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Takin it to the streets

28 May

I’ll begin by apologizing for it being so long between posts, you have certainly been neglected, but not forgotten. As it often does, life in general has gotten to be more than a little crazy the last few months. There have been more occasions than I can count that I have said “I need to blog about this” however the time to do that has been elusive. Let me catch you up a bit.

I was laid off from my part time EMS job about 2 months ago, the company I was working for lost a provider contract and they made massive cuts to the number of EMTs they employed. While for a minute or two I was upset about it, I never had any intentions of staying there after school, simply put, it wasn’t an organization that I felt was going to foster my development as a paramedic. The very same day I found out I was laid off, I got a phone call from the Clinical Coordinator of my Paramedic School – it seems the Chief of the school had been impressed with my work ethic and my initiative and was wondering if I would be interested in helping with administrative duties around the office.

It was a soft landing for me and gave me the opportunity to have some input into Paramedic School, and hopefully make the experience a little more enriching for my classmates. It caused a few ripples in class initially, but once my classmates figured out I really was trying to make class better for us all they smoothed out. The job is as many hours as I want to work, and the pay is better then what I was making working a bus, how could I turn that down?

One of the side effects of taking on such a responsibility has been a serious decrease in the amount of “free time” I have. Towards the end of didactic I was often having to choose between a couple hours of sleep and a couple hours of study time. I usually choose study time, my body however, would choose sleep and I’d awake a few hours later with a drool covered textbook page stuck to my check.

As class wound down there was a general feeling of fatigue setting in among my classmates – 9 months of classroom at least 12 often 20 hours a week and we were it would be fair to say “over it.” The final was on May 9th and for the first time in the history of my program EVERYONE who started the class finished the didactic phase.

As we all enter our Field Internship I’ve heard more than one of my classmates say – holy hell can we go back to class?

I’ve completed 50 hours into the internship post class (which puts me at 150 total) and while I have seen tremendous strides from hour 101 it is clear to me how VERY far I have to go, as well as how little I actually know.

In my first shift I was assigned a “homework” assignment – a paper written on the Pathogenesis of Hypertension in Diabetics – fascinating stuff and so extremely complex that I could spend the next three weeks reading about it with a medical dictionary sitting beside to look up the words I don’t understand in the articles and still not even scratch the surface.

Shift two gave me the opportunity to find the drug we carry on the box that has an off label use to relieve esophageal spasms – thinking through my limited understanding of pharm I came up with Nitro (wrong) Mag (wrong again) and Benadryl (due it’s anti cholinergic properties – wrong again) I finally ended up with the answer – Glucagon… but it took me many hours of searching to find it – due to the fact that no one understands exactly how Glucagon works in that way.

Shift three we ran a multiple stabbing – a tourniquet a few IV’s and lots of diesel and we got him to the hospital.

Shift four was with a new medic – she wouldn’t let me do very much, and I was rather disappointed to not be allowed to be more hands on. It was after that shift that I recognized how difficult it must be for a medic to have a paramedic student, how confident they have to be ability to let their student screw up just shy of the point of doing harm to the patient and then stepping in at the last minute to intervene before it was too late.

Shift five a chest pain call was the highlight of the night and for the first time in 150 hours in a busy system – I ran a call that I didn’t totally screw the pooch on – not that there wasn’t room for improvement – I’m a firm believer that there is always room for improvement – but after the call the conversation went something like this…

I walked out to the ambulance bay and awaited my preceptors feedback – which is often a “painful and eye opening” experience for me – and instead of the way he usually starts the feedback with “how did that call go?” he walks over and says “Where the hell has THAT paramedic student been all this time? Bring him back and run all your call like that”

It was a small victory for me – but it was the first time I ran a call and didn’t wonder “what the hell did I get myself into” It was the first time on the street I felt like wait maybe I CAN do this.

There are 40 more hours of rides this week – I’ll try to do a better job keeping you posted.

 

I just thought I was busy before…

08 Apr

I’ll start by apologizing for it being so long since my last post… It’s incredible how fast the time flies by.

At the beginning of school the information came quickly, but was manageable – I had figured out ways to effectively manage my time between studying, work and wee ones – For a week or two at a time it seemed like drinking from a firehose (as I posted about a few months ago), but after that particular module things would settle back into that intense but manageable level I had grown accustomed to. I had found effective strategies to study and retain the info – I lulled myself into believing “ah this isn’t so bad” and for a few weeks I didn’t understand why I had heard so many stories about how hard paramedic school was.

