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.

One of the final papers I had to write was for a class called “Studies in Contempoary EMS”. It was kind of a fun seminar class where we read research and debated. The last assigment was to answer questions about a fictional EMS agency that you were running. The questions are related to system structure, funding, staffing, protocols and research. I decided to write my paper as a letter to the program director, as if he had called looking for info.

Enjoy. (And yeah… it’s all fictional. I mean, Happyville? Really?)

May 26, 2010

Joe Blow
XXXXX Community College
1111 South XXth Street
XXXXX, WA 12345

Dear Joe,

Thanks so much for your phone call seeking information about the newly formed Happyville Emergency Medical Services Authority (HEMSA). As you may have read in the JEMS article that featured our service, Happyville is a mid sized community of approximately 45,000 people which had been served by a BLS level volunteer Fire/EMS agency for over 20 years. Through attrition, the volunteer agency suffered a decline in membership and there was little interest from the remaining members of upgrading the service to an ALS level. In 2008, an initiative was raised, proposing the creation of a municipal EMS authority, similar to other agencies that follow the Public Utility Model (PUM) of EMS delivery. In late 2009 the initiative was passed, the initial operating funds were earmarked for development of the system, the EMS assets of the fire department were transferred to the control of HEMSA and we began operations as the primary 911 response agency for Happyville and the areas surrounding the city in unincorporated Smirk County in January of this year.

Many people have contacted me about the funding and operations of HEMSA, asking why we decided on implementing a modified PUM, rather than simply placing the EMS services out to bid, as many of our neighboring communities have done. As a public utility model, we found that as a non profit agency, HEMSA, in conjunction with the municipality, was able to develop a professional work environment for our employees, develop stringent response time guarantees, implement a full ALS response to every 911 call without screening BLS vs. ALS, and we are more effectively able to fund the system through a combination of general fund allocations for capital improvements, nominal charges to city residents that appear on the utility bill and insurance reimbursement. As you well know, in these days of less than adequate reimbursement from Medicare and other insurance plans, it is difficult for an ambulance service to subsist on insurance reimbursement alone, yet HEMSA receives more than 70% of it’s operational funding from insurance reimbursement due to our utilization of a third party billing agency.

As a requirement of the Authority’s agreement with the City of Happyville and as a major point in our charter, HEMSA operates as a full ALS agency. That is, none of our units, with the exception of Non Emergency Transport (NET) units are BLS only. Our dedicated 911 units are currently staffed with a Paramedic and an EMT-Intermediate. While we believe dual paramedic units would be ideal in terms of patient care, at the present time it is simply not cost effective to staff our units with dual paramedics. However, our EMT-Is are encouraged to attend the Happyville Regional Community College paramedic education program and HEMSA will provide tuition assistance and a flexible schedule. If an employee of HEMSA completes the paramedic program and subsequently stays employed with HEMSA as a paramedic for 18 months, he or she will be granted full reimbursement for tuition. Joe, we’re a new program, but I feel that growing our own paramedics is a great way to build the team, and we currently have 4 of our intermediates in the medic program now, set to graduate in late June.

The question you asked about our protocols is an interesting one. As you may know, we have recruited an outstanding Medical Director, Dr. Mayhoosh Tyrotiside, who was instrumental in the development of the revised Paramedic protocols in Austin-Travis County Texas. Dr. Tyrotiside was involved in the initial hiring of our paramedics and considers the ability to apply critical thinking to pre-hospital medicine the most important trait of all when it comes to being a paramedic. Therefore, Dr. Tyrotiside developed protocols that are very liberal in terms of procedures, medications and on line control. As one example, our paramedics have done 36 hours of continuing education in the L&D unit at Happyville Regional and have been cleared to perform a field episiotomy if needed. In addition, we have very liberal pain control protocols with several options for analgesia including Morphine, Fentanyl, Dilaudid and Entonox. Joe, I can say without reservation that our paramedics are held to higher standards than most others in the state. Each HEMSA medic is required to spend one day per quarter in the OR with an anesthesiologist performing endotracheal intubation to demonstrate continued competency and once per year our medics will take part in a cadaver lab for practice of more invasive procedures. While our protocols are liberal, Dr. Tyrotiside believes in a strong QCI program and we conduct biweekly run review meetings where interesting or flagged cases are discussed and reviewed. These meeting are held as education, not discipline. Our paramedics feel that they are an important part of the patient care team and appreciate that fact that they are given significant leeway in treating patients, rather than forcing signs and symptoms into an algorithmic box.

As for EMS research, both Dr. Tyrotiside and I feel that research is an important part of what we do and the studies in which we take part, serve to help drive the future of EMS and medicine. At XXXXX in XXXXXXXX County, where I was employed before coming to HEMSA, we were involved in several research programs, including the hypothermia ICE study, RES-Q-POD ITD study and code/non code response time/outcome study. I encourage all of our paramedics to pursue research opportunities in areas that interest them. We assist with obtaining grants and provide administrative support. Research is not a condition of employment at HEMSA, but several of our medics are currently working on a retrospective study of fire based vs. PUM ALS response time and outcome, a study I’m curious to see. In addition, Dr. Tyrotiside and I are preparing to submit a proposal to the IRB for a pre-hospital study that examines the efficacy of Amiodrone vs Lidocaine in refractory VF. It should be some interesting work and our field staff is excited about the possibility of taking part in this project. I’ll be happy to share the details with you when we get the study approved.

