I hate being ambushed.

The other day, I was having what I thought was a private IM conversation with a kid who’s interested in EMS. He’s not a bad kid; he’s excited about EMS and can’t wait to start his EMT-B class. However, he wants to change the world of EMS.

Good for him, we all have to have some lofty goals to shoot for, right?

Oh, did I mention he wants to change the world of EMS RIGHT NOW? With no absolutely EMS experience? He’s not an EMT. He’s never ridden on an Ambulance. Never touched a patient. Never been puked on or shit on or called an asshole by a patient he was trying to help. No experience.

Now, this kid is also enamored with the King County Medic One system. I know that some people think it’s the bee’s knees. I, having worked BLS in King County, am most decidedly NOT enamored with KCM1. Frankly, I think it sucks. That’s MY opinion. And, it’s valid because I’ve been part of both BLS and ALS level patient care there. I’m just not a fan. That’s a post for another day. Maybe.

This kid is also a fan of the “EMS 2.0” movement. Great. I’m all for making EMS a “real profession”. Should every prehospital care provider be degreed? Yep. Should we raise the standards for paramedic education? Yep. Agree and agree.

Here’s where we disagree. It’s my opinion that sick and injured people deserve prehospital paramedic level medicine, even if they’re not circling the drain. Sorry y’all. That’s how I feel. As an example, I think pain management is a huge issue that medics in King County will not touch. C’mon guys, It’s simple, fractures and other ortho injuries should have their pain managed by ALS providers. That’s what I believe. I think it’s what a caring, competent medic should do.

The kid replied, “In my opinion prehospital pain management is unnecessary because in ten, twenty, or thirty minutes the patient will be in the emergency department.”

Seriously? When your grandma is lying on the cold kitchen floor with a hip fracture following a fall, I hope you are there to explain why she’s not going to get any pain meds prior to being seen in the ED. Oh yeah, it’s because you believe that pain management isn’t important and we shouldn’t “waste” an ALS unit on something so insignificant. Seriously.

Timothy, I called you an idiot in my IM conversation, and that stands. I also stand by the statement that you need to gain some experience in the field, even as an EMT, before you start to judge what is right and wrong with EMS today. You need to see sick and injured people before you can make blanket statements about treatment modalities.

Earlier today, I was pretty pissed when I saw that this kid took a private conversation we had and turned it into blogfodder, than I remembered he’s just a goofy kid sitting at a PC in his mom’s basement typing away… and I realized I don’t give two shits about what he thinks.

I wanted to let you all know that I have decided to stay here in the PNW and pursue a career as a Firefighter/paramedic.

WHAT?

Yep. I decided that I want to be a fire/medic. Of course, my dream job at my dream department isn’t hiring yet, but I figured I’m not getting any younger so I need to get the ball rolling. I’ll test for the first time near the middle of the month. I’m sure this will just be the first of MANY attempts to land that elusive fire job.

I’ll keep you updated.

PS: Personal life still sucks. Career goals and doing well in school helps keep me focused on positive things.

Folks, this is killing me. KILLING ME.

Medic school finals for the quarter are 3 weeks away. I’m still in near the top of the class, but it’s tough. I found out my third quarter ride site is with a super busy service that’s based 148 miles from my house. Luckily, they do 48s, so I don’t have to drive quite as much.

Of course the part you don’t know is that my personal life has absolutely fallen apart and I feel like total hammered dogshit. I’m looking for a new place to live and I also have to go back to working as close to full time as I can at OAC to support myself through this mess.

I love you guys and gals. But I just can’t do this right now.

I. Just. Can’t.

Finishing P-School and my own sanity are the big concerns.

I hope I’ll be back soon.

My pager clamored for attention just after 4 this morning. I rolled out of my bunk and grabbed my glasses off the nightstand so I could read the page.

MEDIC RESPONSE: 1234 FAKE ST. RP SAYS DAUGHTER IS MANIC AND RUNNING AROUND NAKED AND SCREAMING. RP LOCKED IN BATHROOM. PD EN ROUTE.

Seriously? Why can’t people go crazy during the day?

Best part of the whole thing? I got to get a line on a naked, sweaty, fighting, cursing whirling dervish.

Did I mention this was just after 4 this morning?

“Yeah, Ativan sounds like a great idea!” I said, as my preceptor waved a vial from the fridge in my direction.

She was asleep by the time we arrived at the ED.

However, I was awake until shift change at 0700.

Back at it again tomorrow.

I crouch down next to the skinny white guy. He looks to be in his mid 60s and he’s not breathing. Little old guy in a tiny house. It’s a narrow, shotgun shack, redolent with the acrid stench of cat urine, crowded with piles of old newspapers and bags of empty bottles ready to go to the recycle bin. The guy shared the cluttered floor space with a Naugahyde Barcalounger and a massive 70’s vintage RCA console TV, which was blaring a green tinted rerun of The Rockford Files at an ear splitting volume.

Captain McGillis is tucked in tight behind the guy’s head, wedged up next to the wall, the BVM pressed tightly on the man’s face. He is rhythmically squeezing the bag every 5 seconds and watching me through his safety glasses.

Eric is on the right side, getting a blood sugar. The glucometer beeps. “Low”, he said, as he looks across the guy’s chest at me.

Doug, my preceptor, is standing back. Unable to fit in the room, he leans against the door jamb, also watching me.

There are IVs you want, and then there are IVs you need.

This one fell into the “need” category.

Now, in the interest of full disclosure, I have to admit that I usually blow IVs when my preceptor is standing there watching. I’m pretty damn close to 100% in the ER, but when it comes to getting the line on scene or in the back of the truck, it’s a 50/50 shot. Nerves? Maybe. Whatever it is, I’m working on getting over it.

I also know there’s a big difference between the line you want, and the line you need. This guy needed a line. He needed an amp of D50 and that meant he needed an 18 gauge or better. And it needs to be done right now.

There was no room to get the drug box, or anything else, for that matter, into the room with us, so I look over my shoulder at Doug and ask him to hand me the IV roll and an amp of D50. As he turns away, I smack my hand down on the TV’s power button, silencing James Garner in mid sentence.

“Hey! I was watching that!” Captian McGills says, from his spot at the head. We all chuckle as Eric manages to maneuver the lifepack around the small end table that is tight against the man’s leg to stick some patches on.