Then we finished Cardiology and all bets were off.

In the two months since cardiology we have covered our medical/trauma and pediatrics modules as well PHTLS, PALS, and EPC. Reading assignments of 100 pages a day in one text-book and another 70 in a supplemental book became the norm on a different topic or body system each day. If the early stages of class were like drinking from a firehose… the last few months have been like drinking from “Old Faithful” or maybe Niagara Falls.

In addition to all the class work there have been 250 hours of clinicals to do.

It took everything I could do to keep myself afloat in class for the last few months. My grades dropped from A to B and after a few of the exams I wasn’t sure that passing was a certainty.

Now I understand what all the “fuss” was about.Understand that the above isn’t meant to gripe or complain about school – I merely offer it as an explanation for my extended absence. All of you that sport the disco patch have been through the same or similar experiences – my situation is not unique by any means.

There is a month of didactic left – operations – it should be some of the “easier” material we have covered in class.

There is a small mountain of other things I would like to share – a layoff – a new job opportunity – moving into teaching classes next semester – the impending field internship – but there isn’t time for all of it today. Let’s say I have a lot of things to share with you all – now I just need to find the time to peck it all out.

Hopefully, I will do a better job of finding time to log in here and peck on the keys for a bit over the coming weeks to keep you posted.

 

 

 

Little Latin Generals (Cardiology and Politics)

17 Feb

I suppose most paramedic students experience some sort of frustration when they are going through Cardiology and trying to integrate what they are learning to recognize on the strip into the ACLS algorhythm and at the same time figure out how to implement their newly found knowledge into ever increasing treatments and interventions they have only read about thus far.

I struggled a little with the concept of recognizing when a dysrhythmia is a good thing that needs to be coddled and supported and when it needs to be escorted from the building in an expeditious fashion so to speak.

The concept became clear for me with a political metaphor of all things.

Before we get the political unrest – Let’s look at a much simplified explanation of how the “government” of the heart is supposed to work…

In normal conduction the electrical activity of the heart is “governed” by the intrinsic rate of the Sinoatrial node (SA) – due to differences in the slope of diastolic depolarization the specialized myocytes of the SA node reach their action potential stage faster then the other specialized conduction cells. Each of these specialized cells has an intrinsic rate that is governed by a leak of ions through the cell membrane leading them towards to their action potential, and they all want to be the “guy in charge” but the “influence” of the SA node is so powerful that they never get the chance to act out due to the SA nodes impulse reaching them before they can act out on their own.

When things start to go awry and the protestors march or occupy or whatever type of political unrest makes it easier for you to comprehend things can change a little.

Let’s start with default rhythms and how I think about them – If the SA node is “in charge” of this political process let’s call it the president – the president of the heart belongs to the sinus party and when he is running the show – we see a sinus rhythm on the strip.

What happens when the “president” for whatever reason can’t do its job – Much like the democratic process we have here in the USA the heart has a backup plan in place – a “Vice President” if you will – the AV node the AV node tends to look like he belongs to the sinus party as well, but subtle difference tell us he really belongs to the junctional party – which shows up as a junctional rhythm on the 12 lead. It runs a little slower then the president does, but can be quite effective at running things.

So what if the President and the Vice president are incapacitated – in our form of Government the Speaker of House would be next in line – in the heart it would be the ventricles – The ventricles belong to a totally different party then either the president or the vice president and they don’t try to hide it either – they appear as a ventricular rhythm on the 12 lead looking very different (in most cases) then either the sinus or junction. The ventricles are slower still and (for default purposes we’ll say they) run things marginally usually just enough to get by.

The heart and our Government are set up to allow lower level sites to take over or pick up the slack for a failed or ineffective “leader” when this happens it’s a default rhythm and we should do everything we can to nurture and support it – drastic interventions into this type of rhythm can lead to “anarchy” completely knocking out the system of government and leading to chaos.

On the other hand – we have usurping rhythms…

These rhythms are the “little Latin generals” staging a coup. For whatever reason an ectopic site (little Latin general) goes off the reservation and decides it can do better job running things and tries to take over. If the “little general” manages to fire faster then “el presidente” he can totally usurp the normal leader’s authority and due to those same conduction fibers make the higher ups bend to his will. Little Latin Generals usually work really fast as evidenced by their tachycardic rate.

