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Rites of Passage

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

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

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

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

 

Posted by on February 15, 2012 in Cardiology, EMS, Paramedic School

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Assessment tools…

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.

 

Posted by on January 19, 2012 in EMS, EMT, Paramedic School

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Machines that go bing

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.

 

Posted by on January 16, 2012 in EMS, EMT, Paramedic School

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Any Surprise? Do you agree?

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?

 

 

Posted by on January 12, 2012 in EMS, EMT, Personal

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Defining Moments

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?

 

Posted by on January 5, 2012 in EMS, EMT, Paramedic School, Personal

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Speaking of Beginnings…

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…

 

Posted by on January 3, 2012 in EMS, EMT, Personal

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Defensive Training for EMS – Neccessary?

In a word – YES

I have written on many occasions how lucky I am to be attending the Paramedic Program I do.  As if I needed another reason to believe it was the right choice for me, from what I can tell it is one of only two paramedic schools in the entire country that offers defensive training for EMS providers as part of their paramedic students education.

I think this is an EXCELLENT idea and should be something more of us get. If not in our schools then certainly when we enter the workforce.

Before you get your 5-11s in a twist hear me out.

I am a former Marine, trained in hand to hand combat, defending myself was never really something I was worried about until I took this class. Was I schooled that I wasn’t as capable with my hands as I believed I was? No, in fact, I was schooled that the way I had been trained may very well severely injure someone unintentionally. Marine Corps hand to hand is all about aggressive tactics, how to hurt people enemies, not how to be truly defensive.

What’s the difference you might ask… ask Alan Miller a former Denver Paramedic who was sentenced to 12 years in prison  for assaulting a patient in the back of the ambulance. (http://firegeezer.com/2009/11/14/denver-paramedic-sentence-to-12-years-for-assaulting-patient/)

I’m not even going to comment on that case, or what happened there, I wasn’t in the ambulance so I don’t know what happened. I do know that whatever happened the injuries the patient received were severe enough that Miller is now doing a 12 year bid.

Having not had the DT4EMS class, that could have very well been me, or any of the 10 to 15 of my classmates who had some sort of “fight training” prior to our class.

Just today a study was released that found 2/3rd of the paramedics in the study have been assaulted on the job – read the report here 

Let’s face it folks pre hospital providers get assaulted – it happens – WAY more often then we care to admit. Regardless of what you are told by your senior partners, supervisors, forum trolls or even medics from back in the “rampart” days IT IS NOT PART OF THE JOB.

I know some of you are saying “don’t be a dick and you wont have to worry about it”

How do I know… I’ve had people tell me that. It is precisely that type of pervasive attitude that makes assaults on providers go unnoticed and under-reported. One of the main focuses of the class is customer service and how to use that aspect of the job to help diffuse a potentially violent situation.

If you are among those who think it doesn’t happen – PLEASE go to the DT4EMS site and take a look at the forums there (here’s a link) and read about the stories that don’t necessarily make the news.

 

Take a look at this video from the DT4EMS website:

 

Another thing I don’t want you to assume about this class – the purpose IS NOT to turn you into a ninja, an assassin or even Billy Bob bad ass paramedic – the purpose IS to get pre-hospital providers to know what to expect in certain situations and how to react should the “worst” occur.

For the basic level class we spent 16 hours between classroom and “the mats”  training to protect yourself in 4 areas

As defined by DT4EMS the four areas are:

  1. Preparing the mind – getting past the initial resistance to defending yourself
  2. Preparing for the street – training in real world techniques to increase your chances of survival
  3. Preparing for the media – How to defend yourself and still APPEAR to be the victim and non aggressive
  4. preparing for the courtroom – know the laws and how to represent yourself as a PROFESSIONAL

 

Yes, the bulk of the time is spent working on defensive tactics and how to be out of the way when an patient turns into an aggressor, but the class itself is so much beyond that.

Interview techniques, on scene responsibilities, survey stances, the assessment L, what a reactionary gap is and why you should try to maintain one, the six steps of DT4EMS self defense, moving in angles and circles, winning the R.A.C.E and R.A.C.E -2- R.E.A.C.T., the 6 D’s (types of potentially violent encounters), when a patient is no longer a patient, scene survey tips, global overviews, levels of response, physical fitness, the list goes on and on

It’s much much more than the perception that it’s a fight class.