The IV gear appears in Doug’s hand over my shoulder as the ECG prints. Eric hands me the strip, because I can’t see the screen at the angle I’m at. Normal Sinus at 72.

I wrap the tourniquet around his skinny arm and silently pray that he’s got decent veins. BAM! Before I can even blink, his cephalic vein pops right up and I grab the chloral hexidine and scrub away. Quickly slipping in an 18, I attach an extension set, tape down the hub and push in the D50.

It’s ten minutes later and our guy is sitting up and looking a lot better. The Cap is puttering around in the tiny kitchen whipping up a peanut butter sandwich and our guy’s blood sugar is now 77. It turns out his name is Louis and he took his insulin this morning, but forgot to eat. No, he’s not married, but his daughter checks on him twice a day. And there was, “no F’in way that he was gonna go to no hospital!”

I get on the phone with Laurie, his daughter, who arrives less than 10 minutes later and talks her dad into taking the ride with us.

Back at the fire station, Doug sits down at the table with me to review the call. He tells me I did the right things. Made all the right moves and nailed the IV when everyone was watching. But the thing he is most proud of, he tells me, is the fact that I just grabbed the phone and called his daughter and got her there to help me talk Louis into going.

“That’s really being a solid patient advocate,” he says. “That’s what I want to see.”

He gets up from the table and pours two cups of coffee. He hands one to me and together we walk out to the bay to restock the medic.

I’m still a student, but this was my first ALS call where I acted as the “paramedic” start to finish.
Obviously, all the details have been changed to make sure I don’t get stepped on by a HIPAApotamous.

Medic 22 was dispatched priority to a private residence for a 56 year old male C/O low blood pressure and feeling dizzy with a slight SOB. PT states he had been feeling unwell, with some chest pain and fatigue since yesterday afternoon following power washing his deck. The pain yesterday was described as a sub-sternal burning pain rated as “13 out of 10”. Believing this pain to be heartburn, the PT took OTC antacid and received no relief. This evening he was still feeling dizzy with some CP, and took his BP with a home machine. His BP was 84/52, so he summoned 911. The PT has a history of hypertension and takes Metoprolol 50mg, Amlodipine 5mg, Clonidine 0.2mg and HCTZ. There have been no recent medication changes and he has been compliant with his meds and is positive he has not taken any more than usual. The patient is also a smoker and has recently reduced his consumption to a half pack a day. PT denies any diaphoresis or nausea or vomiting. PT has no other complaints aside from the chest tightness, dizzyness and slight SOB. PT’s last meal was a turkey sandwich about 90 minutes prior to our arrival. PT is allergic to codine.

Upon our arrival, PT was found sitting on the edge of his bed. He had just extinguished a cigarette as we arrived. He was CAOx3, GC15. His skin was cool and dry and pulse was slow and weak. BP: 90/62 HR: 52 RESPIR: 16 SpO2: 96% on RA. The monitor showed Sinus Brady with a rate of 54 with no ectopy. 12 lead was unremarkable with no noted ST elevation. HEENT: No trauma noted, Pupils PERRL. CHEST: Lung sounds were clear and equal bilaterally. PT says his chest “feels tight. About a 4/10.” No radiation. No palliation. He states he has felt this way all day. ABD: Soft and non-tender in 4 quadrants. PELVIS: Intact. EXTREMITIES: No edema noted. His extremities were cold to the touch, with slow capillary refill.

PT to be transported to XXXXX ER ALS to R/O MI.

BSI, PT contact followed by interview questions and exam. PT placed on 2 LPM of O2 via NC. SpO2 to 99% with Oxygen. Vitals obtained. PT placed on monitor and 12 lead obtained. The patient was able to stand and ambulate without difficulty. He was assisted in walking approximately 10 feet from his bedroom to the front door where he sat on the stretcher and was placed in a semi-fowler’s position, covered with blankets and moved to the ambulance. PT was assisted into a hospital gown. IV access was established in the Right AC with an 18ga angiocath and a 500ml fluid bolus of NS was started. PT was administered 324mg of ASA and 0.5mg of Atropine IVP. Following the fluid bolus and Atropine, vital signs were reassessed. BP: 106/88, HR: 72, RESPIR: 16 Lungs remained clear bilaterally. IV drip rate adjusted to TKO. PT was administered 0.4mg Nitro SL. PT states chest discomfort is gone.Telephone report to ED was made. A second 12 lead showed NSR at a rate of 72 with no ectopy or ST elevation noted. On arrival at ED, PT was transferred to bed 8 via 3-man draw sheet lift and report given to Jane Doe, RN. PT care and transport occurred without complication or incident. Signatures obtained and Medic 22 returned to service.

Not an earth shattering call, by any means… but the first one I ran soup to nuts. And what I did made a difference. 

It was pretty cool. I copied my SOAP here so I never forget how jazzed I was about this first call.

This cold will not go away. Is it becoming bronchitis? Why won’t it go away? Why can’t I stop coughing? Why do I feel better one day and the next feel like hammered dog shit? Why has this lasted a month?

I was at the point today where I almost, I said almost, went to the ER. As I was considering driving over to the local hospital, I was looking at myself in the rearview mirror. “What the HELL was wrong with me? Was I really going to show up in the ER to get checked out for a cold that I’ve had for a month?”

Consider it a momentary lapse of reason.

Needless to say, I didn’t go to the ER and embarrass myself in front of my EMS brothers and sisters. But I will be at the doc’s tomorrow. Antibiotics? Maybe. I need something. This is not getting any better, and I had to cancel tomorrow morning’s clinical because of it. That sucks.
In other news, I just got back from two weeks in the south with my wife at her new place. It’s pretty weird splitting up the household like this. She’s rented a little townhouse and she’s got some furniture from our Seattle house in there. The dogs are with her, too. It’s pretty weird. It’s like “Hey, here’s my stuff and my dogs, but this is not my house and I go home in a week…” Weird.

Well, it’s just until I finish school. Six months seems like forever, but it’ll go by quickly.