Generally speaking the heart (and the Government) is in total chaos at this point and maybe minimal stuff gets done – but all of the Government is in total disarray and the “citizens” (tissues in need of perfusion”) suffer –

These are the instances when as a medic we need to call in “the Marines” and provide some sort of intervention to restore order and the normal balance – whether that means a surgical strike with a specific medication to try and interrupt the ectopic sites overactive ambition or a carpet bombing with the defibrillator where we force em to “ride the lightening” and hopefully reset the normal balance depends on both the rhythm strip and the patients general presentation.

The metaphor and concept seems to work for me and makes it easy to remember – Does it make sense to you? What kind of ways do you use to understand complex processes and how they relate to your treatment plan?

 

Rites of Passage

15 Feb

Ask any prospective paramedic student what they worry about trying to learn and you will likely get an answer that contains at least one of these words: Cardiology or Pharmacology. For some students – myself included the answer contained them both. Adding to my level of anxiety is the fact that the program I am attending is all but legendary locally for its program – and more legendary then the program is the exam – 200 questions – 100 multiple choice and 100 short answer questions relating to 14 different rhythm strips, with roughly a four hour time limit – Highest score ever on the test was a 98.

Interesting to me was the number of practicing medics sitting in the back of the room to “refresh” their knowledge base. The program allows it’s employees to sit in on Paramedic School lectures for CE’s – typical classes have one or two medics back there – Pharmacology had 5 or 6 – Cardiology had 15 – 20 easily EVERY NIGHT for the entire section.

We were told to purchase calipers – as there was no way we could pass the exam without them… Granted most medics don’t even carry them let alone use them in the field – but they wanted to be sure we knew how to break a strip – even the most complicated strip down.

The exam lived up to its reputation – it was EASILY the most difficult test I have ever taken – memorization wouldn’t have helped – the exam required a genuine understanding – after we took the test they told us that as far as they were concerned anyone who got a 70 on that exam was an expert in the field of pre-hospital ECG interpretation – I got a 92 – but I certainly don’t FEEL like an expert…

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If only it was this easy

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Cardiology started with the warning that the instructors goal for us was if someone ever asked us where we learned cardiology we didn’t embarrass them when we gave their names. Both of the instructors are captains at the division I want to work at and one of them is instrumental in the hiring process – cause you know the standard student anxiety over cardiology wasn’t enough for me – I had to ramp it up a little.

I have heard many times so far during school we don’t use a certain book for this because a good one doesn’t exist to teach you what we want you to learn (More experienced providers that write – take notice) Cardiology was an exception – they did have a book for that – but it’s interesting the one they choose.

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Practical Guide to ECG Interpretation By: Ken Grauer MD FAAFP

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Available from Amazon here if you are interested.

What makes Dr. Grauer’s book so interesting is that it is out of print – The program actually contacted Dr Grauer (he includes his contact information in the book in case you want to contact him about the book or cardiology in general – wow) to ask his permission to copy the book for their students – all 500 pages of it.

The process they taught us for breaking down a strip was methodical but lengthy – in fact it takes me 10 to 15 minutes to go through each step and wrote the findings out -

  • Rate
  • Rhythm
    • P- Are p waves present in lead II
    • Q – is the QRS wide or narrow – (if wide examine for BBB)
    • R- Regular or irregular
    • S – Single or married – are the wave complexes married to each other or separate
  • Intervals
    • PRI
    • QRS
    • QT
  • Axis (fasicular blocks?)
  • Hypertrophy
    • Right or Left atrial abnormality
    • Left Ventricular Hypertrophy
    • Pulmonary Disease pattern
  • Infarction – any signs of infarction, strain or ischemia?
    • Q – are Q waves present in any lead? are they pathological? are they expected in that lead?
    • R – Is the R wave progression normal? where is the zone of transition?
    • S – ST segment changes – Elevation, depression, strain pattern?  Are the changes related to a vessel or global? What area of the heart is affected?
    • T – Are there T wave changes? what do they indicate?

The answers to all of these questions only give you HALF of the information you need to interpret the strip – This just gives you the descriptive analysis of the strip – you have to take the patients presentation and past medical history into account or the “clinical impression” as the book calls it.

Dr. Grauer also says that to get the most accurate information possible from a strip you should try to have a prior strip available for comparison – and our instructors took that one step further – if you can actually get a prior strip (unlikely in our setting – but stranger things have happened) was it the patients strip on admission or on discharge ?

My head has been spinning with all the information contained in this module – Brugada’s Syndrome, Ashman’s Phenomenon, WPW (Type A & B),  Default Vs. Usurping rhythms, differentiating between V-Tach and SVT with aberrant conduction, Fib-Flutter, the potential causes of a tall R wave in V1, the causes of QT prolongation…To the point where I have to run through the steps I listed above mentally or I end up staring at the strip with a blank look on my face.

