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A New Beginning

Happy 1st day of 2012 everyone.

I always prefer the beginning of a new year as it’s hopes and dreams have yet to be dash on the rocks of reality yet… it is still full of hope, wonder and optimism.

I typically don’t do the whole resolution thing, I have set goals that I work towards all the time and in reality a new year is just a time for me to reaffirm those goals and the path I’m taking to achieve them, with that said here are my top expectations and goals for the new year.

  1. Finish Paramedic School – It won’t be enough for me to just finish (not that that isn’t an achievement in and of itself) but to finish school with a job offer from the service that runs the program… anything less will be failure in my mind.
  2. FINALLY quit smoking for good… There I said it in public even so I can’t take it back now.
  3. Start taking more time for ME – exercise and more trips to the mountains, I need to find a better balance between work, school, family and personal stuff – somehow I always put myself last
  4. Find a way to step up into some sort of leadership position within EMS – either as a teacher, or mentor or even with NAEMT to help spread what EMS is capable of and help us get to where we want to be
  5. To post more regularly here – It’s a great release for me and really helps keep my stress level down
  6. An end to 10 years of struggle – fingers crossed
  7. Advocacy – More of us need to be part of the solution
  8. To write at least one article for publication in either JEMS or EMS World – Several of you have suggested it, I just haven’t listened – I hear you now – I’ll give it a go at some point

I keep hitting enter like I’m going to keep adding to the list, but those are already pretty lofty goals for a year that’s going to end the world in December…

How about you – What are your top resolutions oe expectations for the coming year – feel free to share them below.

 

Posted by on January 1, 2012 in Personal, Uncategorized

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Goodbye to Yesterday

I suppose it is borderline obligatory for a blogger to post a “year in review” entry. A time for us to reflect on the year we are leaving behind and look with optimism toward the year ahead. It is for me perhaps a good time to take of measure where I am and where I want to be.

2011 has been somewhat of a whirlwind for me both personally and professionally – I sometimes forget just how far I have come.

When 2011 ushered itself in I was driving a wheelchair van waiting for an EMT position to open up at the company where I work. Having 7 1/2 years of experience prior to taking that job it was “humbling” to have to reinvest myself in the dues we all have to pay when we enter the profession. By the end of the month I was doing my third rides to clear to independent duty on the bus.

I went through two partners before being forced by my employer to go to part time status if I wanted to pursue my education.

I discovered EMS social media and the multitude of blogs out there. I read and I read and I read somemore – somewhere in the recesses of my mind I decided I wanted to give this blogging thing a shot… it started with random stuff – I read something that moved me, or about a shift whatever… after a couple months EMS Blogs.com decided to pick up the blog – which was really an honor to me – and now a lot more people read the blog then ever before.

The days when I put out what I believe is a killer post – I’m often disappointed at the numbers of people who read it – or how often it is(n’t) shared on FB or whatever – then I remember what a privilege it is that even one person takes the time to read the drivel I spout here. At those times I remind myself the reason I write is to “vent”, to process, or just to release some of the pent up “stuff” this job brings out in us all – whether anyone reads it or not – I still get that.

I wrapped up all my pre-reqs for paramedic school and stressed my way through the spring hoping I would get the nod for what is THE program for me… after a couple months of sleepless nights and constant stress I got the acceptance letter  and for the last three months paramedic school has all but been my life.

I regularly work on a 911 car now in one of several districts that our company is the provider for… It’s a rare occassion anymore when I work a flex car doing routine transfers.

I’ve learned that I know even less then I thought I did, and that anyone who says they know all they need to is full of crap.

I’ve gotten better at leaving all the “preconceived” notions about calls and patients behind, and am trying to learn to maintain a high level of suspicion on all calls.

I’ve realized that all the fancy machines that go beep and buzz and whirl – they dont really tell you anything you shouldn’t already know from a THROUGH assessment.

I am slowly making the transition I believe is the hardest part of going from being an EMT to a paramedic – being the team lead and running things.

It’s been a year of tremendous growth and rapid change, and one I’ll look back on with fond memories… see you in 2012

 

Posted by on December 31, 2011 in EMT, Paramedic School, Personal, Uncategorized

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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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OOPS I did it again…

Somehow a month has passed – where any of those days went I can’t say for sure. The last weeks of class were extremely busy with ACLS certification, as well as classes on shock. Throw into that working as much as possible to make Christmas better for the kids AND trying to get clinicals knocked out so I don’t get behind on those and the days just flew by.

There were a few stretches in there where work/clinicals went on for 96 consecutive hours… needless to say I’ve been whooped. The break from classes and homework were right on time allowing me to squeeze in more work and clinicals before Christmas.

Pushing myself so hard I expected it to be me that broke down, at some point my eyes refusing to open to the alarm clocks beckon, or just getting sick from being so worn down. Instead it was my truck…

While driving to work yesterday morning the driveshaft of my truck literally fell out on the highway.