Sadly, the pictures taken during the classes don’t show those parts because they don’t make for great action shots… but they are equally important aspects of the training.

Before I get to the pictures of our class – I URGE you to go take a look at the DT4EMS website and get a more in depth look into the program and what it’s founder Kip Teitsort had in mind when he developed the program.

The web site is here DT4EMS

Here are some of the pictures from our class – yes they all emphasize the physical techniques (because they make good pictures) but again the class is much much more than just this stuff.

 

Even without the F.I.S.T. suit, do you have any trouble figuring out which one of these two is the aggressor and which one is the "victim" - How much better does this look then the firefighter who was kicking a patient in the video?

 

After a double tap parry a simple shove is often all that is needed to create separation and allow you to escape.

 

Probably the smallest girl in class - with the instructor as the attacker - will the techniques taught work for her too?

After a double tap parry - a "distracting blow" is quite effective in taking down the attacker - any question whether she can now escape or not?

Using a double tap parry to deflect the attackers blow...

Following the double tap parry with a distracting blow to the ear - notice the open hands

The elbow control takedown drill...

Elbow control takedown step 2

Even experienced people can have trouble - I should not have ended up on top of him after the take down

Escaping from a choke hold - step 2 .The first step is to bury your "meathooks" between the attackers arm and your throat before dropping to your knee

The last step of escaping from a choke... bending forward and twisting your body to pull the attacker down

For the very last part of class we got to “go against” the instructors while they were wearing a F.I.S.T. suit, this part of the class was entirely optional, but it gave us the opportunity to put the skills we just learned in practice.

Here are some pics from my “encounter”

 

Assuming a defensive posture and anticipating the right hook that is about to come my way... A double tap parry followed by a shove will give me some space, but he still has about 50 seconds of the minute long attack to go.

The attacker retreating after a distracting knee to his thigh... that pissed him off and we ended up on the ground lol

It took him about 15 seconds to get through the basic ground defense in the suit, but after escaping the mount - I ended up in this position as the whistle blew ending my minute long session. This is perhaps the only picture that doesn't have a purely defensive feel to it.

I know there was a picture of the smart ass pose I took with my arms flexed sitting on his back… but mysteriously it wasn’t on the camera when I uploaded the pics… Damn, I wanted to put it on the graduation plaque for him 😉

At one point it was one of the instructors (Jeff) vs one of the bigger guys in class - he was a former deputy sheriff and is a big boy... the F.I.S.T. suit wasn't enough to save Jeff from stepping into a distracting blow that laid him out. I only include it to bust Jeff's chops - it is neither a focus of the class nor an intended outcome of a distracting blow... but Brad didn't have any trouble getting away from this attacker, and that after all is the goal.

My last and final point about this excellent class – while you may never ever need any of the physical techniques taught – chances are you wont have to actually do one of those surgical crics they taught you in paramedic school either, but if you do need it – it sure is nice to know isn’t it?

If this class only ever saves ONE provider from harm – I can say for certain that all the effort Kip put into organizing this class will have been worth for him.

DT4EMS – I HIGHLY recommend it – it was an absolute blast of a class and just may save someones life on the streets one day.

 

 

 

Posted by on December 30, 2011 in Defensive Training, EMS, Paramedic School, Scene Safety

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A Day Under The Lights…

For those of us who live this crazy life, share this insane passion for walking on the lunatic fringe day after day, the following is just another day… For those of you who don’t here’s a glimpse in what it’s like to spend a day under the lights…

0300 – The alarm clock explodes in the darkness, shattering the illusions of peace and quiet I enjoy in the tranquil place in my mind. My escape from the brutality of the real world in which we live is over. Dragging my all but lifeless carcass out of bed to the kitchen, the aroma of coffee just a half a shade lighter than mud makes its way to my nose…

One cup in… I open the closet containing my heavily starched uniforms and select one for the day, on goes the ballistic vest, the crisp white shirt, and the highly polished boots.

