Surly Librarians and their Rants

The Digital Research Library has really grown legs over the scant weeks since its creation, and we couldn’t be happier about it. But as useful as it is to present the bare facts and data, it’s also valuable to read deeper, discovering context and patterns. Try as we might, we couldn’t find an elegant way to include this in the library as it stands, and it would clutter up the front page here obnoxiously.

So we made another blog. Introducing: Lit Whisperers. Check it out, know it, love it — updates will be posted to our Facebook page or via EMS Blogs.

Child-rearing and You

Monkey Training School


Despite my forays into educational writing like this, I have never been an FTO.

Field Training Officers or preceptors are responsible for training and supervising new hires, who typically work for several weeks as an additional third crewmember (or “third rider”) while learning the ropes. For various reasons, I’m not sure I’d be good at this, and I’ve never pursued it. On the other hand, regardless of what I want to pursue, I’ve never been able to avoid working with new partners.

By “new,” I mean minty-green new — folks who have never worked on an ambulance, or in some cases, never worked a job at all. Since this kind of EMT is usually paired with a fairly senior partner early on — and since not many people stick with this job long enough to be “senior” — if you’ve been doing this for a few years, you’ll usually wind up with a new guy sitting next to you. It is what it is.

Standard operating procedure is to drink lots of coffee, grumble, boss them around, and let them gradually absorb whatever useful knowledge you inadvertently leak out. Unfortunately, this is both stressful for the new guy, and something less than fully enriching; they learn as many bad habits as good practices, and become jaded faster than they become competent.

I am not a gifted teacher when it comes to in-person training. But like most things in this job, by learning it the hard way, I’ve developed some useful insights. So here are a few pointers for bringing along your new guy and molding them into the very bestest EMT they can be.


Make your expectations clear

For you, it’s Wednesday, you’re tired, and for some reason your left knee keeps clicking. But for them, it’s their first day on an ambulance, and everything is new.

The best thing you can do is to clarify how this game is going to work. What’s going to happen when you walk into a call? How are you going to assign responsibility? What do they know, what do they need to know, and how will that process occur?

I once punched in to find a partner I hadn’t met before. Ten minutes into checking the truck, we got sent out to a seizure at the department store. I drove, she teched. But each time I tried to let her “do her thing,” she just froze like a deer in headlights. Turned out, this was the first shift she’d worked — ever — and her entire training period had been spent running routine transfers. She wasn’t just unpracticed, she hadn’t even seen most of what takes place on an emergency call, never mind attempted it.

Although you could call this a gross failure of the training process (I did), the underlying lesson is that you never know what you’re dealing with. Your partner may have years of experience at another service; he may have just finished high school and never worked a full-time job; he might be a new EMT, but just spent twenty years as a veteran CNA. Maybe he’s a few months in, comfortable with certain situations, but wholly new to others. You need to know where they’re coming from. Not only will they resent the stress and panic induced by stranding them when they don’t know what to do, but they’re just as likely to resent your butting-in (whether explaining something or actually taking over) when they do know what to do; the dividing line can be nearly invisible, but is very real.

Some points to consider:

  • Who drives? Many seniors tend to do most of the driving while their newbie techs in back. The theory here is that you should “learn the back before you learn the front” — that is, patient care before driving and navigation. I find this arbitrary, since driving is as important to this job (and sometimes as difficult to do well) as anything else. It’s reasonable to focus on one skillset before developing the other, but I think driving should start early, because eventually they’re going to be forced into it anyway (driving for an ALS unit, perhaps), and they need to be ready. Start almost immediately by letting them drive between calls on routine matters; this acclimates them to handling the ambulance and navigating your service area. Once they’ve figured that out, they can do some emergency driving on responses. When you’re comfortable they can safely get from Point A to Point B, let them drive while occupied with patients — if they know where they’re going, or at least have a reliable GPS. But don’t throw them into this without some instruction on how to drive smoothly and safely, or you’ll spend the trip getting angry while you slide around the bench, and they won’t know why.
  • Who does what on emergency scenes? Working with experienced partners, I cleave to the golden rule: the tech runs the call, while the driver shuts up and helps out. This makes it easy to avoid stepping on each other’s toes or going different ways. If you’re the tech and your new partner is driving, this still works, because you’ll make the calls and tell them what to do, and they can watch your amazing wizardry in action. But what if they’re the tech? I always try to let them take the reins, but if they pulled the tags off their first uniform yesterday, they’re probably just going to stand there. I give ’em a few beats and then take over (you can’t stand there forever staring at the patient). But between calls, go over what needs to happen, and try to gradually work them toward familiarity with their role.
  • How will feedback be given? Like in any relationship, communication is only ever bad when it’s not undertaken promptly and directly. From day one, make it clear that if they ever have a question, they should ask it (at the appropriate time); if they’re ever uncertain, they should request assistance (you’ll only be mad when they screw up because they didn’t ask); and if they want help, you want to provide it. Conversely, explain that after calls you’ll give suggestions and feedback, which should be taken constructively; they have a lot to learn and must embrace that. If you tend to adopt a direct or brusque manner, as many of us do, warn them that it’s not personal and you’re not rebuking them, you’re just too old and tired to sugarcoat everything. Reassure them that you’ll never talk shit to others when they mess up; when anybody asks, you’ll just make vague remarks like “oh yeah, he’s good.” Above all, remind them that although you’re here to support them, patient care comes first, so there will be times when “teachable moments” need to take a back seat.