Joe, I hope that answers your questions about HEMSA. We’re proud of what we’ve accomplished in the first few months of operation and we look forward to many years of continued excellence in patient care and serving the good people of Happyville and Smirk County. If I can answer any further questions about our operation, staffing, research commitment or protocols, please feel free to call my office or send an email. With luck, we’ll have an opportunity to connect in person at EMS Expo in Dallas this fall. I’ll be speaking on mid sized cities and the PUM model on Friday. Hope to see you there.

Sincerely,

ME
Executive Director of Operations
Happyville EMS Authority

I’m taking a break from writing papers and studying for the NR test. Tonight I am working on a fantatic burger at The Counter, a super duper build your own burger/bar/restaurant kinda place. Just what I needed as I continue my quest for the world’s best burger. (so far the leader is a burger I had in Bulgaria. Freaking amazing.)

My back is feeling much better. The stretches and 800mg ibuprofen really helped.

I had a great session with my shrink today and as a result I’m in an amazingly good mood.

I’m laying in bed, thought I’d blog a few random thoughts.

I’ve managed to get a “fan page” for Medic 22 on facebook. If you’re a facebooker (and really, who’s not?) feel free to “like” Medic 22. If you do a search, it’ll pop right up.

I did something evil to my back yesterday. I took a shower and when I bent over to pull my boots on, my back went “eeeeeekkkkk” and now hurts like hell. I’ve been taking ibuprofen and I have of those thermal wrap heat things on it, but I’m still walking around all hunched over. I saw myself in the bathroom mirror and I looked like a question mark.

I did TWO calls on my last 48 hour shift. Yes, i was the white cloud. I could have stayed for another 24, but my back hurt and I wanted to get home. A few hours ago my preceptor texted me. “Dude! We are going non stop! 7 good ALS calls and two tubes. You shoulda stayed.” Balls almighty.

I feel really confused and unsure about some decisions in my personal life and I wish I had someone here I could trust to help me get through this. I sometimes feel like I’m swimming in a huge ocean by myself, and I’m on the verge of drowning. Am I the only one?

Gang, it’s another cold, rainy night … All I want is to curl up and get a good night of sleep and put my problems aside for a while. Take care… And be safe.

That was the text I just got from my preceptor. That’s all she wrote. I knew exactly what she was talking about.

I worked a code on a 12 week old on Saturday. We got pulses back and when we left on Sunday, the kid had been flown to the big children’s hospital.

We were all hoping for a good outcome. And by all, I mean every person working EMS over there. They all head the dispatch. They all heard fire on scene say “CPR in progress”. They heard us transport priority to the ED.

That was my first code as a team leader. It was also my first pedi code.

And yeah, even though we did everything right, it still feels pretty damn bad.

I just realized I may have NMS. I have some of the symptoms and I’m displaying some of the signs.

Damn.

AD wrote a post about it.

I’ve gotta fix that. ASAP like!

This is a BRLLIANT idea…and it’s one that can help each and every one of us. If you’re a medic, EMT, police officer, firefighter or a just a member of the general public, PLEASE vote for this project HERE!

Pepsi refresh is offering a $250,000 grant to worthwile projects, and this is one of the best!

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How will the 250K be Used?

$ 75,000 Filming and Editing
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I uncapped the 22g IV cath, like a knight pulling his sword from it’s scabbard.

“Schhhhhhiiiinnngggg!”

I held it up, appreciating how the bevel gleamed in the fluorescent shine of the overhead lights. I turned to the 6 year old, a cute little girl, staring at me with wide eyes, mouth in a perfect O, her earsplitting screams already echoing down the hall.

“Mom, I could use your help holding her still…”

Ugh. 7 procedures, but it looks like only 2 tubes today. I’ve been shut out by LMAs, conscious sedation and a patient refusal. Is it any wonder why paramedic students are having a difficult time in becoming competent with intubation? How do we learn if we never get to practice? With so few tubes for the student, I’m not surprised that so many people want to remove intubation from the paramedic’s scope of practice. Balls almighty! I’m not married to intubation, but I DO want to be good at it!

Well, there’s a lot going on in my life these days, and while I feel that sometimes I share far too much on this blog, it really works for me to have a place to write my thoughts and ideas. That was the original intent behind this blog anyway.

Okay. Where to start? How about medic school. That’s as good a place as any, I suppose. School is almost done. I’ve met almost all of the exit criteria and now I’m just working on the last couple of hundred of hours and hoping for another code. Not that I want someone to die, but I need a code lead to demonstrate that I’m proficient in ACLS and can work as a team leader. I’m really going to miss all the friends I’ve made in medic School. It’s been an amazing journey. Monday was the entrance exam for the next cycle of medic students. 91 people tested for the 24 slots, and true to form, our instructor bragged about his current class to the crop of perspective students. He said some rather flattering things about us.

