistake. There's no way to do an adequate job and since the program remains the same number of hours, I have to ask, "What are they cutting?"

Part of the experience was taking separate college classes alongside future doctors, nurses, therapists, whatever with professors who have devoted their lives to the study of the human body and its pathologies.

A&P I/II were AMAZING classes. When I had to purchase the $500 in books for it, I complained and bitched that I couldn't wait to sell them back off. After I finished, there was no question I was keeping the text books and I frequently refer back to them for various issues or just as a refresher. If it wasn't so expensive, I'd like to take them again. Its great that HEWITT was able to take 3 times!

The EMT in question was pulled off one of my shifts. For now, he remains on another day tour with me but I was told that will end soon as well. My attitude is "we'll see" as they tend to forget about these things. Its easier to leave him there than to figure out a change.

On a positive note, several people have already put in for the open shift. I have a solid reputation which hopefully nets me a capable partner. Even if its someone without experience, I'll take someone I can train and work with. They just need common sense and professionalism. That's all I ask. I had a partner the other week who asked me about a DKA patient I had. I explained the whole diabetic pathology to her and she said told me that it shocked her because most medics won't take the time to even answer questions. I love asking questions so I have absolutely no problem discussing things.

About a month ago I had a medic student with me and she started to argue a bit over the diagnosis of a patient when she suddenly stopped and apologized. I told her not to apologize and to keep going. I have no problem being shown up by a student, I encourage it. If I'm wrong, I'm wrong and I want someone to convince me of it. And if I'm right, then I should be able to give a thorough and logical argument to prove it. If I can't provide that argument, then I need to figure out why I came to my conclusion. That's all there is to it.

Edited: Thu Feb 11, 2010 at 2:48 PM by foxtrotdelta

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