Practice, Practice, Practice

The main problem for most new folks isn’t “knowledge,” it’s application. They may have memorized the EMT textbook (although that book, of course, is a little light), but there are a thousand tiny things that comprise the everyday functioning of this job, and they know none of it.

That’s one of the goals behind Scenarioville. To get good at this job, you need practice. And even in a busy system, in a given week you may only do one or two seizures, or drunks, or chest pains, or any other type of call, with a lot of other stuff in between. If they’re weak with something, it takes a long time to to practice enough to get any better.

You can fill that gap with drills, as realistic as possible. In your downtime, make ’em go through the paces. Trouble giving radio patches? Hand ’em the mic (turn it off first) and have ’em pretend they’re talking to the hospital, complete with pressing the right buttons and hearing static-filled replies from you. Do they need to practice driving? Find a parking lot and give them tasks to accomplish, such as backing in a straight line, turning corners, or navigating tight gaps. Bad at lifting? Give ’em workout homework (get thee to the gym and start deadlifting!). Watched them fumble with a skill? Make ’em do it: take a blood pressure off you (with various locations, sizes, and methods), assemble the nebulizer or apply a dressing, or execute a thorough neuro, abdominal, or trauma assessment. In some cases verbalizing a skill is all you can manage, but whenever possible, do it for real; a disposable neb is a small cost to pay for skill mastery, and the first time they open the package shouldn’t be on a sick person.

If they’re interested, you can certainly chat about deeper medical topics like V/Q mismatching and the citric acid cycle. But they can get that from a book. When it comes to practice, something more interactive is needed. Often, I’ll do verbal scenarios, describing a call and forcing them to make decisions as they go. Nothing is quite as frightening as a totally unscripted, unstructured situation, where you stop and stare and ask, “What do you do?” And don’t let them get away with vague invocations like “scene safety” or “manage the airway”; force them to describe exactly what they mean. Oh, you’ll check for a pulse? How? Where? What are you looking for? Okay, where’s that piece of equipment? How do you size it? Are you sure we’ve got one?

History-taking is the most difficult skill to acquire. Force them to talk directly to you as if you were the patient, because they need to be comfortable with that. With experience, you develop a patter, and you have go-to lines at each juncture — what you say in greeting, what to ask for certain complaints, how to unpack certain responses. They haven’t acquired those moves yet, but they need to develop them, so by presenting them with those situations in a practice setting, they have a low-stress way to hone their own tools.

Every new partner I’ve had has gone through a similar learning curve. At first, they don’t know anything. After a while, the first things they get comfortable with are the “skills,” simple, concrete tasks they know how to execute. As a result, when they walk into a scene and don’t know what to do, they immediately start doing whatever task they’ve mastered — taking a blood pressure, writing down meds, etc. The challenge is getting them to move beyond rote psychomotor skills to the nuanced business of actually approaching the patient, greeting them, assessing them medically with questions and focused physical examination, deciding what’s wrong, and making decisions accordingly. This is tough, and occasionally I’ve had to take things away from people (cuffs, glucometers, nasal cannulas, pens) so they couldn’t “hide” in them.

In the end, the key to mastery is repetition. A single repetition is nothing. When the two of you run a call and you realize they need to practice something, debrief afterward by discussing the details, make them describe the considerations and goals, and spend the rest of the day verbalizing scenarios similar to the call you did. Once they’re absolutely sick of it, you’re starting to make progress, because boredom means they know what to do, and that’s the whole idea.