A gentle kiss to the forehead of the boys before leaving the house and 30 minutes later I pull into the garage. The rig is checked, necessary equipment gathered and we are out the door… 30 seconds, not even enough time to make it to the driveway and the radio crackles to life… Medic 8 I need you at…. for a man down… it’s 0408

Can you imagine the helplessness I feel as I check the pulse of the lifeless body on the floor, the feeling of inadequacy I’m filled with as I have to look up into the horror filled eyes of the man’s wife of 40 years, her barely audible pleas to save him blasting through the early morning silence like thunder.

I know it’s too late, and as much as I would like to clear the call and get back to that second cup of coffee in the rig; I give my partner that look – the one that says I know it’s hopeless, but we’re gonna work him for his wife’s sake. Without missing a beat the pads go on, the compressions and interventions start – not for the long gone soul lying between my knees, but for his wife, that she may feel some comfort in knowing everything that could have been done for him was.

We’ve known all along that we would pronounce this gentleman, all we’ve really done is prolong the time we have to decide which words to use to tell her. Knowing that she will hear them over and over in her head, likely for the remainder of her days, it’s no small task to figure out just what to say.

The helpless inadequate feelings have to be replaced with quiet confidence and the strength to reassure her when she starts wailing that if only she had found him sooner he might still be alive.

We pronounce the gentleman, and put ourselves back in service.

1/2 way to our assigned post – Medic 8 I need you at….. for an MVA with entrapment

 As I reach into the twisted metal to help the firefighters extricate the battered and bloody teenage girl from the carnage caused by a full speed impact into the concrete divider, my mind wanders, wondering how I would react if this was my sister, my daughter, how would I react to the news of the accident?

30 minutes after they arrived on scene the fire crew has succeeded in freeing her.

Her soul beat her body out of that pile of twisted metal by at least 10 or 15 minutes.

She is pronounced on scene – this time we don’t go through the motions.

Loading the gear back into the bus my mind again flashes – to opening a door and finding a police officer standing there; his head down as if examining the shine on his shoes, his hat in hand, a voice that wavers ever so slightly as he begins “ma’am I’m sorry to inform you… ”

This time when we go back in service, we don’t even get an assigned post – Medic 8 I need you at…. for a 96 (psychological emergency)

Still not even 1/2 way through that second cup of coffee, we arrive on scene – the man standing there bleeding around his handcuffs isn’t happy to see us – he knows that our presence all but guarantees that his suicide attempt will be unsuccessful.

We load him into the bus and transport him non emergent to the local trauma center – 10 minutes of the most scorching verbal abuse I’ve ever been unfortunate enough to experience. (I went through Marine Corps bootcamp at Parris Island – so that’s saying something) I’m forced to put a spit hood on him, because no amount of trying to calm him or reassure him that I’m there to help curbs his deadly accuracy with his bodily fluids. The verbal lashing continues all the way there and through our hand off to the receiving facility.

The nurse who takes my hand off report only half listens, more concerned with what and who her fellow ED nurses did last night. When the doctor comes in she calls us “the ambulance people” and only gets 1/4 of our report right.

We are trained to not take the verbal abuse of our patients personally, and we are conditioned  shortly after we enter the field to expect lack of respect and belittlement from some less educated “medical professionals.”

We are told to let it roll off our backs – in theory it works –  in real life sometimes not so much. I’ll tell you with my voice that it didn’t bother me, that I’m used to it by now and we’ll crack a joke or two in a pathetic attempt at veiling our true feelings… if you listen to my eyes though they tell a different story.

The radio is full of life now, seems the city has started to stir and as it does it inevitably chews some of the residents up. We have to wait our turn to clear the hospital, and when we do we are immediately dispatched again.

Medic 8 I need you at ……. for a 45 female with chest pain.

More inappropriate jokes about 12 leads and hoping shes at least 1/2 way attractive en route. In other company the jokes would be seen as cold, harsh maybe even borderline perverse, for us its more of the same.

It’s almost sad now that I think about it the ways we mask the impact of the job, the masks we wear among the only other people who really understand what we go through.

Upon our arrival, we are straight faced and all business.

We find our patient lying on the couch, her husband trying to to keep their 4 children at bay while we enter. Two steps in the door and my partner and I share a knowing a look – she’s sick no question about it.

We work fast, running through our interview and packaging her for transport. She’s having a massive STEMI (non medical translation – REALLY BIG heart attack) the cardiac alert is called in and we make haste for the door. It’s almost funny how our training totally takes over and we lose all the humanity of our job when its a serious call. 1/2 way through the livingroom I’m reminded of the humanity as I feel a small little tug on my sleeve.

