Hmmm.

My life feels a little empty. It really feels strange to not be running around like a headless chicken careening from a clinical site to a third ride to a class session. I woke up yesterday morning at 0800, SURE that I was late for a shift. My heart was pounding when my eyes jerked open and I glanced at the clock…

“Oh. That’s right. Class is over.”

So now what?

Well, here’s what’s going on. I’ll fill you all in as best as I can.

My wife and I have decided to split up. I’m not going to go into any details here, but you should know that she is a fantastic woman who put up with a lot from me. I still love her, but it was just not something that I could continue. And yeah, the dogs are with her.

I’ve decided to stay in the PNW and pursue some paramedic jobs. The last service I rode at has expressed interest in hiring me and I’m going to take them up on that. At least as a part time medic. They know that I know their system and they consider me pretty much a turnkey employee. Once I take the protocol test and get signed off by the MPD, I’m good to go.

The other thing that’s cooking is the opportunity for me to work as a resident firefighter/paramedic at a department north of where I currently live. (More about that in sec…) This is a great chance for me to get a LOT fire experience, get a TON of training, attend fire academy on the department’s dime and work as a medic. Sounds great right? The down side is, it pays for shit. Like a hundred bucks a shift, but I’m going to do it just to get the experience. We work 48/96s there…and I’m sure it’ll will be an experience beyond all others. Just think, this 40 year old fat guy will competing with super fit 22 year old kids on the drill ground. I know I’ll be working harder than I’ve ever worked before…and I’m looking forward to the challenge. Of course, it’s not official yet, but they did measure me for bunker gear after my interviews, so I think I may be in. I have to agree to work there for 2 years or untill I get a full time career firefighter position. It’s a win/win.

OK… the move. I’m moving to the big city south of Seattle to a small apartment. Moving my share of the household goods is a stressful endeavor. My new little apartment is in a funky little neighborhood. I’ve got friends that live close. It’s a LOT cheaper than Seattle. There’s cool restaurants and stuff close by. I have a really good feeling about it.

I’ll be moving over the next few days and I’ll be checking back once I’m plugged in at the new place.

Medic friends, be safe.

Paramedic school has ended. I’ve passed the program. I’ve passed ACLS. PALS. PHTLS. I’ve taken both the practicals and computer based testing for national registry. And yeah, I passed those too.

I am now an NREMT-P.

Now, I just need a job. (Anyone hiring?)

Friends, there are BIG changes happening in my life. I’m a little busy with moving and stuff right now, so I’ll write more about what’s going on in the next few days. But it’s all good!

In the mean time… allow me the pleasure of one big “WOOOOHOOOO” to celebrate that I am now, at long last, a medic.

This is my first piece of published fiction. I’m kinda jazzed about it.