The most reassuring message came after the exam – you don’t have to be an expert at this stuff now – nor do you have to be an expert during your rides… or even during your Field Internship when you get a job as a Medic… You DO have to be an expert when you are cleared to independent duty and are making the interpretation “solo” – That’s a relief I have probably another year of practice then.

Our instructors recommended several books and a few blogs to take our studies further – I’ll share them here in case some of you may be interested

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Practical Electrocardiogr aphy by Henry J. L. Marriott (Hardcover) - Called the bible of ECG by our instructors

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Pathophysiology of Heart Disease 4th (Fourth) Edition by Lilly (Paperback)

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Pure Practice For 12-Lead ECGs: A Practice Workbook by Robin Purdie RN MS (Paperback)

 

The blogs they recommend – Dr. Grauer’s Blog , www.ecgpedia.org , www.ems12lead.com , Dr. Smith’s ECG Blog

Be good – get good – or give up

 

Assessment tools…

19 Jan

I’ve been trying to figure out how to explain this concept for the better part of a week now, and I’m still not sure I will do a great job without some sort of visual reference – but I’ll give it a go.

One of the things my preceptors have been stressing during my rides is maintaining a high index of suspicion on all calls so you don’t miss an important finding. Maintaining that level of suspicion is often difficult for me, as I said in an earlier post, I am pretty comfortable with the “sick/not sick” decision – by no means is it  flawless and by no means 100% accurate – I don’t pretend to know everything… in fact the further I proceed into school the more I realize how little I actually do know.

I had forgotten how as a student you need to verbalize things positive and negative, suspected and not in order to allow your preceptors inside your thought process. I often forget to verbalize things I don’t suspect even though they can’t be ruled out.

Two of the most classic differentials that can’t be ruled out on the ambulance and have such varied presentations they are on almost every list of complaints – MI and PE.

After failing to verbalize them for complaints where I didn’t suspect them, the preceptor explained a concept to me I thought I would pass along – its called Webbing. Named for the medic that came up with it (by him of course), but also something the finished product vaguely represents.

Mastery of this process takes considerable time, especially when you first try one, as you are looking all kinds of stuff up in the textbooks – but after doing a few you can do them in your head.

To start your “web” take a fresh sheet of paper and in the center of it write down a chief complaint – lets say Shortness of  Breath. Now think about some of the differential diagnosis you might arrive at that cause SOB and list those in a circle around the CC.  It was suggested that we try to find at least 6 – of course you could add as many differentials around that initial CC as you want. In listing those 6 differentials it is important to think of what differentials would be the most life altering for the patient, especially if they were unrecognized.

Here’s where the thinking and reference materials come in – once you have those 6 differentials listed – draw three lines off of each one – the first line is for symptoms – what do you expect your patient to complain of, how do you expect them to answer relevant questions, what kind of history or medications do you expect. If possible try to include things that can help you narrow down your list – for instance the onset of a PE and the onset of pneumonia are typically very different – the answer to your interview questions may help you narrow down your list.

The second line is for signs – what do you expect to find in a typical presentation of that differential – what type of vitals, what are your “machines that go bing” going to say – what type of physical findings are you expecting

The third line is for treatment – how do you need to treat the patient for that differential in order to improve their outcome the most.

Now that you have your foundation laid… you start using the lists to “rule things out” or perhaps the “better, more accurate” way to say that is – make things fall into the less likely to be the problem with my patient though I can’t rule it out category.

As you conduct your physical exam and interview you can mentally cross things off the list to help you find the likelihood of your differential being on the right track

Sudden onset vs gradual, clear lung sounds vs Rhonchi, tenderness and redness in a calf vs none – these things all help you narrow down what you think is wrong and base your treatment decisions on.

You will ultimately be left with a few causes you can’t say are ruled out and maybe one you are fairly sure of – here is where that treatment list comes in – for SOB – MI and PE are two of things you can’t “rule out”

IF those are the problem – how will your intended treatment affect those?

Wheezes… are they cardiac in nature or pulmonary – does it matter ?

Will Albuterol and Atrovent exacerbate the problem or make it better ?

It is a complex process and definitely NOT something you could do on an actual call – but perhaps those times when you are posted under the shade tree “borrowing” WIFI from the hotel across the parking lot…. you might try to work through some of these exercises and see if they help you focus your exams and maintain your level of suspicion – you never know, you might find with practice you can do it mentally and quickly and use the process on those calls when you just aren’t sure what the problem with your patient is.

