“Train like you fight. Fight like you train.”


I have no idea who said this or when, but I think it is one of the smartest things ever said. I have had the honor and good fortune of being a paramedic in one of, if not the best EDs in the world. What makes it so? High quality equipment? Nope, we didn’t have that.  The best training possible? Sort of. Diversity? Yes. Teamwork? Yes. High volume of both high acuity and low acuity patients? For sure! But what really made it great were the people. Many of us are no longer there, a few still are. Most of us still keep in touch.  You see, all of these people were highly experienced at their job, genuinely cared about patients, even if they did sometimes bother us, but most importantly were passionate and wanted to be the best.  On more occasions in 4 years than I could possibly recall, we proved that a team is greater than the sum of its parts.

That could not be in greater contrast to where I work now. There is no team. Diversity is frowned upon or outright hated. 70% of providers I encounter are only concerned with money. Another 29% I have met are only concerned with doing the minimum they have to not to get fired. (Which believe me, is minimal).What’s worse is I only encounter the 1% on an irregular basis. It is not to say these people are bad at their jobs, they are actually very skilled. But there is a difference between doing a job and being great at it.

Some of it can be traced to the system, which is a copy of the German “Herr Dr. Professor,” system where the professor is God, and everyone else is basically nothing serving at God’s leisure. There is no independent thought, no reward for excellence, no pride from owning your job. Another problem is this is a former Soviet bloc country and many of the senior people grew up in communism. Unfortunately, they also have not grown from communism yet. Between the two, many hold as a value not standing out. Even more simply wait to be told what to do by the people who will never deviate from what they have done for 100 or so years.

So how did I end up here? Well, it’s actually pretty complicated, but I chose it on purpose. I am trying to do my best with it, but some days are harder than others. I often say any day I do not join the French Foreign Legion it is a successful day. I have even had days when I called one of their recruiters.

Today while at work in the ED, a real emergency patient was brought in. Apparently she was in the hospital for a specialty consult and she collapsed. She was rushed over and the biggest cluster fuck of resuscitation I ever witnessed ensued. There was nobody in charge, clearly nobody had any clue what to do, and I was told to stay out of the way because how could “the new guy” have any concept of what to do in a “real emergency.” When my shift ended for the day some hours later, the lady was still in the ED hooked up to a nonrebreather. Had not yet had a CT scan. No ultrasound. No blood gas. No Xray, and No Foley, the ED cannot do a urine toxicology screen, the hospital cannot do a toxicology screen at all I am told,   Was given some IV NSAID for pain, was semiconscious, had a neurology consult which was inconclusive, and a intensive care consult that said “reconsult after you get some information.” Despite arriving unconscious/unresponsive, providers of all types stood around staring at the lady in what resuscitation experts refer to as “the circle of death” diagnosing and treating her with “the stare of life.” It took a full 3 minutes before anyone decided it might be helpful to get a BP or hook her up to a monitor. It took another 5 minutes before anyone decided an IV might help. That’s when somebody had the idea to put her on the NRB. As she regained consciousness on her own, providers started disappearing until nobody was left except for the patient laying on her side semiconscious, the monitor beeping away, BP cuff still not attached, much less cycling, and me, wondering what if anything I could do for her without breaking the chain of command mandate of “stay out of the way.”

I sat for hours today comparing this nonsense to my time at Metro. Where this lady would have been taken to a resuscitation bay where, usually at least 1 paramedic, 1 emergency nurse, 1 or more emergency doctors, would control the airway by the fastest possible means, cut the patent’s cloths to ribbons, perform a full head to toe, front, and back physical exam, start 2 IVs, have a full set of vitals, a bedside ultrasound, 12 lead EKG on at least the left, maybe the right too, blood gases, a portable chest xray, stat laboratory results from every blood test that could be run, a foley catheter and urine toxicology screen, and be on their way for a Como-Gram (local term for a full body CT scan to include Head, Chest, Abd, and Pelvis, with contrast, reconstruction of the spine, and upon suspicion “supersized” to include the face and soft tissue of the neck.) In most cases the team was so proficient, communication was often silent except for the occasional warning of “X-ray” and the total time for all of this to happen, including the CT scan, was less than an hour. All except the CT scan in less than 15 minutes.

When I went to work in Afghanistan, as the “emergency” doc, I was paired with a Romanian EMS nurse. (Nurse who works on an ambulance in the same role as a medic) She was also a former scrub nurse. Despite being from different countries and speaking different languages, we worked together as seamlessly as the experts at Metro, usually performing every possible intervention, from controlling airway, cutting cloths, running the blood tests ourselves, and even the Xray which we shot ourselves, in under about 15 minutes average. We were a team and we were expert and passionate about being the best.

All of these expert tem members, from the US to Afghanistan, trained to be the best. Constantly. Many, including myself spend our off hours, teaching, and seeking out opportunities to be even better. We train like we fight, and we fight like we train.

I was told today that at the end of the month I must attend mandatory resuscitation training for 2 days. Honestly I have no idea who is teaching these classes or what their experience and capabilities are. My only hope is that they are at least passionate about what they are teaching and that they actually fight like they train.

I considered just contacting them, showing them my CV and credentials and asking for the professional courtesy of being “signed off” so I can go about my business of pursuing my passion at the level I am used to. But ultimately, I decided against this. I decided to put in the time because I will be in a class with my colleagues, who have never been a part of this before. I hope to encourage them to be passionate or at least train like they will fight. Because their day to fight is coming and I really don’t want them to replicate what I witnessed today.

It is easy to sit here and criticize and compare, quite another to step up and demonstrate and educate. At the very least, I hope they will at least see what resuscitation could look like. We shall see. I will probably just be vilified for showing off.    


4 thoughts on ““Train like you fight. Fight like you train.”

  1. Joe Davola

    Sounds like the EDs in Eastern Europe are a lot like the EDs in the US prior to EM becoming a specialty. Interesting.

    • Like most things here, it depends on where you wind up. One of my observations in the difference between the US and Central European medical systems is in the US most providers are average, with very few being outside the mean in either direction. The Bell curve looks just the opposite here, with most providers being either extremely great or barely competent. But this is a case where nobody in the ED wants to be there. It is very different in places where they are passionate about it. In fact, after spending time in one of the EDs that was very dedicated here, I was under the impression that EM doesn’t need to be a specialty at all.

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