“Chicken devil rotten bastards. Obama mama in the vitamin D escape pod with your fucking SHOES!” she says, trying to hold steady while kneeling on a filthy mattress.
We all stand listening, crowded in the doorway of the stagnant room, redolent of acrid, burnt crack and unwashed bodies, our collective flashlight beams trained on the swaying, screaming woman. She is perched on the edge of the mattress babbling a non-stop stream of obscenities and nonsense as she rapidly whips her head back and forth. This woman, who looks to be in her late 60s but is probably much younger, bares her toothless gums at the closest police officer as he steps closer. I watch as droplets of blood from the cut on her head arc from her Medusa-like hair to splatter on the gouged wall, a surreal hemoglobin rendition of a later Jackson Pollock. “Blood on sheetrock.” The three cops in the room all step back again to avoid the spray.
“This chick is Coo Coo for Coco Puffs,” a sheriff’s deputy says as he takes a step forward and reaches behind his back to grab his cuffs.
“Rotten, rotten, ROTTEN!” The woman spits the last word, looking at the cop with crazy wide eyes rolling in her head, like a gut shot horse, as she tries to get up off the mattress.
“Okay,” the cop snarls, “It’s 2 in the morning and I have had enough of this shit.” He reaches down to grab the woman by her scrawny arm and drag her to her feet. She lets out an ear splitting howl as the cop propels her toward the door.
“Soup spoon lovers with no account box car chummy shit eaters.” The woman tries to grab at each of us as she is hauled across the room.
“This young lady and I have a date downtown. You guys can hit the road. Thanks for coming.” He half walks, half shoves the yammering woman down the stairs, to the waiting police cruiser, with the occasional “FUCK YOU” echoing up the stairwell in the abandoned building. Tim has said little and he beat the cops down the stairs, taking most of the gear with him. I shake my head, grab my bag and walk down to the idling ambulance, where Tim is already in the driver’s seat. He has the truck in drive and rolling down the street as soon as I close the door.
Back at quarters I kick my boots off and climb back into my still warm bunk. I close my eyes and try to slow my breathing, but sleep seems to be a long way off. Trying a little self hypnosis, I image myself on a warm beach with waves crashing in the background. A beautiful redhead is on the towel next to me. She leans over to gently brush her lips against mine, a wicked glint in her eye. She leans close and whispers in my ear…
“Medic 92, Medic 92 a call for unknown aid. Respond Priority One.”
I sigh, push back the covers and shove my feet back into my still warm boots.
Tires crunch over gravel and broken glass as the stutter flash of the strobes light the dark alley behind the Greyhound station like a garish carnival midway. I shrug my shoulders into my jacket as we roll to stop behind a couple of police cruisers parked next to an overflowing dumpster. I glance around the lot and climb out of the ambulance, locking and slamming the door behind. Tim pulls our stretcher from the back of the truck as I heft my bright orange alchemist’s bag of medicines and breathing tubes and sling the Lifepack monitor over my shoulder to walk across the trash- strewn, potholed, blacktop toward the fluorescent lights behind the cracked and taped glass entry doors of the city-subsidized apartment building. I’d been here before.
The cop sitting on a folding chair next to the pay phone in the graffiti tagged lobby never looks up from the clipboard he is writing on. “Sixth floor boys,” he says, blithely gesturing toward the elevator. I crush a syringe under my boot as I walk past him.
Tossing my gear on the stretcher, Tim and I stand in the urine soaked elevator, not looking at each other as it slowly creaks way up to six. I try to hold my breath, but my lungs betray me at the 4th floor and I am forced to breathe in the fetid air. Tim coughs in sympathy but neither of us says a word. We’d ridden this elevator, or one like it, before. We know what’s waiting on six.