I look back wondering what I could have snagged my sleeve on and am met with the epitome of innocence, maybe 5 years old,  tears streaming down his dirty face – his voice cracks as he speaks… “Mr is my mommy gonna be ok?”

It never ceases to amaze me when the bulletproof shell I have built around me breaks down, somehow its always at the times when I need it the most. I can’t look him in the eye, and I stand there for a second, trying to cough words around the lump in my throat, the tears well up in my eyes as I squat down and tell him she’s in good hands and I’ll do everything I can for her, but we need to get her to the hospital.

It’s hollow, it’s not what I want to say… I don’t have the time to give him an gentle embrace and I’ve been doing this long enough to know not to make promises I have no control over… I can’t explain how it isn’t up to me if she makes it or not, all I can do is try to get her to the cath lab before I have to work another arrest today.

She makes it to the cath lab and hopefully beyond – but I have more calls to run, I’m only half way through my shift I can’t take the time to follow up right now.

Six hours later – we pull into the garage – the afternoon was a little easier than the morning, not as much acuity to our calls and no more death notifications, so I’ll take it. We service the rig and get it ready for the next crew.

12 hours – no time for breakfast, no time for lunch and back to the barn 30 minutes past end of shift, another typical day.

The guys are all standing around talking about their day on the street – I’d love to talk some, maybe it would help to prevent some of the burn out I’m racing headlong toward – but I don’t have time…

I have class for the next 4 hours and if I’m lucky I can make the cross town drive and get there in time.

2200 (10 PM) class is over and in 30 minutes I’ll pull into my driveway – I’ll get my leftover dinner out of the microwave, and eat it cold like I always do so the beeping timer doesn’t wake anyone.

I stumble through the darkness careful to avoid any noisy toys so i can kiss my boys on the head before collapsing into bed at 2345 (11:45 PM)…

0300 will be here before I know it and I’ll have to it all over again.

For those of you who don’t live this life, or live with someone who does -I wish you could realize the physical, emotional and mental drain of missed meals, lost sleep, lost family time and forgone social activities that we all experience, not to mention all the tragedy our eyes see each and every day that we pull on our uniform.

I wish you could know the brotherhood we share and the satisfaction of having saved a life on the rare occasion when we get lucky enough to actually do that, the sense of purpose that comes from being able to be there in times of crisis.

Unless you have lived with one of us, you will never truly understand or appreciate who I am, who we are, or what this job really means to us…

I wish you could though.

 

Posted by on December 29, 2011 in EMS, EMT, Personal

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Interesting Perspectives

This week I had the opportunity to gain a unique and interesting perspective on a call from an angle we as EMS providers don’t often get to see.

It was an “off week” from class due to Thanksgiving and I decided to use the extra time to get some of my clinical time in. Wednesday night from 2300 to 0700 I worked in the ED, and Friday morning at 0645 I was in the OR.

During my extremely busy ED shift a trauma activation came in – “gun shot wound to the head – pulseless and apenic – CPR in progress”

I knew what to expect having called in activations to this busy urban facility in the past… call in the Calvary – Trauma 1 was readied while the ambulance was en route – The docs and nurses had their stuff wired as they readied the room… who’s getting first pressure, who’s got the drug cart, who’s going to bag, who’s recording… They orchestrated the symphony before the particular piece of music arrived. The senior resident was at the head of the bed ready to conduct and all of the members of orchestra stood ready – shortly thereafter the “sheet music” arrived via gurney.

He was a large 30’s male CPR was in progress and they moved him from the gurney to the bed in no time flat. Report lasted about 10 seconds.  (I had heard about these “loud and proud” reports in the trauma room, but I’ve never seen one given, it was impressive.)

Immediately after he was placed on the ED table – compressions resumed, lines were started, orders called out. Doc asked why no tube was in place, medic replied with,  “jaw was clinched and we couldn’t get it”.

“Fair enough” he said as he inflated the cuff on the tube he had just dropped.

Two minutes – nothing.

“Let’s go one more round and call it.”