I hope someone finds it helpful – it seems to be working for me so far.

 

Machines that go bing

16 Jan

During a recent class I had one of my “illusions of being a paramedic” shattered it was illuminating for me and bears repeating. I’ve heard many of my partners say treat the patient not the (insert machine that goes bing here). I guess while I heard it I never really understood what they meant, until class the other night when one of our instructors said “you should never use a machine that goes bing without knowing what that machine is going to tell you.”

WHAT ?!? Wait just a minute – you mean I get to finally use all these shiny gizmos in the back of the ambulance and more than that, understand what they are telling me and I don’t really need them ? Talk about a bubble bursting…

The more I thought about what he said, the more sense it made. I have next to no experience at all deciding which tools to use when and even when I do get to make the decision now, its with a preceptor “holding my hand” to make sure I’m on the right track. What little practice I do have I’ve ALWAYS been asked to justify why I wanted to use the monitor, or the glucometer or the capnography – What did you find in your assessment that leads you to believe that it’s necessary to use that particular piece of equipment. If I could answer that question to their satisfaction (which occasionally I could not) the next question was what do you expect to see when you use it.

The first few times I was asked that question I was scratching my head thinking well isn’t that why I’m using the machine in the first place to find out what it says?

Over the years I’ve developed a pretty good sense of “sick, not yet sick, not sick” based on my assessment – it isn’t 100% for me or likely for anyone else within those first few moments – and I base my treatment decisions on those findings – however protocol says all patients complaining of chest pain get a 12 lead – whether I think they are really sick from a cardiac cause or a trapped gas bubble – so I tried that for an answer

I want to put the patient on the monitor because they have chest pain – ok go ahead – what do you expect the 12 lead to look like? uhhhhhhhhhhhhh I don’t really know but the protocol book says we have to do one for all chest pain patients – take a seat = I’ll run the rest of this call and we’ll talk about it later

Damn it – how am I supposed to know what the monitor is going to show before I even have the electrodes in place? I was frustrated and I’ll admit for a few minutes I thought it was haze the paramedic student stuff.

After the patient was dropped off at the ED my preceptor came out and explained it to me – I spent the next several hours kicking myself in the keister for not putting the pieces together. It wasn’t paramedic student hazing, it wasn’t pushing the student to figure stuff out – it was basic and something I should have already realized.

His logic was a simple as it was eloquent – The conversation went something like this:

Preceptor: When you checked the patient’s pulse – tell me what you learned

Me: They had a pulse, it was strong,  and regular their skin was warm and dry and based on the fact that he had a radial pulse his pressure was likely above 90

Excellent – now tell me what if his pulse had been irregular

I would have suspected he had a cardiac issue – most likely a-fib

Good – what about a thready pulse?

Again I would have suspected a cardiac issue – although lots of things could cause a weak thready pulse, but based on his complaint I would have thought cardiac

Good – now what if the patient’s skin had been pale, cool and diaphoretic?

With his c/o being chest pain – I would have suspected MI

You got all that info from a pulse?

Yes – that and his complaint

So – since this patient had chest pain with a strong regular pulse and pink warm dry skin was it likely he was having a cardiac issue?

We can’t really say based on just that information – we can’t even rule out an MI after a 12 lead that takes hospital tests

True – but based on his presentation and the rest of your assessment did you suspect he was having a life threatening cardiac issue ?

Honestly, no

I didn’t either – so based on that information – what did you expect to see on the monitor?

and then it clicked for me…

I didn’t expect to see any significant changes on his 12 lead in all honesty

Then that’s the answer to what do you expect to see, just like with the irregular pulse you would have expected to see an irregular rhythm or non perfusing beats, or possibly an ineffective rhythm with the thready pulse or significant ST segment changes if he had been pale cool and diaphoretic… are you following me?

Yes was my answer (although it was directed at the top of my boots) – I felt stupid that I didn’t piece all that together.

When you were an EMT everything was black and white – now that you are training to be a paramedic you have to remember everything is in varying shades of grey. Yes we have more tools to use, but your assessment as a medic is no different than your assessment was as a basic – you will still form your clinical opinion based on the patient’s presentation not what the machines say. If your patient says they have sharp 10 out of 10 substernal chest pain that is non reproducible, radiates to the left shoulder and jaw, is nauseous, vomiting , pale, cool and diaphoretic and they tell you they think they are dying and the 12 lead shows a normal sinus rhythm at 88 does that mean they aren’t having an MI? Of course not. If you have an asymptomatic young adult cyclist with a heart rate of 50 are you going to treat him for bradycardia just because the monitor says so?