Tim and I worked B shift on Medic 92 in District 5. The old guys called it “The Knife and Gun Club.” Lots of fights. Lots of overdoses. Lots of bad shit. We’d been partners for a little over two years and I could see that the stress of the job was beginning to get to him. Rather than grab a beer or come over to the house for a BBQ, now he bolted for his car as soon as the tour ended, making excuses about family commitments and forgotten dinner plans. He had withdrawn from the rest of the guys on the crew, keeping mostly to himself. I’d overheard him on the phone with his girlfriend the other day. He was saying he didn’t think he could take much more. Personally, I can’t understand why he’s so broken up. It’s just a job. It’s like I told him when we started working together. “You need to take the emotion out of it. People die. Get over it.”
The elevator doors slowly open on to the sixth floor and I push the stretcher out and hang a right. We walk in step, our heavy black boots clomping down the linoleum hallway, the sound echoing off the industrial gray cinder block walls, decorated with spray painted gang tags and misspelled obscenities. We can see a bright light spilling from the open door at the end of the hall, the black silhouette of two cops at the threshold, waiting for us. Together, we walk toward the light.
The first time Tim and I worked as a team, our first call was to this sixth-floor apartment for a heroin overdose. My old partner had just transferred back to an engine and Tim was brand new to the medic unit. I could see that he was jazzed. In the beginning, every call gets you pumped. It’s that scary feeling of not knowing what you’re going to find when you walk in to a room that sends that little blue ball of electricity screaming down to the pit of your stomach, where it rolls around, sizzling. Makes your hair stand up and your breath quicken. Skydivers tell me it’s the same feeling they get as they push through the door.
I glance over at Tim as we walk down the hall. He’s shaking his head, fists clenched, eyes closed. It looks as if he’s muttering to himself.
In the apartment that first time with Tim, we met Julia. Later, we saw her so often, sometimes once or twice a shift, we had taken to calling her “Our Julia”: A woman who looked worn-out, but was a still a young girl, no older than 22. Always dressed in dirty clothes with filthy hair, nails bitten to the quick. Track marks ran up and down her arms but she was somebody’s daughter. I could see that she was pretty once, Our Julia. Anybody could tell that. That first time we found her, she was lying in a puddle of vomit in a tiny bathroom, barely breathing. Her junkie friends said she spiked up and the next thing he knew, she “looked dead, man!” I had dragged her limp body out from between the toilet and tub and crouched behind her motionless head, tipping it back, placing the mask of the ambu bag over her face. Squeezing the purple bag, I forced air into her lungs. Tim had struggled to start an IV in her delicate hand vein. I watched him draw up a syringe of Narcan, a drug used to counteract heroin, and quickly inject it into the port on the IV tubing.
We made it to the end of the hall. The cop on the left, a younger Hispanic guy I’d seen a few times before, looked down at my gear piled on the stretcher. Shook his head sadly. “You ain’t gonna need that stuff Bro.”
That first visit, a few minutes after the Narcan hit, Julia started breathing on her own, but she was also puking and ready to fight. Tim and I held her down as I leaned in close and quietly tried to explain what had happened. That she had almost died. That she needed to go to the hospital with us. She writhed underneath us, sweaty, trying to bite, trying to break our grip. A feral cat, caught in a trap. Pupils pinpoint in dark green eyes, she looked up, looked through me, but spit at my face, luckily missing. “Fuck you! Now I have to score again.”
The cop at the door was telling the truth. We didn’t need any of our resuscitation gear. Julia was dead, and from all appearances had been that way for a while. She was sprawled on the floor of her pitiful Section 8 apartment, her left arm resting in moldy remains of take out food and cigarette butts that had been ground into the carpet. The cop came up behind me.
“We just need you guys to verify the death and you can hit the road.”
“Let me just run a strip for you,” I said as I reached to pulled the monitor off the stretcher. “Tim, you mind grabbing…” I looked up, Tim was gone. I looked at the cop and he shrugged then motioned to the door.
“Give me a minute guys,” I said as I stood up, my knees popping. The cops laughed.
“Don’t worry Mikey, she’s not going anywhere.”
The laughter followed me out to the hallway to mingle with the echo of my boots on cheap linoleum as I follow the sounds of sobbing that will lead me to my partner.