My personal life? Well… that’s getting better too. Thanks to the help of a great therapist, my wife and I have started to fix the issues that have been plaguing our relationship. These came to a head during medic school and for a while, it looked like the 10 years I had with my sweetie were going to go by the wayside. I feel a huge sense of relief that we are working thorough these problems, and I can say that I’ve grown more as a person over the last year. Anyone who says medic school doesn’t put a strain on a relationship is a liar. It’s brutal. It chews people up and spits out chunks.

Internship? It’s been great. As I mentioned, I’m working in a very busy system on the East side of the Cascades. It’s a long drive from home, but worth every minute of it. Every shift brings really interesting cases and another opportunity to shape and grow my practice as a medic. As a student that’s a little bit older than most, I’ve got the benefit of age on my side when I walk into a house. Little old ladies just feel a little more comfy with a 40 year old guy than a 22 year old kid. Hey, I’ll take it. I’m working in the role of the “lead medic” and my preceptor and EMT partner act as my assistants and Sherpa. It’s really a great way for me to get a lot of practical experience quickly. This system is so busy, if you’re not spun up to the level of being able to run complex calls right out of the chute, it can be difficult to get your feet underneath you.

I also learned that as the lead, I need to set my expectations for the crew at the beginning of the shift. I didn’t do that a few shifts back and I made a huge mistake with the EMT that was on my truck. It was a pretty painful shift and made for a really awkward day. Needless to say, now when I work with a new EMT, I let him know my expectations first thing. It’s pretty simple. I say, “I like the patient packaged with a couple of blankets. When we’re in truck I want all the lights on and my preceptor sitting in the airway seat. I don’t need you or anyone else in the back, unless I ask. When I say I want a set of vitals in the house, that means BP, HR, Respiration, temp, Monitor, SpO2 and a dexi… unless I say otherwise. When we’re in the back of the rig, you don’t drive until I say “drive”. You don’t ever question my treatment in front of a patient or talk to my patient unless I say it’s OK.” I didn’t set these rules at the onset a few weeks back, and I got burned. I like to be a nice guy and get along with everyone, but I’m not riding on the medic unit for social hour, I’m working my practice… and I need to make sure my team is on the same page.

So…anyway. I’m getting ready to head to the dentist for a teeth cleaning and another 48 tomorrow morning. It’s almost over.

Here’s a quick update for the folks who may still actually check my blog.

Wow. All I can say is wow. This quarter of school is kicking my ass. I mean, literally, beating me into a pulp. I’ve been working 48s on an incredibly busy Medic Unit. As an example, last shift, our 6 crews of medics got 8 tubes. Only one for me, but still… we see lots of shootings, stabbings, serious car wrecks and overdoes galore. Talk about experience.

This week in class, I’ll be presenting a case study of one of my “interesting calls”. After the presentation, I’ll post my case study here for y’all to look at. It was a pretty odd case, and worth reading, I think. And don’t worry HIPAA freaks, I’ll redact any and all identifying traits.

I’m also writing a research/opinion paper on Paramedic Pediatric Intubation. As a medic student who frankly enjoys the opportunity to intubate patients, I’m disappointed when I read articles from Dr. Wang stating how bad paramedics are at intubation. Do I think intubation will go away as a paramedic skill… my gut tells me yes. But, that’s another post for another day. And yeah, I’ll post my paper here, too. It may make for some interesting discussion. Maybe I can refer to someone as an idiot again.

I continue to try and work at OAC as much as I can. I just got off a 24 that crushed me. It was call after call after call… and, to add insult to injury, we’re doing double reports, as we get ready to move to an ePCR system. It was a non-stop parade of folks who were classified DNNA. Don’t Need No Ammalance, yet we transport ‘em anyway.

I need to run out and grab some lunch and take a nap. Folks, I miss you all…and I’ll try to be back soon.

I’ve been thinking a lot about the storm of controversy that my vigorous exchange with Tim Clemans caused earlier this week.

Not so much about the actual exchange of ideas, because I think the intent was good… more about how angry I seemed in my reply. How quickly I just blew up.

Folks, that’s not me. Not me at all.

But, as I reflect, ya know what? I feel really angry. I guess it’s not so much angry, as edgy. I’m just fried with school, my marriage has fallen apart. My dogs are gone, for God’s sake.

Things are shitty in Medic 22 land…

So, if you’re one of the haters that thinks I’m a huge jerk for telling Timothy what I think, I’m sorry. I really am. Try to forgive me. If you can’t get past it, well, you own that problem.

As I was planning before, I am taking a break from the blog. I hope I can come back some day, but frankly, all the fun is gone from this.

Friends, thanks for reading.

…and I’m on Twitter, even though I don’t tweet all that much. @medic_2_2

See ya.

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.

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.