Another thing I’ve discovered about the south, I like all the food, except biscuits. Can’t stand biscuits. I like grits. I like BBQ. I like collard greens and black-eyed peas and sweet tea. However, I can’t stand biscuits. When I have breakfast, I want toast. How hard is that? It’s just bread, warmed up. Easy-peasy. Don’t look at me like I’m an idiot, I’m a Damn Yankee. I like toast. I know y’all got some bread back in that kitchen. Work with me.

Hi all. I’m still on the holiday break, and rather than frolicking in a winter wonderland, I’ve been fighting a miserable cold since the first week of December. As I mentioned in some past posts, my wife has taken a new job in the southern part of the country while I finish school in Seattle and work on selling our house. I’m actually down south with my sweetie now, and have been for the past week. I can already tell I’m going to really like living here a lot. The people are nice, the weather is great, the cost of living is significantly less than the PNW and frankly, I’m tired of living in the perpetual gray that is Seattle.

As the year is quickly coming to an end, I wanted to thank each of you who’ve read my blog and commented on my posts. Medic School continues on Jan 4^th, and this quarter is going to be even busier with clinicals and classes. It looks like I won’t have a free day until mid February. I’ll keep you updated with what’s going on. This quarter, I’ll be taking more of a “lead medic” role on ALS calls and I expect to really learn a lot.

I’ve also started to compile a list of things that I want to accomplish over the next year. Not really New Year’s resolutions, more so a list I can refer back to and check off as I get things done.

In 2010, I want to:

• Attend a comprehensive difficult airway class.
• Remove fast food and soda from my diet totally.
• Clean out the garage and sell all of the junk
• Make it a priority to work out once a day.
• Lose some more weight.
• Make sure I tell my wife I love her, every day.
• Remind myself why I decided to become a paramedic whenever I have doubts.

Sounds easy… but doing it every day might prove to be difficult, but I’ll work on it.
Friends, I hope you all have a great 2010 and keep checking back… I promise to get back on the posting track very soon.

When you’re a paramedic intern, your field rotation is a tremendous experience. You’re playing in the big leagues now, brother. It’s no longer imaginary patient scenarios; it’s the real deal. You’re standing in the middle of someone’s living room at 2:40 in the morning and you’ve got a sick person sitting on the couch in front of you, and you’re expected to treat him or her appropriately. Oh, and did I mention that all eyes in the room will be watching your every move?

In talking to my preceptors, I’ve found that most paramedic interns don’t have much trouble with the actual medicine. However, they do have trouble with the other 22 hours of the day. The time they spend in the firehouse with the crew. So, to help those medic students who may be venturing out on their first field rotations, I’ve compiled a list of handy tips to help you make the most of your field time and to keep you from ruining it for future students. Most of this is common sense… but remember, this is from my preceptors, at my ride site. Your mileage may vary.

First, remember that you are a guest in somebody else’s home. Respect for the house and the crew is your number one priority. Simple things mean a lot. Wipe your feet. Knock before you just barge in. It sounds pretty easy, but you need to remember that the crew in the firehouse is a family, and you’re an interloper that can easily disrupt the delicate dynamic that exists. Oh yeah, bring a gift. To be more precise, bring food. Cookies, muffins, something. Here in the PNW, it’s expected that the medic student bring Ice Cream on the first day of rotation. Snacks are always appreciated. Don’t make a big deal about it, just put the cookies or muffins on the counter in the kitchen. It’ll vanish before you know it.

Arrive at least 30 minutes before shift change. Introduce yourself to everyone. Look them in the eye, shake their hand and say, ‘Hi, I’m, ______ a medic student riding here today.” Be proactive in letting people know who you are and that you’re part of the crew today.

Learn what’s expected of you as soon as you walk in. On your first day you should be asking where you ride on the engine and what spot you take on the medic unit. Which bed is mine? What bag or box you’ll carry into the house. Where is the mop and broom? Figure out where to find your traffic vest for MVAs. Ask if you need a helmet and gear for calls. Anything you need to know should come out as soon as you get there. Ask your preceptor or the senior firefighter, “Hey guys, this is my first shift here. What do I need to know?” And don’t wait for them to volunteer that info, get it!

Expect to work. Don’t fall into the trap of letting the crew treat you like a probie where you’re expected to scrub toilets and kitchen tile grout for your whole shift, but pitch in with the station chores. Don’t wait to be told. Grab a broom or a mop and get to it. The crew may not say anything to you, but they’ll notice that you’re helping and they appreciate it. Usually station chores can be done pretty quickly and then you can move on to the real business at hand…

Learn the location of everything on the medic unit. Everything. Spend as much time as you need in that truck to be able to put your hand on anything your preceptor may ask for or you may need in the course of doing your job. If the same equipment or medication is in multiple locations on the truck, know them all. It should be your mission to do a full rig check every time you walk into that station. Physically inspect every drug vial. Touch them all so you make the connection with the location in the drug box. You want to be able to open the box and know exactly where the Adenosine or Solu-Medrol is. Touch every piece of equipment in the truck. Do you know how to turn their brand of monitor on? Where’s the capnography plug in? How many sets of combi-pads are in the rig? Is every laryngoscope blade bulb tight, white and bright? Can you put your hand on the bougie without having to root for it in the airway bag?

Spend some good quality time with your preceptor and get to know what he or she expects from you. Conversely, let your preceptor know where you think need help and guidance. Expect to be grilled on your medicine and treatment plans by not only your preceptor, but also other medics in the station, the shift captain, the MSO and anyone else who happens by. Don’t think you can skate through this. You need to know your stuff. You need to know drug dosages. You need to know WHY you give certain drugs. You need to be able to grab gear off the truck without fumbling. Your preceptor is watching to see how much you know, how you handle stress and where your weaknesses are. When you roll out together, some preceptors may want you to just observe how they run calls for the first shift. Others may tell you to run it all while they stand back and observe. It’ll be up to you and your preceptor to find that comfortable groove where you can get great patient care experience and he can guide you in shaping your practice. And if he or she knows you need help with certain skills, they can be right there to help you out with tips and tricks to get it done.

Have some presence. My instructor calls it “Medic Swagger”. You’ve simply got to be decisive in your treatment and interaction. After all, you’re going to be the guy that everyone on scene looks at for answers. There’s nothing worse than being unsure. When your preceptor says, “This guy’s rate is 42, what are you gonna do?” Don’t scratch your head and say, “Uhhh…maybe some Atropne?” That is the wrong answer my friend. If you know it, say it. If don’t know, ask your preceptor. Don’t guess. If you do guess, expect to get grilled on treatment for that situation when you get back to the firehouse. This isn’t something you’ve got to have nailed on your first shift, but soon after you start riding, you’ve got to be able to step up to the plate and be the medic.

