RSS

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

3 Comments

Tags: , , , , , , ,

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

3 Comments

Tags: , , , , ,

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

2 Comments

Tags: , , , , , ,

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

1 Comment

Tags: , , , ,

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

Leave a comment

Tags: , , , ,

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

1 Comment

Tags: , , , , ,

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

5 Comments

Tags: , , , ,

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

1 Comment

Tags: , , , ,

Target Fixation

Target fixation is defined by Webster’s dictionary as: a process by which the brain is focused so intently on an observed object that awareness of other obstacles or hazards can diminish. Also, in an avoidance scenario, the observer can become so fixated on the target that the observer will end up colliding with the object [1]

Image credit

The term seems to have originated from World War II fighter pilots, who spoke of a tendency to want to fly into targets during a strafing or bombing run, focusing so intently on their target everything else faded from consciousness.

That’s really interesting, but how in the world does that relate to EMS? Replace an observed object with patient and you’ll see where I am going with this.

We as providers are called to bad scenes, to violent crimes, to people’s home courts – not all of those people will be happy to see us. Sometimes, we get so fixated on the sick patient that we forget about everything else in the surroundings… I wrote about a time when this happened to me here

Wait a minute we are the good guys/gals why would anyone want to hurt us?

In 2005 NAEMT cited assault as the leading cause of injury to EMS providers accounting for 52% of all line of duty injuries. [2]

We all joke and make jazz hands saying BSI/Scene safe during our testing, but I seriously wonder how many of us forget that the world isn’t such a nice place sometimes, and we, fellow providers, are often on the front lines of that nastiness.

In that same study NAEMT found that only 21%of us expressed our safety as our primary concern. [2] That says a lot about the people who dedicate their lives to helping others, but it also shows how vulnerable we often are.

Let’s look at a couple less than obvious scenes, any of these sound familiar to you:

You respond to a street party for a DK (local term for intoxicated party) with a head lac – I know it’s a stretch to imagine such a call… Your “windshield survey” reveals of crowd of about 100 people in the street – many of them jumping up and down and waving their arms – you exit the vehicle and hear several people yelling in your direction “damn, it took you guys 15 minutes to get here – what the hell…” Undaunted,  you make your way to the patient – he has a baseball sized egg in the middle of his forehead complete with a 5 or so inch lac – your evaluation of the patient reveals he has an alcohol like odor on his breath, and he is not orientated to anything but self… he has to go to the hospital because you legally can’t leave him here – he adamantly refuses – and when he realizes his refusals are falling on deaf ears – he resorts to screaming – “OW YOU ARE HURTING ME ” the crowd wasn’t on your side to begin with and now they are all squarely focused on you and what you are doing to their friend… More screams “I’M NOT GOING ANYWHERE WITH YOU MOTHERF***ERS – YOU CAN’T MAKE ME GO” Somewhere in the crowd a lone voice says loud enough for you to hear it “They can’t do that – we gotta stop this”

That one might have made your spidey medic-sense tingle – how bout this one

You respond to an abdominal pain call for a 68 YO F – U/A you find a nice home, in a nice neighborhood, the house is well-lit and there is a family member standing in the open door waiting for you. You grab your gear and head for the door, as you enter, a gorgeous yellow lab nudges you wanting to be pet – you look at the family member in the doorway and the individual says “oh that’s just Ole Yeller, he doesn’t bite”, with a smile you reach down pat the pooches head and continue in to your patient. She is pale, cool diaphoretic and on her nightdress is the faintest hint of coffee ground emesis… you go to work

As you palpate the woman’s abdomen she lets out a pain induced cry – from the corner of the room Cujo Ole Yeller,  the gorgeous yellow lab you pet on your way in, hears her cry and springs into action to protect his master from the people hurting her.

Neither of those is a scene you would necessarily “stage” for – maybe the first one depending on your system. For the first one I would expect PD on scene, does that mean that violence can’t happen? Are two EMS providers and a couple of officers enough to “handle” the crowd?