My 2010 research/opinion paper.

For more than 20 years, the “gold standard” for definitive pre-hospital paramedic level airway management in both adult and pediatric patients has been endotracheal intubation (ETI). ETI can best be described as the process of inserting a lighted laryngoscope blade into the oropharynx to displace the mandible and tongue in order to view the glottis while passing a hollow plastic tube through the vocal cords into the trachea to allow for direct ventilation. In several non scientific polls where paramedics are surveyed, endotracheal intubation has been identified as the one critical skill that differentiates paramedics from EMT-Basic and Intermediate level providers, even more so than manual defibrillation and IV drug therapy. Paramedics have often called ETI, “the skill that makes us medics.” However, there are several published studies that question the amount of training that both paramedic students and credentialed paramedics receive and the lack of ability of students to demonstrate baseline competency in ETI. Also questioned in numerous studies is the efficacy of pre-hospital ETI by paramedics in both adult and pediatric patients and the relationship of pre-hospital ETI to patient outcome. This paper will examine paramedic level intubation education and it’s associated competency baselines, programs of continuing education for field providers and the recommendations of health care providers in relation to pre-hospital ETI in order to answer the question, “Should paramedics still be preforming pre-hospital pediatric intubation?”

ETI Baseline Competency
Paramedic students learn the techniques of advanced airway management primarily in the classroom by performing practice intubation on airway manikins. After demonstrating competency with manikins, the USDOT 1998 National Standard Curriculum for Paramedic Education recommends that students perform at least five human intubation procedures, either in a hospital operating room (OR) or in the field. It is widely recognized that this OR experience is a fundamental part of paramedic training as it pertains to ETI. However, a study presented at a meeting of the National Association of EMS Physicians in 2009, which surveyed paramedic education program directors that utilized OR time for student ETI practice, showed that due to limitations in OR access for paramedic students through competition for ETI practice by other allied health students, coupled with the usage of alternative airway adjuncts in the OR, such as the LMA, meant that in several programs, students were unable to meet even the baseline recommendation of at least 5 live intubations, which is far below the requirements for other health care professionals, despite the importance of intubation in airway management. As illustrated in a 2009 study from Harborview Medical Center in Seattle, five ETI attempts is far too to few even approach first pass ETI competency. The Harborview study illustrated that over a period a of three years, as 57 paramedic students first pass ETI attempts were tracked over 576 patients, “Increased ETI success rates were associated with increasing clinical exposure.” In fact, an additional study measuring competency of ETI skills of respiratory therapy students, paramedic students and medical students with no prior live ETI experience, conducted in Canada in 2003, showed that the competency score for an “uncomplicated” ETI in a controlled, well lighted environment, such as the ED or OR, only reached 80% after a mean of 35 laryngoscopic intubations, even after the student performed 20 or more intubations on training manikins. In this case, competency was measured by successful placement of the ET tube on the first or second attempt, without assistance from the anesthesiologist that was monitoring the student’s progress. Obviously, student expertise in managing more difficult airway cases would require many more live ETI attempts before baseline competency could be established. A similar study, published in Anesthesiology in 2003 statistically showed that a 90% chance of a “good” intubation would require a minimum of 47 prior student intubations, and proposed that the standard manikin training was insufficient to prepare students for actual live intubations. These studies illustrate a simple concept that makes sense. “The more you do, the better you get it.” It should be noted that the vast majority of intubation opportunities afforded to paramedic students are for adult patients in the OR, and the above mentioned studies all focus on adult ETI with no mention made of pediatric intubation skills or competency baselines.

Pediatric Intubation Overview
The pediatric airway has many anatomical differences from the adult airway. Some significant features of the pediatric airway include a larger, more floppy epiglottis, a larger tongue and smaller mandible, a smaller, shorter and more narrow trachea and funnel shaped anatomy inferior to the vocal cords. In addition, infants and small children have a larger, rounder occiput which causes the neck of a supine child to be in a flexed position. Fortunately, aside from the anatomical differences, pediatric patients rarely present with a “difficult airway” as scored by the “LEMON” method, however the lack of opportunity for paramedic students to practice pediatric intubation may very well result that the first time a pediatric ETI is attempted by a medic, it is in the field during an emergency call. In that instance, a chaotic scene, significant major trauma, hysterical parents and bystanders and the emotional impact of treating a child, coupled with a lack of experience in the invasive management of a pediatric airway may result in disaster when a paramedic must intubate a pediatric patient. In 2000, Gausche, et al, conducted an alternating day study of Pediatric Intubation vs Bag Valve Mask (BVM) ventilation of patients in Los Angeles and Orange Counties in California. This much contested study claims that there was no increase in positive outcome when pediatric patients were intubated compared to being simply ventilated via BVM. In fact, the study shows patients who received ETI were subject to prolonged on scene times and suffered frequent complications, and in no way did pre-hospital ETI improve survival or neurological outcome. Following this study, both Los Angeles and Orange Counties have disallowed paramedic intubation of pediatric patients and other locales are following suit. A 2009 newspaper article in the Riverside California Press Enterprise noted that Riverside County paramedics had pediatric intubation removed from their scope of practice by medical director Dr. Humberto Ochoa, who directly cited the 10 year old Gausche study when he claimed that BVM ventilation was “…a much less dangerous procedure… we thought we would probably do better by going back to the basics.” However, when asked about specific problems related to paramedic intubation of pediatric patients, Ochoa declined to comment.