I'm pretty sure THAT isn't conducive to driving

Being afoot has given me some unexpected time off from work and clinicals, and while I have a 500 page cardiology book to work through (that’s the next 5 weeks of classes) I am going to take advantage of the time to get some writing done. Yes Mom I will study too I’m already 1/4 of the way through the Cardiology book.

What most people don’t understand is that pecking on these keys is a therapeutic release for me, and I have been missing it greatly. So for the next few days I will be taking advantage of the new found time to catch up on posts and get the pent up stress from school, work, the holidays and yes, even broken down vehicles out.

I have been sitting on several topics for posts, waiting for the opportunity to allow my brain to put together a semi cohesive thought.

If not now, when?

 

Posted by on December 28, 2011 in Paramedic School, 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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Turned loose on the street…

This week we started our stage 1 ambulance rides (100 hours with the goal of “observing”) Learning how the system works, where things are in the ambulance, how to manage scenes, hand off reports etc – observe how the paramedics we will be riding with do things.

Before we talk about how the rides have gone thus far and what I’ve learned specifically about myself. Let me explain a few things… The service we are riding with is my DREAM job – I want to work there so badly I can taste it. My program is “sponsored” by that particular organization and is considered a year long job interview – impress and perform and you are in… Fall flat, have a crappy attitude, demonstrate you are not up to their high standards and you’re toast.

Knowing all that creates A LOT of self imposed pressure. I want to impress, I want to show confidence, I want to sit in the FRONT seat of that ambulance.

As someone who generally performs better under pressure – I was ready for my moment in the sun so to speak.

Classes to this point have focused mostly on skills – so for all intents and purposes I am a Basic EMT who knows how to do advanced skills: I know how to intubate, perform a cricothyrotomy, administer medications, calculate doses, apply CPAP and capnography, start IV’s , apply the monitor and name the dog in the rhythm strip, hell I even know how to dart a chest… The trouble is I don’t know WHEN to do any of these things – OK granted some of them are obvious – but formulating a treatment plan at this stage of class is still limited to basic knowledge and basic skills.

Ok enough background… Let’s get to the clinicals shall we ?

I went in to my first ride thinking the plan was to basically observe and practice the skills I had learned and SEE when they are used in the field. I met my preceptor and he agreed – Any procedure we need to do I want you to perform; help me at my direction through the shift. Hell I can do that… I mean in reality that’s what I do now everyday when I go to work right ? I knew how to prepare for all the procedures and set them up for my paramedic partner – the difference this time would be, instead of handing the syringe and vial (so he can check medication and that I drew the correct amount up) I drew up to the medic and him handing me back the vial to toss, he’s going to hand me the syringe so I can administer the medication… Cool.

The first 10 hour shift passed with no real acuity to any of our patients, but I helped as I could.

My preceptor evaluated me as a basic and as he expected a paramedic student 2 months into classes on his first ride should be evaluated, giving me very high marks on my evaluation and told me I would be a good medic. These words were music to my ears… I had impressed him and he let me know it – NICE. I was disappointed in his evaluation though… Why?

When all you tell me is great job, you offer no room for improvement, no suggestions for how to get better, no suggestions on expanding my scope or things that I will need to do better or different as a medic. That doesn’t help me, it doesn’t challenge me, it doesn’t force me to grow.

The next day I showed up for my second shift it went a little different.

OK that’s an understatement it was ALOT different….How?

That’s Friday’s post.

 

 

Posted by on November 23, 2011 in EMS, EMT, Paramedic School, Uncategorized

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Wait a minute how did that happen…

*** This post contains images some may find graphic or disturbing – stop reading now if you are sensitive to graphic photos of surgical procedures***

Two weeks… Really???

I looked back at the date of my last post to find it had been two weeks already. It hasn’t seemed that long in the real world. There are so many things that have come up in class that I want to share… Illicit drugs, Excited delirium, Cocaethalene, Capnography, intubation… its been a busy two weeks.Which is probably why they flew by without me even realizing it.

We have the upcoming week off – although for me it is full of rotations through clinical sites – maybe I can catch up on some of the topics I am eager to write about in that time frame.

I have been outed as well… One of my classmates found the blog on FB and started reading it and was like WOW this is all of the stuff we are talking about in class, couple that with the info in the about me and stuff I’ve shared with classmates in conversations and my time in the Marines turned out to be what gave me away. While on the one hand it’s cool to get some recognition for what I write on here, it makes it a little more awkward as well… there is something to be said for writing anonymously – it takes away the pressures of having to be ultra careful about what you say and being able to express yourself without reservation. I don’t think it will affect the blog much as I only write about those topics I really believe in and express opinions that I would not be ashamed to defend.  I am conscious of it though so I suppose if there is any blow by effect it’ll reveal itself down the road.

Last night we did a cric lab where we did both a needle cricothyrotomy and surgical cricothrotomy on sheep tracheas… Pics posted below.