After the call, you clean and restock the rig. No questions. Just do it.

Study. There’s going to be downtime at the station. You better have your books with you. Use that downtime to feed your head and prepare for the next class. If your preceptor is a newer medic, chances are he’ll quiz you on some esoteric stuff that you’ll be expected to look up and report back on. No, he’s not picking on you. Well, okay he IS picking on you, but he’s also helping you to learn. And just think, in a few years when you’re precepting a medic student, you can do the same.

Dinner. On some shifts the evening meal is a big deal where the cooking starts just after breakfast. For other shifts, it’s pizza or Thai food ordered in. You’ll need to talk to your preceptor about what’s expected. At the station where I ride the rule is, Medic Students are not expected to cook and are never asked to buy in. The guys there remember what it was like to be a student and how having no money is the norm. I appreciate that, but I always offer. (And yes, I did cook for the crew a couple of nights ago. My roasted chicken with wild rice was received with rave reviews.) If you don’t cook or pay in, you’re still expected to help. Did you hear that? Offer to help! When dinner is done, clean the table and the kitchen and do the dishes. Don’t say anything, just do it.

Coffee. Make sure there is always coffee on. If you’re studying in the kitchen, it’s easy to do. I always throw a couple of bucks into the coffee fund when I’m there. One of my preceptors doesn’t drink coffee, so she always loudly announces to the crew that I can drink her share. The captain on that shift has a constantly full mug, so I make sure there is always a fresh pot on. Remember, it’s a respect thing.

Fitness. Most crews have a period of time during the day set aside for PT. If you’re comfortable working out with the crew, ask if they mind. Most don’t. Some spend their PT time “discussing” department politics, and they may not want you around for that. Don’t be offended. However, you should take an hour out of your day to work out. My firehouse has a great workout room and I spend at least an hour in there every shift.

There’s an old joke in the fire service, “If I wanted your opinion, I would have told you what it was.” While you’re not expected to be silent, it is prudent to keep your yap shut. You have two ears and one mouth, so do twice as much listening. If you’re studying in the kitchen and two firefighters come in talking about something, don’t insinuate yourself into that conversation. If they want to talk to you, they’ll include you. Most times they will. If a discussion becomes heated or turns into a rumor mill discussion, it may be better to quietly pick up your books and head to your bedroom or the bay.

At my station, evenings are pretty mellow. They cross staff a medic unit and engine so we have a small crew, usually three and me, sometimes a crew of five plus me. Around 1900 or so most of the guys settle into their recliners for some TV. Medic Students are never allowed to sit in a recliner unless they are invited. Don’t ever break this rule. You are not there to watch TV. You’re there to study and learn. Now, most preceptors will give you the wave and say, “Hey, put those books away and come over here and sit down.” When I’m invited to watch TV, I do so for a short period and then excuse myself to study more or hit the rack. Be polite, but don’t expect to just hang out and watch the tube. It’s not cool.

Sleeping at the firehouse is tough for some. One guy I know can’t sleep unless he’s almost totally naked. That’s got to be rough. If you’re that guy, don’t make them wait for you. The fireguys have bunker gear to put on, so they can be ready pretty quickly. I usually just sleep in my uniform pants and a t-shirt and throw on a quarter zip with my Student ID for that middle of the night call. I also keep a box of Altoids in my jacket. Mints are always appreciated in the middle of the night. Also, make sure your bed is made neatly and you keep everything orderly in your room.

To clarify, this is MY situation and it may be different for you. ALL of our clinical time is with Fire. There is no separate ALS only service. ALL of our rotations are 24 hour shifts. We spend the entire shift with the crew, and many of the students pull 48’s to meet the criteria for number of required ALS calls, as juggling the required field time with hospital rotations and classes can be difficult. Unlike some Medic programs, we don’t do “ALS Engine Sleepovers.” ALL of our patients are transported by Fire Medic Unit, even the BLS calls, and the medic student has patient contact with every single one of them. I ride the busiest ALS unit in the county and average about 16 calls per shift.

Many of the departments in my area cross staff both an Engine and a Medic Unit.The engine has a full compliment of ALS gear on board but it’s not the primary ALS response unit. However, if the engine rolls on a fire call, the medic student is expected to be on board. If the engine responds to a call that tuns out to be medical, the medic student and preceptor will manage that call to the hospital on a separate medic unit which will be called to the scene to transport.

Your field rotations can be a great learning experience and you can have a lot of fun. Just remember to respect the crews you’re working with, say please and thank you and pitch in on the work. “I’ll do it” is a great attitude to have. I’m sure you’ll do fine. If you have additional tips, put ‘em in the comments section. I’d love to keep this post as a living document for new medic students to refer to.

Constant reader, my apologies. I feel simply awful that I’ve neglected you and all of my other my blog readers for the past few weeks.

However, I do have an excuse.

It’s the final couple of weeks of the first quarter of Medic School. That means I’m cramming clinical and ride time in, studying all of the material we’ve covered for the past 3 months and trying to have a little bit of life on the side. It’s tough.

So, I’m sure you’d love to read about what’s been going on… here’s a little recap of the past few weeks.

I’ve shown some marked improvement in my IV skills. It’s simply a Jedi Mind trick. If I visualize the catheter advancing in my mind, it will happen when I do the skill. I also met some great nurses and other medics during my ER rotations that are helping to hone my skills.

The ER rotations are fun for me. I know some of the other guys look at them as a waste of time. “Let me get my sticks and get outta there!” I like talking to the Docs and learning more about how THEY evaluate the patients and what happens after we bring ‘em in. It’s really a great learning experience. I do my last ER shift of the quarter tomorrow morning.

My ride time has been strange, to say the least. I’m riding with a department that has 4 platoons and medics that float from station to station depending on debt days and staffing needs, so I never have the same preceptor. That’s something I’m not really happy about. Although, I guess at this point in my education, it’s more about me learning how they work in the field.