I climbed up on the stool next to the bed and began compressions – fast and deep, fast and deep over and over – while it shouldn’t be any different it felt like I was being graded by all the docs and nurses in the room and I wanted to be sure every single compression was as perfect as I could get it.

Two more minutes – and one of the docs says – “I have a pulse”, initial pressure was something like 60/30. Meds went in and a physical exam began.

Here’s where it started to get interesting, the patient did indeed have a “hole in his head” and a broken jaw, he also had a hole in his back and in his right bicep. ED Doc decided that the hole in his head was not due to a bullet (no palpable fracture or crepitus below the wound) but that the other two wounds were. A chest tube was inserted and 2300 cc of blood were drained from his chest – he began to stabilize and was sent up to trauma surgery.

The rest of the shift was pretty uneventful and at 0700 I called it a day.

Friday morning rolled around and I headed up to the OR, I was more than a little nervous about intubating my first actual patients. It was a slow day in surgery with only 3 cases scheduled day (a typical day sees between 20 and 30 scheduled surgeries in the 13 different OR suites). The first case however intrigued me, it was the gunshot victim I had worked in the ED.

He had been taken into trauma surgery from the ED and had the bleeding in his chest and right arm controlled, a second chest tube inserted and then was sent to SICU to stabilize before further surgery. Since he was already intubated there wasn’t much I could do, but I was allowed to observe from bedside.

They reopened his chest and after removing several handfuls of clotted blood they began to examine his lung. When the surgeon found out I was a paramedic student and that I had worked this guy in the ED he invited me to “scrub in”.  What an amazing opportunity – how many of us get to not only observe but actually scrub in on a patient.

After the obligatory hand washing to your elbows, the whole dressed by the nurse twirl to get the gown on and sterile gloves I was ready. The surgeon invited me to watch over his shoulder as he showed me the damage the bullet had done to the lung tissue, he explained what he was looking for and at. It was amazing to see the lung in his hands as it inflated, if I looked at just the right angle I see the pulsating aorta as it exited through the diaphragm – this beat cadaver lab hands down.

Satisfied that he had adequately repaired the lung the doc said he was going to attempt to find and remove the bullet – “do me a favor – hold this” he said as he gestured at the retractor sticking out of the guys chest. I looked around through the safety glasses I was wearing, not seeing anyone else he would have been talking to, I pointed at myself (careful not to touch the gown) and said “me?”

I swear I could see the surgeon smile through his mask while he reassured me that I could in fact hold his retractor.

I took a firm hold and was careful to follow his instructions to the letter… he found the bullet and repaired some more damage, it was fascinating to watch. My amazed wonderment overcame any lactic acid build up in my shoulder and arm and I didn’t miss a beat. The surgeon explained to me what he was doing and why as he did it.

Once he was finished and getting ready to close I asked where the bullet had entered and what it had damaged. He invited me around to the other side of the bed and explained that the bullet had just missed the spinal cord and the aorta, and he slid his hand way into the patients chest – he lifted his hand lifted the lungs in the process and said – Here slide your hand against mine – be careful not to rip your glove there are some broken ribs back there.

Could this experience get any better? I slid my hand into the patients chest and could in fact feel the shattered ribs, the vertebral column and the pulsations of the aorta – I’m pretty sure I had that same look a kid who sees Cinderella’s castle for the first time has – It was a truly amazing experience, one I will probably never get again.

Interestingly enough even after surgery the docs weren’t sure if the hole in the patients head was due to a bullet or something else. I suppose it doesn’t really matter, and is a further illustration of how inexact our practice can be sometimes.

It also gave me perspective that most EMS providers never get – while I didn’t actually pick this guy up on the street, I did get to “follow” him from his arrival in the ED to his discharge to ICU. What an amazing experience and how fascinating to watch the treatment plan be implemented and carried out.

 

Posted by on November 28, 2011 in EMS, EMT, Paramedic School

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Consciously Incompetent

Back during our scene safety lectures the instructor said that EMS providers could be broken down into 4 categories and that each marked a different level of progression in our evolution as professionals.