The service we are doing our rides with has a waiver for surgical crics, so we are expected be able to do those as well as the standard needle crics.

Here is the set up we arrived to

We each got a chuck, a 14g angio, a scapel, and a 6.5 ett, along with a syringe to start with

Add one fresh sheep trachea (still cold from the fridge)

Trying to hold the epiglottis up and open the trachea enough to give you a view of the cords and the glottic opening

The first step was to perform a needle cricothyrotomy - insert the catheter at a 45 degree angle in a caudad direction through the cricothyroid membrane

If your question is the same as mine was at this point – ok we are in the airway but how the hell do we ventilate this patient ? Attach a 3 cc syringe to the angio and the adapter from a 7.0 ETT will fit down into the syringe allowing you to hook a BVM to the catheter. Other methods were demonstrated for us as well… but that was my personal favorite.

Next we moved onto surgical cricothyrotomy

We started by cutting our tubes down to just above the tube that inflates the cuff (in reality we would have used a full size tube and cut it after getting the patinet ventilated)

Then we made a surgical opening in the cricothyroid membrane

Beginning the incision into the cricothyroid membrane

From my blurry hand and scapel you would think I was cutting at light speed... damn cell phone camera

Passing the tube through the surgical incision

Successful insertion of the ETT through the surgical opening we created. This "patient" is ready for ventilation now

It was rather interesting to actually perform these skills on something that was close to the real thing, hopefully should I ever need to use these skills this lab will have given me enough confidence in the skills to perform them without unnecessary hesitation.

 

 

Posted by on November 17, 2011 in Airway Managemnt, Paramedic School

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Hindsight is always 20/20 or If had known then…

It’s only been a short while since paramedic school started, but I am already looking back to the prerequisite courses with regret. Just like most programs, my school required an A & P pre-req, as of this year they changed the minimum from needing 8 credits worth to 4; instead of the year-long course they are now accepting a one semester intro to A & P (I have my own thoughts on that, but I’ll save them for another day). I opted for the 8 credit 32 weeks of Anatomy and Physiology knowing that the knowledge gained there would provide a strong foundation to build upon during paramedic school. That was a wise choice and I have no regrets about that at all… here’s what I do regret –

Listening to all the paramedics who told me I’d never need to know most of what I was learning. The Krebs cycle (now called the Citric Acid cycle) Action potentials, Ph… the list I’m sure by the end of school will be extensive.

I have said many times that I am not now nor have I ever been interested in being a cookbook medic… give this drug for this then give that drug for that – regardless of the patients presentation… In my mind all chest pain does not necessarily equate to Oxygen, Aspirin, Nitro and Morphine – that’s not to say this isn’t effective treatment for chest pain – just that I don’t believe just because the patient says they have chest pain we HAVE to follow that particular algorithm every single time…. I want to be allowed  encouraged expected to actually THINK.

Here’s the thing that no one bothered to tell me – to understand a drug… ANY drug – you have to understand the physiological actions of the body process the drug effects FIRST in order to then understand how the drug alters that physiological action.

Do you need to understand those specifics to pass the NR exam? probably not… but again I am not interested in just memorizing a list of drugs and what they are used for… I have always wanted to know the hows and whys behind the pharmacology.

We had three lectures (the first three pharm classes) that were all about action potentials – what ions move where when, how that effects the cell and what happens when we alter the normal phases with chemistry. Two of those lectures focused strictly on Vaughan Williams antidysrhytmics  4 (5) classes of drugs that are classified by which ions movement they effect (and beta blockers).

Why did no one tell me this sooner, why did no one say… hey bud- make sure you remember that stuff cause its going to come back big time in p-school? Does it go to the educational standards of other paramedic schools where as long as you can remember the drug info on the NR sheet they don’t care if you understand what you are doing? Is it more the medics I spoke to are by definition “cookbook” and I just didn’t know it until now? Sadly, I don’t have the answers to those questions.

As a basic I wanted a good solid foundation to build on, but I only had people who had been through paramedic school already to guide me as to what was important to learn and what wasn’t. So if you follow this blog and are preparing for paramedic school – I’m telling you now

LEARN about cellular physiology – study action potentials, which ions move during which phases and what that means both to you as a provider and to your patient. Study the ways that the body maintains homeostasis, learn µ, α,and β receptors – where they are located and what they do. THIS simple thing will make your pharmacology classes SO much easier.

I am wasting valuable study time re-learning stuff I should have had down before school started – Don’t make that mistake.

Don't neglect the cellular physiology when you prepare for P school - so figures like this one don't cause you panic

 This stuff IS important and yes my friend you DO need to know it if you want to progress beyond being a cook book medic.

You can’t say I didn’t warn you…

As a reminder its Movember, and I’ve donated my face to raising awareness and funds for Men’s specific cancer… please make a small donation to help raise awareness and funding for research… You can make a tax-deductible donation here

 

Posted by on November 2, 2011 in EMS 2.0, Paramedic School

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