No his clinical presentation would tell me that’s likely normal for him.

Treat the patient not the machines, always know why you are using the machine and have an idea based on your assessment what that machine is going to say before you look at it, and remember what those readings on the machines do and don’t mean. They are, in a nutshell, extra information that helps you reach a conclusion but they are not in almost every single case what you are going to base your treatment on.

It was so simple I feel silly for not realizing it ahead of time. Yet another valuable lesson learned on the path to the disco path.

 

Any Surprise? Do you agree?

12 Jan

Recently, CareerCast published a list of the 10 worst jobs in America in 2011 and low and behold coming in at number 6 – EMT.

“On the other hand, jobs like EMT have considerably better hiring prospects, but rank among the 10 worst jobs of 2011 due to harsh working conditions, high stress and inexcusably low pay given the extremely important nature of the work.” Source

Reading through the list it seems the factors they weighed into their rankings were : Work environment, Stress, Physical demands and hiring outlook it also seems they weighed in average pay across the nation. According to this site – the 5 jobs worse then EMT : Roustabout, Iron Worker, Lumberjack, Roofer, Taxi Driver in order from 1 to 5.

I have worked a few of those jobs throughout the years, and I have known people that have worked the ones I haven’t. I agree they are all worse jobs then being an EMT, but not for the reasons the site says.

For those of you that do not know my history, I walked away from owning a successful residential remodeling company to return to EMS, taking a SUBSTANTIAL pay cut in the process. Since making that decision I haven’t looked back even a single time.

The ranking may be helpful for someone considering entering this profession, possibly alerting them to what they are getting into. I’ve seen the wide eyed wonder drain out of many noob’s eyes when they realize this job isn’t what most people think it is. For those people, I can see where a list such as this may be helpful. However, for those who have been around for more than a couple years, it’s no surprise that an outsider would rank our chosen profession so low.

The list does take into consideration the low pay, the “disrespect”, the strenuous conditions and the stress – I do not dispute any of those things – they are all a part of the job. There are a number of other factors that I can see being viewed negatively by folks both inside and outside the profession – what I don’t see factored into the ranking are the rewards.

Speaking only for myself – I didn’t come back to EMS for the money or for the “hero” image – I had done this long enough before leaving the field that both of those bubbles had been burst for me. I didn’t come back for the adrenaline rush, or the driving fast or any of the other things a lot of folks enter the field for – I came back for the intangible rewards of the job.

Not many people get the opportunity to know they make a difference is someones life – I’m not talking about the naive notion that – we save lives for a living… sure on the rare occasion it does happen – but that isn’t what we do everyday. When it does happen its more timing and luck then anything we do. What we do do (if we are any good at this job) is make what is potentially the worst day of a person’s life better.

Riding to the hospital with 95 yo nana while gently holding her hand and maybe even coaxing a smile from her – knowing that she will remember my face long after she has faded into my memory… knowing my presence alone made what was an incredibly difficult experience for her better in whatever small way – that’s a reward most people don’t get.

I’ve described this job many times as the highest highs and the lowest lows and sometimes the two are separated by one call… an emotional roller coaster some days.

When it’s all said and done and I take off my boots for the last time years from now (I hope) I will “retire” from the streets knowing without a doubt that I made a difference – a real difference in making people’s lives better. For me that makes being an EMT the best job in the world and makes every other job out there ahead of it on the worst jobs list.

What about you? Are you surprised by the rating? Do you agree with it?

 

 
3 Comments

Posted in EMS, EMT, Personal

 

Curse of the Krokodil

09 Jan

* Warning – imbedded videos are extremely graphic*

After writing this post, I seriously debated publishing it or scrapping it, it wasn’t until I was reminded that there are some very large communities of Russian immigrants out there, and those of us the serve those areas may have some type of exposure to the effects of this drug, that I decided to go ahead and  hit publish.

A couple weeks ago as an after thought one of our instructors told us about a new drug sweeping through Russia called Krokodil.