The Four levels of progression as defined by our instructor:

  • Unconsciously incompetent – At this stage of development the provider doesn’t know how much they don’t know – I suggest most beginning paramedic students fall into this category.
  • Consciously incompetent – At this stage the provider begins to understand how woefully inadequate their knowledge base and skill set really are. – This is where I am finding myself these days.
  • Consciously competent – When they reach this stage if they really focus on what they are doing and concentrate fully on the task at hand they can perform their duties and provide adequate patient care.
  • Unconsciously competent – this is where the rockstar medic lives – they go about every call looking like they knew what was wrong with the patient before they even got there and make everything from handling an MCI to holding 95 YO nanna’s hand look like something were born to do. Executing flawless appropriate patient care without even thinking about it.

As a basic, I considered myself among the top two – certainly competent whether it was consciously or unconsciously depended on the call.

Now that I am a paramedic student, at the very beginning of my rides – I am more than aware what I don’t know, how much work “my game” needs and where I fall flat on my face.

When my preceptor for my second ambulance shift got in the bus he opened every sealed cabinet so I would know exactly what was in every box, gave me the narcotics code (hell I don’t even have the narc code where I work), and told me it was MY show to run that day… scene management, assessments, treatment plans, procedures ALL of it. “I will let you totally run the show, until you show me that you can’t, and then I’m going to take the call from you. I won’t let you kill you anyone and I will approve or squash your treatment plan before you implement it – you good with that?”

Seriously? You are going to take the proverbial leash off and let me run the call? HELL YES I’m good with that.

I am totally convinced that somewhere someone has etched “HELL YES I’m good with that”  down as famous last words…

Our first call was for a woman with stomach pain. I jumped out of the bus, grabbed the kit and was off. Ma’am I’m Jeff, I’m with the paramedics can you tell me the problem today? Was about as long as I lasted. She said her stomach hurt and curled up face down on the couch. I looked up at the preceptor probably with that deer in the headlight  look on my face, like now what? That was all the prompting he needed. He got her to sit up, asked his questions and got a response faster than I could even think what I should be asking next. I blew two IV attempts en route to the hospital and felt like a heel… Talk about screwing the pooch. Since I came back to EMS  I haven’t had to deal with someone who wanted our help but was uncooperative… I’ve watched my partner do it, but its never been up to me and my brain just wasn’t going to move that fast.

The second call was a guy who was punched in the face after trying to stop a shoplifter… my assessment was ok (there was really nothing to assess) but being unfamiliar with how refusals work I had to left him take the call from there so it was done properly.

Third call chest pain… I’ve been on a thousand chest pain calls… I had this one down cold – My assessment was good, my line of questioning solid and appropriate, I had come to the conclusion the lady was having a panic attack and so had he… she refused transport and I handled it – we’ll call it a double in baseball terms, good but not great.

Two more refusals and 5 hours of being posted at the airport later the shift ended. That 5 hours without patients was the best part of shift, not because I’m lazy and don’t want to run calls, but because it gave my preceptor time to TEACH me how to do the things I need to work on better. My biggest regret was that I didn’t get to show him how I could implement the suggestions he offered to me into my assessments. I learned a lot about myself in that shift and a lot about how to get better. The scores on this eval weren’t nearly as high as the first ones… but he evaluated me as a paramedic student not as a basic. He challenged me to get better, he pushed me to learn, he asked questions I didn’t know the answers to and then told me how to find them.

When my third shift came around I asked if I could work on the scene management and the assessments because I had identified weaknesses in those area on shift two. My preceptor was happy to oblige and add that he also wanted me to do the hand off reports at the hospital.

Awesome another challenge – now we’re talking.

My assessments were better and I was able to implement a lot of things I had been told the day before, still not great but a whole lot better then when I started. Hand off reports were a little sloppy, but again not something I get to practice often. I tried to implement all the suggestions and make things smoother and more orderly. I felt like I was getting into the rhythm – then we got a call for a sexual assault… It was a teenage girl – tops she was twenty. She had been severely beaten, most likely raped and left for dead naked in a heap on a snow bank.

That rhythm I had been developing was gone… I guess I just stood there unsure what to do because my preceptor jumped in and ran things right out of the bus. Evidence, the suspect, the tragedy this young woman had just endured, injuries My head was spinning and I had no clue which should come first.

My preceptor was a pro – he handled it all professionally, preserving/gathering evidence, assessing and treating all at once – it was impressive.

It was also the point when I realized just how incompetent I am.

 

 

Posted by on November 25, 2011 in EMS, EMT, Paramedic School

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