Pediatric ETI in Practice
While BVM ventilation of many patients in respiratory distress or arrest may well be an acceptable alternative to ETI, as noted in the Gausche study, there are instances where pediatric ETI is the preferred method of airway control. Cases such as inhalation injury, anaphylaxis and restrictive airway diseases, which may require high pressure ventilation, can only be managed with ETI. It is imperative that paramedics be well educated and prepared to definitively manage the pediatric airway in these cases. In 1993, a study of licensed EMS agencies in Oklahoma showed that only 4% of the EMS responses were for pediatric emergencies. Also, many of these agencies were reluctant to allow their paramedics to practice advanced pediatric resuscitation skills, disallowing ETI in patients under the age of 12, and only 57% of the agencies that responded to the survey covered pediatric topics in continuing education. A study, conducted at Michigan State University in 1998, examined the frequency of advanced EMS field interventions in children and showed that opportunity to perform advanced skills in the field was rare and of the 535 pediatric EMS runs audited, only 19.3% had advanced procedures (i.e.: venous access) performed in the field and no children were intubated. It is obvious from these studies that a relatively small number of pediatric calls that require ETI, coupled with poor education and the reluctance of some agencies to allow paramedics to preform pediatric skills could leave EMS providers ill prepared to efficaciously manage the critical pediatric airway. With these rare field opportunities, it is logical to propose that strong initial training, coupled with continuing education is the key to success in pediatric ETI. There are several studies that show significant increases in paramedic skill competency following the completion of a Pediatric Advanced Life Support (PALS) course. In one 2009 retrospective study that examined the efficacy of PALS Training in emergency medical service providers, showed the that success rate of pediatric intubation by PALS trained paramedics who had performed ETI in the pediatric OR under the eye of a pediatric anesthesiologist climbed to 85% compared to just 48% for non PALS rescuers over a three year period.

Summation and Conclusions
Even though paramedic ETI has been the gold standard of advanced airway management for over 20 years, a hard look should be taken at the number of intubations that paramedic students are required to perform before being judged competent at the skill. Several studies have shown that the recommendation of 5 live OR intubations are far to few to develop a baseline competency in adult intubation. As for pediatric intubation skills, the only training offered in most programs is on a manikin and there are very few opportunities for paramedic students to perform any live pediatric intubations. Prior to being granted the ability to intubate infants and children in the field, I feel that paramedics should perform a sufficient number of live adult ETI opportunities to be judged baseline competent; scored as placement success on the 1st or 2nd attempt without asking for assistance, 80% of the time. After that baseline competency has been established, paramedic students should be required to manage pediatric airways in the OR, under the supervision of a pediatric anesthesiologist until baseline competency with the pediatric airway has been established. Until that point, student paramedics may be allowed practice in the field, cleared for adult intubation only. In most cases, this will prove to be effective, as was noted in the Gausche study, for most pediatric cases, the airway can be managed adequately with a BVM and there is no correlation to positive neurological outcome or survivability between pediatric patients who’s airway was adequately managed with a BVM versus those patients intubated in the field.
In summation, it is the opinion of the author, that pediatric ETI not be considered a basic paramedic skill, instead it should be an additional advanced skill that is cleared by the medical director only after baseline adult ETI competency is established, if it is not done in the initial paramedic education program. In addition, more stringent continuing education standards should be established, with paramedics in their first re-certification cycle required to perform adult and/or pediatric ETI in the OR once per quarter to demonstrate that they maintain their baseline competency. After the first re-certification cycle, paramedics should visit the OR twice yearly to demonstrate competency. With competition for OR time fierce and airway adjuncts such as the LMA replacing ETI in many surgical procedures, these goals may be out of reach for many paramedic programs. In any case, it is clear that paramedic educators must explore different options for pediatric airway training, aside from the traditional OR and ED rotations. Options such as performing presurgical intubation at a veterinarian’s clinic or the intubation of freshly euthanized cats may be the outside the box thinking that will help to assure that new paramedic students are not only well educated in pediatric airway management but are competent at performing the skills.