My first 24 was pretty laid back. 2 ALS calls, both very minor. My preceptor told me, “Just do it. If you’re gonna kill someone I’ll stop you.” Not exactly the learning environment I was hoping for. But, all went okay, and I didn’t kill anyone.

I just finished a 24 this morning and it was another strange one. The first medic I was assigned to was very cool and seemed really interested in training and teaching. We really clicked. However, he was only working a couple of hours on a fill, so he left at noon. The senior medic who came in to cover the rest of the shift wanted nothing to do with a student. The third guy on the truck was a precepting medic and he was running all of the calls. It was confusing and a little messy and I just tried to stay out of the way and do what I could. The Captain on the shift said he could send me to another station if I wanted to work with just another medic. By that time it was mid afternoon and I figured I’d just stick it out.

Three ALS calls for the day. A possible CVA, a cardiac arrest and a fall/fracture that was ALS due to pain meds.

The CVA was really a marginal ALS call. The PT had some slurred speech and left arm drift. We did run a 12 lead as she had a history of Afib, got a dexi and we tried to get a line. No success. The transport time was short (under 5 minutes) so I suggested that we just load and go. Nobody disagreed, and off we went, code to the ER.

Shortly after that we responded to an Extended Stay motel for a “Citizen CPR”. Young adult male, unknown down time. Best guess? “Awhile.” The guy was at least 300 pounds and gray when we arrived. He was asystolic on the monitor and that never changed through 40 minutes of ACLS. I did attempt to get the tube, but no dice. The guy was huge. A Mallampati Class 4, no neck and his jaw was pretty rigid from the extended down time. But, I figured I should give it a go. The medic handed me a Mac4. (not my choice. I wanted a Mac3, due to the size of his mouth.) I grabbed a pillow off the bed and crammed it under his shoulders, stuck in the laryngoscope to take a look and couldn’t see the cords. I mean, I couldn’t see nuttin’! He had very little jaw excursion and it was tough even getting a look. One of the other medics switched places with me and just shoved the tube in while I gave some cricoid pressure. He told me he didn’t see the cords either and just went for it, hoping he’d hit the trachea. Good bilat breath sounds and the capnography was showing a good wave form with ventilation. Luck? Experience? Maybe some of both.  I wasn’t comfortable enough to just try and jam a tube in blindly. The guy also had no veins and he wound up getting an IO drilled in each tibia and we pushed drugs that way. We worked him for 40 minutes and after we called it, the story we got from the cops was that he had a history of sleep apnea and took a bunch of Percocet with his buddies … and that was that. Lots of help on this one. There were 4 guys on my Medic Unit and we had an additional Medic Unit and an Engine Company. So aside from the firefighters and cops, there were LOTS of medics on scene. At least four, plus me (the 1/3 medic.)

Later in the afternoon we rolled to a call for a mid 50’s female that fell and dislocated or fractured her ankle. It was on the verge of becoming an open fracture, so we did a pillow splint and got her in the truck. It took a long time to find IV access, as she had no veins. She eventually got a 20 in her hand, some fluid and 10mg of MS that really took the edge off by the time we arrived at the ER. Personally, I think I would have lingered a little longer on scene to get the IV and some pain meds (and maybe some Diazepam) on board before we took that long, bumpy ride to the ER. But that’s a personal preference thing.

The rest of the night was quiet. Pizza for dinner, got a lot of studying in. However, I don’t know if I’ll go back for a ride with that shift again. I guess I just have to take what I can get.

I’ll admit, spending long shifts in a fire station is a little awkward at first. I have a history with Fire, so I know the rules. But, it seems that some of the other students didn’t and that makes it rough for all of us. When you’re a student doing ride time at a fire station, you need to remember you’re a guest in someone else’s house. I’ll write a full blog post on “how to behave during field shifts” in the next day or so. I think it’ll be valuable to anyone who is nervous or unsure about what to expect and how to act. The EMS part is easy… it’s what you do for the other 22 hours that you need to think about. Here’s a couple of big tips; don’t argure with your preceptor and always do the dishes!

Okay then… Today is Sunday so that means some football, some studying and early bedtime to get up and ready for my final ER shift in the morning.

Wednesday is lab day at medic school. Most of the people in my class groan on Wednesday, because everyone knows it’s a day where you have to have all of your ducks in row and you’re expected to be able to treat patients appropriately. We worked through 6 stations today including assessment, static cardiology, electrical therapy, med math, intubation practice and more IVs.

Maybe I’m weird, but I love Wednesdays. When I do a lab practical, I look at the whole thing as a game. The objects are simple: Follow all the rules, get as many points as you can, don’t step off the cliff with a critical fail and allow your “paramedic presence” to grow.

I think my two favorite practical stations are Medical Patient Assessment and Static Cardiology. Anyone who’s been through medic school knows the drill. For patient assessment the proctor gives you a scenario and follows along with the National Registry check sheet. Fun! Static Cardiology is just “read ‘em and treat ‘em.” You’ll be handed a sheet with some info and a strip.

78 year old man, weak and dizzy for past hour. HR: 52, BP: 112/62, Resp: 14

Now, go! You’ve got to identify the rhythm, and treat him appropriately. Do 4 of those in under 6 minutes.

Yeah, I know it’s beginner stuff but it’s still simply a blast. I love this class.

Well, I survived my first ER rotation. Got a fair amount of sticks in. Unfortunately there were more attempts than actual patent, unblown lines, but hey… all good things come with time. By the end of the night, I hit every one I tried. So, I guess that’s a good thing.

We’re still cranking our way through cardiology and the cardiac pharm. Big quiz today and I think I did pretty well. It’s always a positive sign when you can identify the rhythms and answer all of the questions. There weren’t any head scratches on this one.

So, I wish I had something exciting to tell you, but I’m just kinda wiped out. Between now and the holidays almost every minute is being sucked into the swirling vortex of ER and OR clinicals, field hours on the medic unit, the weekend ACLS course and the regular class/labs. It’s tough to try and have a life.

But no whining. I wanted this and damn it, I will muscle through.

…as soon as I take a nap.

That poor bastard, all he wanted to do was make a nice home for Virginia Ventricle…

Read the tragic story here.

You’ll never look at heart blocks the same.

Thanks AD.