Managing your own blood pressure

One of the biggest challenges, of course, is not losing your mind.

Even smart students will sometimes drive you out of your gourd. Usually, this is because they don’t know something you figure they should. In fact, everybody should know that. In fact, how in god’s name can you be old enough to drive a car without being able to figure this out? It’s common sense!

The trouble is, it isn’t common sense. When you started out, you had to learn it. But that was so long ago, you’ve forgotten how much you originally had to learn; many of the routine aspects of the job are now second-nature to you. But they’re not second nature to your partner; he has to consciously learn them all, and think about them when he does them, and he can only internalize so many at a time. So while he’s trying to remember to do X, Y, and Z, he might forget A and B. Even if A is something that he does know. And maybe he never even learned C. See?

When they develop confidence, they improve exponentially, because once they relax they can actually think; most dumb stuff is the result of blind panic. (The secret of veteran providers is that they often don’t know what to do, but they use their noodle and do what makes sense. This isn’t a difficult skill, but you can’t do it while holding your breath.)

My own pet peeve is when I tell ’em something, and next week tell ’em again, and six months later I swear I’m telling ’em the same thing, and they’re staring at me like they’ve never heard it. Ain’t you listening to me, Jethro? Well, they are listening. But I’ve also been talking a whole lot, and between the V/Q mismatches and everything else, they’re not going to remember all of it; it’s going in one ear and most of it out the other. So either I can slow the flow a little, or expect to repeat myself. Either way, my problem, not theirs.

The point is that there’s a great deal to learn just to master the basics of this job, never mind acquiring true clinical acumen. Combined with the fact that many new hires are young, and haven’t developed the general problem-solving skills that only come with years and failures and overall life experience (being a good employee, talking to other humans, empathizing with suffering, avoiding dangerous situations, and so on), and you get a perfectly intelligent person who sometimes seems like they’ve had a lobotomy.

Take deep breaths, try to remember what it was like when you were in their shoes… and warn them early that you will occasionally get fed up, sometimes act short, and at the 15th hour of a shift, will not always be gentle Grandpa Patience. Advise them that you’re not perfect and will not always act out the principles you espouse. And request that, although you like to teach and you like your job, when you’ve been working for 60 hours straight you may need some quiet time.

Most of all, look around at all your competent coworkers who once upon a time made their partners pull out their hair and ask whether they were working with a trained monkey. Because it does get better, and years ago, that monkey was you.

Cutting the Ribbon: The EMSB Digital Research Library



Around here, we’re big believers in evidence-based medicine. Yes, it has flaws, and yes, it can be challenging to properly interpret and apply, but like they say about life, it’s the only game in town.

And sure, you can let other people read the research and tell you how to treat patients. And since by and large, we work under protocols written by physicians, that is inevitably what we do. Yet everybody understands that within that framework, there’s still a great deal of leeway — there are decisions that need to be made every day, and you cannot make them intelligently without understanding what you’re doing and why. If you’re not basing your decisions on science, you’re basing them on personal prejudice, anecdotal experience from your career (which is inevitably weaker than you think), and the similar poor compasses of colleagues and coworkers.

No good. We should all strive to have reasons for the things we do, because that lets us modify our actions, omit them, prioritize them, and otherwise tailor our care to the unique situation and unique patient in front of us.

Unfortunately, directly engaging with peer-reviewed medical research is challenging. Searching through it is an acquired skill, reading it takes practice, and in many cases, we simply don’t have access to published full-text articles unless we’re affiliated with a university. The result is that many prehospital clinicians who want to practice intelligent, evidence-based medicine aren’t able to do so, at least not easily.

In response to this, we’ve launched a new project. Drum roll please…

The EMSB Digital Research Library!

This is an index of medical papers on topics relevant to EMS, ranging from spineboards to sepsis; it’s easily searchable, and can be organized or filtered by the user according to whatever characteristics are desired. Rather than a raw data-dump from all the world’s journals, it’s hand-curated by our volunteer editors, who read each piece from cover to cover, summarize the contents, file them and rank them by quality and relevance. The result? If you want to discover what we know so far on a specific topic, instead of facing a blank, unending sea of medical research, you’ll have a structured library of material organized for your convenience.

When you find the research you’re looking for, what then? If you lack academic or institutional journal access, we’re here for you. Simply email us a request for the papers you need, and we’ll provide them to you privately. We wish it were possible to simply post them online for the world to access, but that would violate copyright law in an egregious way. (When specific papers have been made freely availably by their publisher, we do link them directly in the index.)