The second call could easily be just you and your partner.

Did you anticipate the outcomes? Did you recognize the risks? Did you prepare for them?

As responders we tend to fall into 1 of 4 categories with regards to our street medicine – I suggest we also fall into these same categories with our scene safety assessments

  1. Unconsciously incompetent – we don’t even know what we don’t know – sadly ALOT of providers fall into this category
  2. Consciously incompetent – holy crap I don’t shit, how the hell did I ever get out of school – (Step 1 to becoming an awesome provider)
  3. Consciously competent – I have a clue and if I focus really hard on what I’m doing I can pull it off – (There is a REAL danger of target fixation here)
  4. Unconsciously competent – It’s all second nature to me – it just happens and I don’t have to think about it much

How does one advance from one stage to the other – Practice and experience, time and exposure. This is the same way we can get good at recognizing hidden threats on scene.

How many of us do any or all of the following:

  1. Strategic parking on arrival
  2. A scene report from the passenger seat – fire is GREAT at this
  3. Scanning the windows of the house/vehicle as we approach
  4. Take the wheels/cot over land through the yard approaching at a diagonal instead of up the walk
  5. Identify the last shred of cover we can hide behind if we need to – from that point forward you are in no man’s land
  6. Is there a crowd, pet, “bad actor” on scene
  7. Are people running in the opposite direction you are going
  8. Do you pull up lights and sirens blaring, or are you discreet and shut down a couple blocks away – leaving only the running lights on as you arrive
  9. Do you search your patients before you get in the box with them? If so do you take their belongings or remove them from easy access?
  10. Do you ask – who else is here when you arrive at a house
  11. Do you stand in front of the door when you knock
  12. Do you identify the way out and position yourself with unobstructed access to that route
  13. Do you walk around the rig instead of between it and the car with the slumped over driver in it?
  14. Do you approach a vehicle like the one above from the passenger side?
  15. Do you stand in front of the elevator doors waiting for them to open, maybe even chatting with your partner (Bad guys often have to leave via the same route we enter)

Just a few examples of things we can and should do on calls. Some of them are controversial sure – (I would LOVE to debate some of them if you disagree) ALL of them will help you get home safely at the end of the shift.

Expect the unexpected.

For most of us when we evaluate a patient we start with the worst possible thing that could be wrong with the patient – Chest pain calls are MI’s until proven otherwise, man down calls are full arrests until proven otherwise – then we begin to rule those life threats out through our assessment and questioning until we arrive at an accurate picture of what is wrong with our patient.

Why is our scene size up any different? Shouldn’t every call start out by ruling out all the life threats – to YOU?

 

 

 

 

1 – http://www.websters-online-dictionary.org/definitions/Target+fixation

2 – http://www.ems1.com/ems-products/press-releases/16033-NAEMT-Finds-High-EMS-Injury-Rate/

 

 

Posted by on October 6, 2011 in EMS, EMT, Scene Safety, Warning bells

4 Comments

Tags: , , , , ,

The Pride Defense

Now that I’ve had ampule opportunity to digest my heaping portion of syllabus salad with boot camp dressing (And So It Begins…), it’s high time we take the swan dive off the high board and find out just what it is I have gotten myself into. With blind enthusiasm, I lept; landing with a thud and a huge splash in medical legal issues class.

Medico-Legal class – what else can I say. Yes, it is dull, it is boring, and it is necessary. It turns out I had prejudged the class though… this one was about to get interesting

My twisted sense of humor grew fond of the instructor (a lawyer-paramedic) telling us “unless you want your policy and procedure manual and that big ole binder with our protocols in it reconstituted in suppository form by some slimy lawyer, you will…” It would be remained funny if he hadn’t said it so often. I had a similar fascination with recto-cranial impaction for awhile so I get the draw.

After the standard misfeasance, malfeasance, abandonment, HIPPA, Good Samaritan laws, etc. Something came over him and he changed from the boring legal guy into a genuine caring paramedic.