If you’re in A&P or thinking about taking the class before you apply to medic school, here’s my big tip:

Any time your teacher mentions the sympathetic or parasympathetic nervous system or acetylcholine, PAY VERY CLOSE ATTENTION!

…and if you don’t understand it, ask as many questions as you need to.

It’ll come in handy later.

That is all.

One of the things I enjoy about being a paramedic student is learning the rituals. All the tried and true patterns of practice. I take comfort in the fact that mnemonics and acronyms have been coined and refined to make the actions of the job automatic so my mind can focus on interviewing the patient and getting to crux of the problem.

A firefighter in my class said, “If you go blank on a call, just fall back on VOMIT HAM.” I looked at him questioningly. “VOMIT HAM,” he said again. “It’s easy to remember when all else fails. Vitals, oxygen, monitor, IV, transport. And History, allergies and medications.”

I love all of those abbreviations, memory aids and mnemonics. OPQRST, MONA, “My Baby Looks Hot Tonight” and the Rule of 9’s. All simple ways for us to remember the basics, so your hands can do the work automatically while your brain looks at other things. Of course some are used so infrequently that you know they mean something, but you just can’t quite remember what it is … like APGAR.

I spoke with a friend of mine who sneered when I told her I liked mnemonics. She told me that I wasn’t getting an education, I was only getting trained. I disagree. If I don’t know WHY I should give ASA, Nitro, MS04 and O2 to a patient with chest pain, it would be a different story. Is it bad that I use the “Big Lie, Little Lie, No ass at all” mnemonic to remember the sections of the heart that are interpreted by the various leads? Or how about what we all learned when we first put leads on a patient, “white on the right, smoke over fire”.

Frankly, I have so much information and education to soak up, I’m happy to have a few mnemonics to stick in my back pocket to help me out. As long as I don’t have to VOMIT HAM too often, all will be good.

I was tasked with writing an opinion paper on CISD for my “Well Being of the Paramedic” course that’s part of my medic school’s curriculum.

Names and locations have been redacted.

I’d like to hear your thoughts.

The line of duty death of a coworker, a tragic accident involving a child or a serious mass casualty incident are all critical events that may trigger powerful emotional responses in the parties involved. Due to the nature of the work it would seem that Fire, Rescue and EMS workers would be at the greatest risk for the development of posttraumatic stress from these incidents. Created as a peer driven stress management tool, Critical Incident Stress Debriefing (CISD) was developed to help those exposed to such incidents deal with their emotions. However, since it’s inception, the idea of critical stress management has polarized many EMS workers. The simple idea behind CISD, to prevent or limit the development of posttraumatic stress in individuals exposed to critical incidents, may in some cases exacerbate the stress these individuals experience. After interviewing several individuals that have taken part in the CISD process and recalling my own personal experience with the CISD process, I can argue that while some I spoke with did receive some emotional benefit from the CISD process, each individual’s emotional coping skills are different, and a “one size fits all” CISD counseling session for stress management may do more harm than good in the long term.

In conducting interviews for research, I used a posting on the popular online EMS forum XXXXX.com to solicit responses from EMS professionals who have been in the field for longer than 5 years and had taken part in a CISD event. I received numerous responses and sent standard interview questionnaires to the individuals. I received four complete responses that met my criteria and used these questionnaires, along with specific follow up questions and telephone interviews, to frame my opinion.

I spoke at length with XXXXX, a ten year EMS veteran, who is employed as flight paramedic for XXXXX. XXXXattended her first CISD in 2003 following an incident where an acoustics manufacturing plant sustained a significant explosion and fire, which injured over 40 people and killing 17 in XXXXX XXXXX. After hearing the details of the incident and how the CISD was planned for the team of emergency responders, I asked XXXXX how she felt about the CISD process as a whole. She replied, “I became frustrated during the CISD process because I felt I was pressured to give responses I hadn’t quite come to grips with yet or really had the chance to sort out for a bit myself. I’m a very private person by nature and didn’t appreciate people trying to pry emotions out of me that I wasn’t comfortable expressing to those I didn’t know, which was ultimately the reason I got up and left. I prefer to deal with a few close people I know rather than a large group. I also wasn’t comfortable with the fact it was a forced attendance.” I was surprised to find that this CISD event had a mandatory attendance requirement and XXXXX agreed, stating, “It seemed almost as if they were forcing us to relive the event when we were discussing things … We also felt we would have been better served by a more informal process with simply the offer of additional help if we needed it rather than being thrown in front of a social worker and told ‘Okay, express yourselves’”. XXXXX went on to say that following the formal, mandatory CISD, she took part in several informal gatherings with her crew members and found that in the informal setting, she was better able to evaluate her performance and actions. XXXXX said it took a long time for the memories of that incident to fade and went on to say, “I have very adverse feelings to a formal CISD as I think it actually intensifies the incident and prolongs the recovery period from it.”

I also spoke with XXXXX XXXX, a six year EMT-B from the XXXXX Rescue Squad in XXXX. XXX took part in his first CISD following an unsuccessful pediatric resuscitation. In direct contrast to XXX’s experience, when asked about his experience and why he attended, XXX said, “It was definitely non-mandatory. All of the personnel were invited. I went simply because I felt slightly disturbed by how the family thanked me after I was unable to revive their loved one. I didn’t feel that I should’ve been thanked.” I then asked how he felt about the call and it’s outcome following the CISD event. XXX replied, “I felt more validated and eased in my mind about how I did things.” Even though XXX received some positive feedback and appreciated the opportunity to talk about his feelings following the incident, he was reluctant to recommend the CISD process to other EMS workers, stating, “…simply because what works for me won’t work for everyone else.”