I had never even heard of the drug before our instructor mentioned it, but it has received a lot of press. In fact, back in June, Time did a story about it – “The Curse of the Crocodile: Russia’s Deadly Designer Drug  (http://www.time.com/time/world/article/0,8599,2078355,00.html#ixzz1i39LyQmu)

It was mentioned by our instructor that the emergence of the drug is at least in part due to the US military’s involvement in Afghanistan cutting off the supply of the poppy used to make heroin – I suppose at least in part that could very well be at least part the cause, I suspect though it has more to do with the fact that it is about 3 times cheaper than heroin and very easy to make from ingredients that are available over the counter.

The main ingredient of this literally flesh eating drug is Codeine which is sold over the counter in Russia.

“The active component is codeine, a widely sold over-the-counter painkiller that is not toxic on its own. But to produce krokodil, whose medical name is desomorphine, addicts mix it with ingredients including gasoline, paint thinner, hydrochloric acid, iodine and red phosphorous, which they scrape from the striking pads on matchboxes. In 2010, between a few hundred thousand and a million people, according to various official estimates, were injecting the resulting substance into their veins in Russia, so far the only country in the world to see the drug grow into an epidemic.” Link

In much the same way as dealers in the US took an over the counter medication (pseudoephedrine) and turned it into methamphetamine, dealers in Russia are using an Codeine which is sold as an over the counter medication in Russia. The Russian government is now making Codeine available by prescription only, which in theory should help curb the steady rise of abuse.

The addicts typically experience their skin turning scaly and green before it literally falls off – in some cases as seen in the videos below – rotting every bit of flesh all the way down to the bone.

WARNING : THESE ARE EXTREMELY GRAPHIC VIDEOS!

Take a look at the following videos from youtube – I apologize for not having the narration translated – but the videos speak for themselves

With Codeine being a prescription only medication here in the US it is unlikely that scenes like these will be seen on the streets here, but we should all be aware that these types of substances are out there.
 

Defining Moments

05 Jan

In talking to some of my fellow students and a couple of the instructors, it seems that the students who do the best in Paramedic school all share one common trait – they had a single moment when they knew it was time for paramedic school.

Dictionary.com defines epiphany as “a sudden, intuitive perception of or insight into the reality or essential meaning of something, usually initiated by some simple, homely, or commonplace occurrence or experience.”

It’s term I’ve heard used far too often, and usually in the wrong context, but in this case I think it is rather fitting. Some of the “moments” I’ve heard are major events, running an extremely critical without ALS assistance, MCI’s etc, but for most it was a seemingly benign event that turned the light bulb on for them.

For one of my instructors – the moment came when he no longer broke into a profuse sweat when the “tones dropped”. He tells of having to wear sweat bands on his wrists to keep his hands any semblance of dry, and of sweat running down his face to the point it often obscured his vision. One day he just realized that it wasn’t happening anymore and he knew he was ready. It’s kind of humorous when he tells the story, but for him that was a defining moment in his career.

For me it was a little more subtle, but no less of a moment of clarity. I ask you to try to remember those first couple of calls you were sent to as a brand spanking new EMT, and see if any of you can relate.

For the first little while every call I got was “life and death”, the radio would crackle I would hear my unit number and every pore in my entire body would squeeze out a single drop of sweat… my pulse would quicken and the giant ferris wheel in my stomach would start revolving. For the first month or two my more experienced partners would have to put their hand on arm and say - just breathe man – we got this.

I remember thinking it was going to take me forever to get over that adrenaline dump when the radio told it was our turn at the plate. Slowly, man down unknown medical calls stopped becoming cardiac arrests in my mind, MVA’s stopped needing every victim to be cut out of the car and rushed to the trauma center… and I hit my stride.

Even on those truly rare occasions  now when we get an actual critical call – I’m a cucumber – cool collected and able to perform my job as expected without needing to change my undershirt because it’s soaked with nervous sweat.

A few months into my current job I was assigned a new partner – a brand new paramedic – ink not even dry on his cert yet. Watching him work his first few scenes was like looking into the “back in time’ mirror… I could see the nervous tension just below the surface on each and every scene, and was reminded what those first few calls were like for me too. He held his own and became not only a great partner but a great friend.

A few more months and I got another new partner – yet another brand new paramedic with ink still wet on his cert – the same things I said about my first new medic partner apply equally to my second…

Then one day we were sent to a local clinic – they had a patient in sustained V-tach that needed to be taken to the hospital – hearing the call over the radio – I flipped on the lights and the siren, and did my best maverick impersonation to navigate us to the facility….

Somewhere between the lights coming on and the rig coming to a stop in front of the clinic I noticed that all the color had drained out of my partners face. He fumbled with combination to the narcotics safe and we literally had electrode confetti throughout the back of the rig… And then it happened -

I reached out and grabbed his arm – and said – Man breathe – we got this….