How effective is aspirin for chest pain? What’s the chance a patient with head injury has a C-spine fracture? Does it matter if your stroke patient walks to the stretcher? Is supplemental oxygen important during sepsis? What’s the number-needed-to-treat for endotracheal intubation? These are the kinds of questions that are hard to answer now, but will be easy to answer using our library — at least, once it’s grown enough to address those topics. There are tens of thousands of papers out there, and one day we’d like to list them all, but we’re starting with a seed of about a hundred — a very well-developed body of spinal immobilization literature (probably over 90% of the quality research on the subject), plus a scattering of interesting material in other topics. Everything starts somewhere, and it’ll continue to expand.

The Library is managed at this time by my colleague Vince DiGiulio, Head Librarian and Master of Evidence-Based Codices. I help him out, along with a team of associate librarians. In any case, general library-related queries, research questions, or paper requests can all be submitted to librarian[at] Please remember that we’re all volunteers over here, so give us a little while to reply. And if you’re willing to contribute some time to help curate the database, let us know — we need help!

Folks, this will be a constantly-growing project. We’ll be striving to continually add more material, both new and old, and updates will be announced on the library page (as well as the Facebook group). The entire system is still in the early stages, so bear with us through any changes or hiccoughs. And remember: if you’re not thinking about how you know what you know, you’re not a clinician, you’re a monkey. And if the way you know what you know isn’t through science and reason, you’re just a witch doctor.

Use this stuff. Don’t be a witch doctor.

Year Two



Two years!

The inaugural post on this website was published two years ago to the day, and starting tomorrow, we’ll be moving forward into year three.

Time flies like a banana, doesn’t it? Over the past year, the site has grown and evolved. Due to personal obligations (I’ll be heading up in a few short months to matriculate at a PA program), I confess that the output of general content has dropped off. In comparison to the 81 posts made in the first year, this past year I cranked out only 34. Despite that, annual traffic has swelled from 30k unique visitors to over 72,000.

Some things stay the same. The most popular pages are still the What it Looks Like series (which we continued with a popular edition on Cardiac Arrest and CPR), the Drug Families: Anticoagulants and Antiplatelets tutorial, and our guide to orthostatics. We keep talking about how to be a good EMT, and ran some posts about the basic challenges of patient care and how to manage them. In keeping with the basic mission of the site, we discussed things like performing great BLS-level resuscitation.

But some things change. We ran a new multi-part guide on glucometry that was well-received, and a series of posts examining BLS airway and ventilation that have become some of the most popular on the site. We tried our first collaborative community podcast and experimented with video lecturing.

Perhaps most excitingly, we launched our most ambitious project yet: Scenarioville, an alternate reality allowing us to present frequent everyday patient scenarios in a consistent environment. Although we’re still tinkering with the format, after the first 16 scenarios I’m very happy with how it’s working out, and I think it allows for learning in a unique way. The only downside is that it’s also a time sink — by making a commitment to post a new scenario every week, with chapters added Monday-Wednesday-Friday, I’ve had less time for producing new front-page posts with real meat behind them.

What’s next? It remains to be seen how the site will continue to unfold, particularly as my spare time becomes increasingly thin. But I’ll keep punching out as much good stuff as I can — and there’s a new project unveiling soon that’ll bring things in a whole different direction. I think you’ll like it.

The good folks I acknowledged last year still deserve a nod. And I want to extend my thanks to everybody in the audience who’s been reading, commenting, and sharing across social media; this content wouldn’t have reached nearly as many eyes otherwise, and perhaps I wouldn’t still be creating it.

I also want to give a wave and a tip of the hat to a smaller gang of friends. There’s a circle of some very smart and passionate folks who I’m proud to know, namely Christopher WatfordVince DiGiulio, David Baumrind, Tom Bouthillet, and others. Through collegial discussion, sharing circulating noteworthy cases, bouncing ideas hither and yon, and overall collaboration in the best spirit of EMS 2.0 and the internet age, they’ve had a tremendous influence upon my way of thinking, my bank of knowledge, and my belief in the education of prehospital providers. Keep an eye on them, because people with this much dedication and brainpower can’t help but change the world.

I hope everybody has learned something from these pages and enjoyed the process a little bit too. And I hope to see everyone again, and new faces too, as we move forward into another year.

Stay safe and sane, and check back soon.

Super Soakers: Building a BLS Irrigation Device