As for my own experience with Critical Incident Stress management, I took part in my first CISD in 1990, following an MVA with multiple fatalities in my hometown in XXXXX. I was the first EMT on the scene and was assigned to triage. It was immediately obvious that two of the patients were DOA and several others would require lengthy extrication. Making this chaotic scene even more emotional was the fact that several of the victims were young adults I knew from High School. The day following the incident, we were all invited to a CISD workshop at the Firehouse. I attended, not because I was having difficulty in dealing with the emotional aftermath, instead I was goaded into attending by the repeated urging of my Chief. During the CISD, I recall being repulsed by several of the other firefighters in my department referring to the trapped occupants as “hamburger” and “DRT” (Dead Right There). The braggadocio and swagger that was on display from my fellow EMS workers upset me more than the actual event. I didn’t say much during the entire event. I recall sitting on my cold metal folding chair, sipping cold coffee from a Styrofoam cup, listening to each member of my crew speak, knowing that it was important for me to listen and my just being there was helping to support the crew. I later spoke with the CISD facilitator about how I was feeling about my crewmembers and he explained that often people covered their shock and emotions with bravado, and that if I had problems I should talk to him. I never did talk to the CISD facilitator again and I continued working in EMS for several years following that incident. After the experience I had, watching my crew, I doubt I would attend a CISD event again. I’d much rather talk it out with my partner, a close friend in EMS or my priest.

As EMS professionals, we will be exposed to critical incidents as a matter of course and it is clear that dealing with Critical Incident Stress is an important part of maintaining the health and well being of the EMS worker. However, I believe that a formal Critical Incident Stress Debriefing, no matter how innocuous or well meaning the intent, may force individuals to attempt to cope with these stressors before they are emotionally ready and willing to face their coworkers. Instead, I feel that department leaders and EMS management should adopt a flexible strategy to deal with traumatic stress situations. A more fluid, less structured and rigid plan, based on the needs of each individual, consisting of informal chats, the freedom to take personal time or the offer of mental health professionals or counselors could be the next step in replacing a regimented, formal, and in some cases mandatory, Critical Incident Stress Debriefing following a traumatic event.

We had our midterms yesterday. 150 multiple guess questions. 150 A,B,C,D scantron choices.

I did okay. Not great, but okay.

I finished with about a 90%, since the instructors threw a couple of questions out. It worked out to 132 correct out of 147 possible questions. I guess that’s not bad, but I still feel like I could have, and SHOULD have, done better. I will next time.

I’m all checked off on Med Administration, IV starts, Blood Draws and ET tubes. Now, the fun begins. We’ve been assigned our ride locations and next week we’ll get our ER and OR assignments for the next 6 weeks. I’m pretty excited to get movin’.

Cardiology and Pharm is the main focus for the remainder of the quarter.

Oh yeah, I did suffer a grievous puncture wound at the hand of a fellow student who held the IV cath like a harpoon. He let fly like one of the Japanese fishermen on “Whale Wars”. I looked down to see the cath buried to the hub at an almost 90 degree angle in my forearm.

“Muthafu…” I bit my tongue. “Can you please take that out? I think you went through the vein.”

Now I have a HUGE purple and green hematoma that looks like a Martian  sunset on my arm … and when it’s my turn to stick him again, he’s gettin’ a 16. Or a 14, if I can sneak one past the proctor.

I’m back home after 4 days in New England. It was great to see the friends and family, but oh so nice to be sleeping in my own bed last night.

Allergies suck.  Dipnenhydramine is good. Although I seem to fall asleep in the middle of almost ever… ZZZZZZZZZZZZ

Quiz and test scores still near the top ‘o the class. Good stuff. I got my medic unit ride assignment yesterday. I’ll be spending the next 5 months on a truck in the county north of Seattle.

If you haven’t read Epi’s blog lately, go HERE and read. She’s having a rough go of it.  Kids are tough.

I’m off to lab. More IV starts today. I’m not looking forward to having lines  started on me by some of the ham fisted goons in my class. And anyone who says, “I’m gonna float it in…” is gonna get punched.

Yeah baby! I am rackin’ up those frequent flier miles! When I fly somewhere, I make sure it counts!

This weekend, I’m off to the great state of Connecticut (via Providence Rhode Island) to see my folks and on Saturday night I’ll be zipping up to Portsmouth New Hampshire to see some old friends from my radio days.

Lucky for me it’s a LONG flight so I’ll have plenty of time to study my notes for the Paramedic midterm coming up on Thursday.  So far my quiz average is a 93 and I’m feeling pretty good about all of the material. Of course, I occasionally confuse easy stuff like the roles of potassium and sodium. I think I know it inside out, then when the quiz come, I totally blank. That’ll be fixed with this round of studying. Promise.

School is really clicking. Every Wednesday morning, our lab group, “PM lab,” meets for a couple of hours prior to the actual lab session. We dig out the gear and practice lines, rhythm recognition and all of the other skills that will help us work together as a team. ACLS mega codes are a few weeks away and we want to be a machine by that time. It was a great idea. We also meet as a whole class every Thursday for a couple of beers following the last lecture to defuse and unwind.  It’s a good group of people. There’s some very smart folks in that room. It’s a real treat to be in the same group with these guys and gals.

Okay. I’m off to finish packing my stuff for the next few days. See you after the weekend. And to all my friends in Fire and EMS, be safe.

This weekend my wife and I flew to the “secret location” to check out a potential job for her. It looks pretty good. They want her and offered her a stupid amount of money. Now we just have to decide if we can live apart for the next 8 months while I finish medic school in the PNW. We’ve lived in a split household before, when I moved to Seattle, she stayed behind to sell the house. It was 6 months of racking up frequent flier miles. Not fun, but certainly not something that was a marriage ender. We both know it’s the means to an end.

While she was interviewing, I grabbed the keys to the rental car and cruised around. I was checking out potential places to live, looking at the city… all that fun stuff. While I was sitting at a red light, waiting to jump back on the freeway, I looked to my left and saw a Paramedic rig posted in a parking lot.

“Aha,” I said to myself, “I’ll go pick the brains of those guys in the truck.”

So I pulled in, introduced myself and spent the next 45 minutes discussing the pros and cons of their system, their protocols, pay, morale and everything else. Score!

First, it was a dual medic truck. That’s very nice. It was also a decent truck. It was clean and neat, Phillips monitor, standard load out for a medic truck. The medics were in crisp, neat uniforms. The condition of the rig and the guys in it says something about the company, don’t you think?

An additional plus, the medics were both really nice. Very forthcoming about the pros and shortcomings of working for *****. (Yeah, I’m not saying the name. Sorry.)The pay? Not too bad. The protocols? Not bad. They’re doing hypothermia for cardiac arrest but no RSI. “We’re mostly dropping King tubes,” the medic told me.