At that single moment, it became clear to me I was ready. How that translates into I’m ready to challenge myself by taking my skills and knowledge to the next level, I can’t exactly say for sure, but it was like someone flipped a switch and all of a sudden I knew.

That’s my epiphany, defining moment, whatever you want to call it – How about you? What were some of the defining moments in your career? What was it that finally whispered “your ready” into your ear?

 

Speaking of Beginnings…

03 Jan

The stories of how people end up in EMS are always fascinating to me… So while everyone is talking about beginnings, I thought I would share my story…

A long time ago, in a galaxy far, far away – Wait that’s another story

I guess it was 1988, 89 something like that – I was living in Kalamazoo Mi and trying to find my way in the world – I received my discharge from the Marine Corps and really had no idea what I wanted to do with my life.

Shortly thereafter I started dating a girl – you knew the story would involve a girl didn’t you?

Anyway – Both of her parents were a part of the local volunteer Fire Dept. and her mom was a first responder on the ambulance as well as a firefighter. I still don’t know exactly what it was about the stories they shared that I found so fascinating, or what it was about becoming a volunteer I found so appealing, but I always sat and listened to the war stories with a sort of wide eyed wonder. Eventually her mom talked me into coming down and finding out what it was about… that was it I was hooked.

I joined at the first opportunity I could, although if memory serves me correctly I had to attend several meetings and then have someone nominate me for membership. After the nomination process and attending more meetings I was finally voted on and made a probie.

Great I’m a member – now how do I get lights and a siren in my car ?!? It’s funny looking back on it now, and funny how such a stupid question can change the course of your life – but hey I was a young guy and lights and sirens were cool to me back then (and they meant I could drive fast ;) ) The answer was simple – complete your probationary period, AND either firefighter 1 and 2 or EMT school. Hmmmm FF 1and 2 was offered free by the department but it was like one class a week and near as I could figure it would something along the lines of a millennium to finish (my sense of time was a little off back then too) or I could EMT school – 1 semester and a couple hundred bucks – well that was a no brainer.

I attended my initial EMT training at Kalamazoo Valley Community College and was certified as an EMT-Ambulance (yes that’s what the certificate said) I still remember the instructors name – Paul Dickens NREMT-P and my first clinical rides with Mall City Ambulance.

After graduation I got a job with Mall City on their non emergency transfer car and loved every minute of it…

Eventually, I moved back to NY and worked my way through several private companies before ending up with NYC EMS (which was NOT a fire based service back then).

Several years later I again moved this time to Texas for personal reasons… and it was the beginning of the end of my initial period in EMS.

The town where I lived had a volunteer fire based service and a private company that provided 911 service… Jobs with the private service were few and far between so I joined the local VFD and became a part of the “first response and rescue” service.

Provided purely for your laughing pleasure.... Judging from the "pornstache" you can probably guess the decade LOL

 

While I was there I finished my FF 1 and got trained in the use of the hurst tool, high angle, low angle and swift water rescue – I had an absolute blast – BUT (there’s always a but isn’t there?) the devotion to the volunteer squad and the training didn’t leave tome for a real job – and the VFD didn’t pay – so being unable to find an EMS job, I went back to my old standby of construction, which was what I did to buy beer lunch money in High School.

Eventually the time demands of the job and the family took what little time I had left from the VFD and I resigned because I couldn’t give them the commitment they deserved.

When renewal time rolled around, I saw no point in renewing my cert – I wasn’y using it anymore so what the hell let it lapse…

Fast forward 15 years and you will find me running my own construction company, successful but ABSOLUTELY HATING every minute of my days. I started to fall into a depression and while soul searching I realized how much I hated what I did… It was cross roads time – Can I take the HUGE pay cut and come back to EMS and not hate my job or do I suck it and keep bending nails?

After a long period of soul searching and lots of support from friends, family and loved ones – they convinced me it was more important to be happy.

I researched schools and moved here in the hopes of working for the service that runs my paramedic school program – I enrolled in EMT school (again… what was that comment about letting that certificate lapse… )and I haven’t looked back even once since making the decision.

Here I am now – 1/4 of the way through paramedic school (a second time for that as well) and on the cusp of making what has truly been the dream of my adult life into a reality – fortunately I’ll graduate before the Mayan calendar ends _ so even if the world does end in December – I’ll go out with a disco patch on my arm

What about you – share your story below – and tell us if you choose EMS or if it choose you…

 
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