“Look I know this stuff sucks, but it is important” Now that we have talked about the required DOT stuff let me give you MY medico-legal class. The stodgy lawyer guy was gone, as were the bad jokes and the lawyer “smell” that permeates the room sometimes when you there is an ambulance chaser attorney in the room.

There before us was a medic who genuinely cared about us as students, about his patients and EMS in general. “I’ve been doing this a long time ladies and gents, and it all comes down to three things. Three little rules that will ALWAYS have you on the right side of any encounter or treatment you render. 3 little rules that will ensure you are delivering the highest quality patient care that you each are individually capable of, and yes for those of you that worry about such things, 3 little rules that will cover your ass.

“Get out your pens and something to write with – THIS is important. In this line of work it isn’t a question of if you get sued, it’s a question of when, and in addition to making you a better medic, these 3 rules will make you as bulletproof as a medic can be. Ready…”

1 – Do what is in the best interest of your patient (this of course should be our guiding principle always)

2 – Do what your medical director would want you to do (sometimes harder to know than what is in your patient’s best interest – depending on your particular medical director and service – this one could be a sticky wicket for some of you out there.)

3- Do what you would be proud to defend. (WOW… I have never heard it put so simply and so brilliantly before.)

“Do those three things and your patients will get the treatment they need, your service will get the medic they deserve and YOU ladies and gentleman will be able to sleep at night and hold your head high when you tell people you are a Paramedic. Have a good night.”

The moment was lost on some, as they eagerly picked up their books and bolted, or began to discuss what bar they were going to meet at for beers after class. For a few of us though, we just sat there in stunned silence – jaws agape.

I felt like I had just been given the meaning of life…

Let’s be honest, if all of us could just do number three ALL the time, how much simpler would our lives as EMS providers be. Would we even need rule number 1 or 2 if we could always do 3?

Call me an idealist (you’d be right), but think about all the negative news stories you have ever heard about EMS, EMTs, Paramedics, ambulance services – public and private – How many of those stories would simply dissolve into nothingness if the individuals involved had followed rule number 3?

Do what you would be proud to defend – it’s so simple yet so eloquent.

It should be easy to remember, not most of the time, not for 98% of the calls – but for EVERY single call we run – including the “drunk” at 3 am that swears that telephone pole jumped into the road, 95 YO nana who fell down and just wants help back up when all you want to do is sleep, AND the emergent response to 7-11 – you know the one the “man down” call that proves to be a convenience store attendant is tired of looking at the homeless guy sleeping outside so he calls 911 and says “man down”.

I can’t speak for anybody but me, but I know I would not be proud to have to defend every single action I have ever taken on a call. How about you? Can you look at yourself in the mirror and say that you have honestly given every patient you have ever encountered your best?

If you can say that, then either you are deluding yourself, or your best might need a little work. For those who will say I have given every single patient, every single time nothing but the absolute best I had to offer and are neither delusional nor incompetent – where do I put in my application, I would be honored to work with such an legend partner  EMS God.

For the rest of us human EMS providers, I learned something when I was in the Corps that has stuck with me to this very day “If it feels good to do or to say – you probably shouldn’t” Following this mantra has extracted me from more than one situation that could have turned out much worse then it did. I have used it in both personal and professional life; it wasn’t until sitting in a classroom full of bored paramedic students that it hit me. My mantra was indeed sound, but it didn’t go quite far enough, particularly when dealing with someone who very well may be having the worst day of their lives.

Pride is defined as “feeling pleasure or satisfaction over something regarded as highly honorable or creditable to oneself” (1)

As I continue the journey toward the glittery disco patch, the first standard of care that I intend to change from my days as a basic is to try to remember to always ask myself  “Would I be proud to defend what I am about to do ?”

Now that is a gold standard to try and live up to.

(1)    http://dictionary.reference.com/browse/proud

 

Posted by on October 1, 2011 in compassion, EMS, EMS 2.0, EMT, legal, Paramedic School, Personal

Leave a comment

Tags: , , , , , , , , , ,