So, I asked about turnover. The senior guy on the truck had been there for 13 years and there wasn’t a lot of turnover. Sweet. How about quarters? They do System Status Management. Ohhh no. That sucks. I asked if he tought it would be difficult for me to get a job there. He looked me over and said, “If you know your shit, we always hire good medics. We like to hire older guys, too. There’s less cowboy in ‘em.” Then he grinned at me.  I shook his hand and said thanks and got on my way.

Hmm. Sounds promising.

It seems like an okay job. Morale is pretty good, there’s decent pay and the trucks are mostly dual medics. The downside, SSM and 12 hour shifts, no 24s. I guess you gotta take the good with the bad.

We’re flying home tomorrow and we’ll decide if we’re going to make the move or not within in the next day or two…

I wish I could say that I spotted it right off the bat. That I stood up and said to the firefighters crowded into the small room, “Hey guys, somethin’ ain’t right. Let’s get a medic here now!”

We marked on scene. I knew we were in the area. The fire apparatus parked on the street corner was a dead giveaway, but I couldn’t find the house. I double checked the address on the MDT. It should be right here.

“Where is this damn place,”‘ I muttered to my partner as I checked house numbers with my flashlight, walking from mailbox to mailbox.

A little kid with no shoes ran out to the street to wave us in. The small house was tucked behind a chain link fence and a stand of trees at the end of the dead end street.

When Mark and I walked in, we found the tiny house was packed with furniture and relatives and a steaming rice cooker. It smelled like a luau and  felt like a sauna. A crowded sauna. Tropical music was blaring from a radio as I walked toward the pile of BLS gear in the hallway.

The guy was 350 pounds if he was an ounce. The guy was sprawled on the queen sized bed, looking like he had the flu. The guy had said he’d been ill for the past week and now he felt weak and crummy and wanted to get checked out. The guy wanted to know if he could just skip this “ambulance stuff” and get a ride to the hospital from his wife.

“I started feeling really lousy about 5 hours ago,” he said. “My wife made me call.”

“Any pain in your chest?”

“Nope.”

We went down the list, asking the questions. Abdomen? Nope. Short of breath? Nope. We were looking for anything that might suggest this was more than a guy who simply didn’t feel well.

Yeah, his BP was high, but it was always high. He wasn’t compliant with his meds, he said. He couldn’t remember the last time he took his Lisinopril or HCTZ.

“Yes,” he said when we asked him about other medical issues. “I have diabetes. I take Glipizide and I just had some juice. I thought that my sugar was low and that’s why I felt crappy.” His BGL was 110.

His O2 sat was about 92% on room air. We got him on the cot, and I put him on 3lpm on a nasal and his sat went up to 96.  It was a big effort getting the guy into the truck. It took 4 firefighters to help load him. They handed me a SOAP, and off we went.

As we were en route, I was doing another exam in the truck. I noticed his pulse was kind of thready, but rapid. His BP was 200 palp and he was diaphoretic and cool to the touch. In clinical terms, he was looking like crap.

“Shit.”

I told my partner to put his foot down and get us to the ER. I swapped the guy over to a NRB at 15.

We rolled in to the ER and the RN said, “Is this the ‘been ill for a week’ guy?” I nodded and said, “Yeah, but I think it’s an MI.”

Zip! Off to a Cardiac Room, quick 12 lead and yep, it was an MI. “Wow,” the doc said. “Look at that ST elevation in V2 and V3.”

I had guessed right, but felt like shit.

We were so focused on the fact that he was denying chest pain and any of the other typical MI symptoms that we didn’t even consider that it might be cardiac.

Now I agree with the guys that say every patient deserves an ALS evaluation. Some Nitro for vasodilation was defiantly in order. Aspirin? Yeah, that would have been nice too.

Am I going to look at every “sick/unwell” patient a little closer? You’re damn right.

I’m not a medic yet. I have a lot to learn. And I don’t know about you guys, but I use almost every call as a learning experience.

During a break in the pathophysiology lecture in school this morning, I spotted a TXT on my phone from my old partner…

So this is how EVERY call went last shift, “My elbow hurts, it’s been hurting since 1967 and I just can’t take it anymore, and I want to go to St. Faraway Hospital.” I’m not kidding. FML.

Oh damn… that’s nothing but a bad shift, considering we did about 12 to 14 calls per shift on that truck.

I’ll take a pathophysiology lecture any day!

Before I say anything else about medic school, let me say this … if you don’t like to read a lot, or have difficulty in comprehending dense textbooks, medic school is NOT for you.

The reading assignments have been substantial. And very dense.

Luckily for me, I’ve never had much difficulty in working over the text to get the important stuff out. I’m good with that. It’s not so easy for some of my classmates. One of the guys I worked with is also in my class and he’s admitted that he’s having a tough time with the reading already.

And it’s just going to get worse.

We’re into airway management and our first quiz on that is tomorrow. I’ve built a set of flashcards that address the DOT objectives and should get me thorough it no problem. However, I’m a little concerned about how in depth we need to be on all of this stuff. I mean, do I need to know all of the details on HOW a depolarizing muscular blocking agent works, or do I just need to know that the correct dosage of Succinycholine is 1.5-2.0 mg/kg? The instructors haven’t been really clear on that, so I’m just  cramming every bit of it into my head. Too much information is better than not enough, right?

Now, aside from the fact that I have been whipping out flashcards like a fool and reading and studying almost every waking minute, I have to be honest and admit that I love this stuff. This class is amazing and it’s where I was meant to be. I’m going to mine those instructors and docs and respiratory therapists and guest speakers to get as much info as I can from each of them. This class is the foundation of my education as a medic and I want to make the very most of it.

I worked a fill in 24 shift over the weekend in the eastern portion of district where I was recently working full time, so I knew the area pretty well, and was able to get to all the calls sans mapbook or GPS. That was sweet. It was also a VERY slow shift, with six calls total, so I had plenty of study time. As a matter of fact, we were able to sleep straight through from about 1 AM until 6, then up for a quick call, which we were canceled on, and then back to sleep for a couple of hours. It was most excellent.

As I alluded to below, I will be moving the blog to a new spot. I was invited to join a group of other EMS and fire bloggers at a new “blog portal” and I will be changing the URL to reach the blog and slightly redesigning the site. I’ll have more about that soon. It’s been tough to fit blog work in among the flashcards.