Works Cited
Anshuman, Sharma. “Pediatric Airway Workshop.” Pediatric Airway Workshop. St. Louis Children’s     Hospital, Web. 10 May 2010.

Baker, Troy W., Wilson King, Wendy Soto, Cindy Asher, Adrienne Stolfi, and Mark E. Rowin. “The Efficacy of Pediatric Advanced Life Support Training in Emergency Medical Service Providers.” Pediatric Emergency Care 25.8 (2009): 508-512. Pediatric Emergency Care. Web. 17 May 2010.
Burge, Sarah. “Riverside County paramedics no longer can use breathing tubes for children.” The Press Enterprise [Riverside] 3 June 2009: PE.com. Web. 23 May 2010.
Gausche, Marianne, Roger J. Lewis, Franklin D. Pratt, James S. Seidel, Samuel J. Stratton, Bruce E. Haynes, Carol S, Gunter, Suzanne M. Goodrich, Pamela D. Poore, Maureen C. McCollough, and Deborah P. Henderson. “Effect of Out-of-Hospital Pediatric Endotracheal Intubation on Survival and Neurological Outcome.” Journal of the American Medical Association 283.6 (2000): 783-790. Effect of Out-of-Hospital Pediatric Endotracheal Intubation on Survival and Neurological Outcome. Web. 10 May 2010.
Graham, Charles J., John Stuemky, and Tom Lera. “Emergency medical services preparedness for pediatric emergencies.” Pediatric Emergency Care 9.6 (1993): 329-331. Pediatric Emergency Care. Web. 12 May 2010.
Johnston, Bradford D. , S. Robert Sietz, and Henry E. Wang. “Limited Opportunities for Paramedic Student Endotracheal Intubation Training in the Operating Room.” Academic Emergency Medicine 13.10 (2008): 1051-1055. Academic Emergency Medicine. Web. 3 May 2010.
Reed, MJ , MJG Dunn, and DW McKeown. “Can an airway assessment score predict difficulty at intubation in the emergency department?.” Emergency Medicine Journal 22.2 (2005): 99-102. Emergency Medicine Journal. Web. 12 May 2010.
Reisdorff , Earl J., Keith Howell, Jenna Saul, Brent Williams, Ranjan Thakur, and Chetan Shah. “Prehospital interventions in children.” Prehospital Emergency Care 2.3 (1998): 180-183. Prehospital interventions in children. Web. 13 May 2010.
Salzman, Joshua G., David I. Page, Koren Kaye MD, and Nicole Stretham MD. “Paramedic Student Adherence to the National Standard Curriculum Recommendations.” Prehospital Emergency Care 11.4 (2007): 488-452. Paramedic Student Adherence to the National Standard Curriculum Recommendations. Web. 12 May 2010.
Wang, Henry E. , Judith R. Lave, Carl A Sirio, and Donald M. Yealy. “Paramedic Intubation Errors: Isolated Events Or Symptoms Of Larger Problems? .” Health Affairs Spring 2006: 501-509. Health Affairs. Web. 5 May 2010.
Warner, Keir J., David Carlbom, Colin R. Cooke, Elieen M. Bulger, Michael K. Copass, and Sam R. Sharar. “Paramedic Training for Proficient Prehospital Endotracheal Intubation .” Prehospital Emergency Care Summer (2009): Prehospital Emergency Care . Web. 2 Mar. 2010.