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.

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.

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.

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.

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.

Out of all of what’s listed above, I’m happiest about the new preceptor. If you read my “Lessons Learned” post, he was the medic on M11. After that call we talked for a while outside the ED and we really hit it off. Soon, the conversation turned into “Ya know, if you’re into it, I can to talk to our MSO and see if I can be your main preceptor.” Yeah. I was into it. I’ve ridden a couple of shift with him and the crew on M11 and it was a great move. He’s been a medic for 12 years and loves to teach. Loves to let students get in the thick of things and is still excited and interested in EMS, something that was rare with some other medics I worked with. It’s a really good thing.

We’re cranking through school. Toxicology, Environmental, OB/GYN all down and now it is all about trauma, pedis and geriatrics. PHTLS and PALS will be all I think about for the next few weeks.

We took a surprise quiz today that knocked everyone for a loop. At the end of the expected material there was an added bonus: two pages of drug calculations. Yikes. After not doing ‘em for a while it was a rude awaking. I’m digging out the drug calc worksheets and running through some problems this weekend. I won’t get caught out again.

Really, medic school is turning out to be a much better experience then I thought it would be. Everyone in the class is truly excellent. All are different, but each is a great patient care provider. I’m thrilled to work with all of them and I consider each a friend.

OK, it’s bed time now. I’m off to the ER tomorrow morning and then an OR shift on Monday Morning to try and knock out some intubations. Let’s hope everyone gets a tube and the Docs decide to NOT go with LMAs. Wishful thinking, I know.

Be safe friends.

I’ve been on some excellent calls recently. Calls that I’m sure seem mundane to my preceptors, but present me with a new learning experience every time I step out of the medic unit. Every chest pain call is an opportunity to hone my assessment and interview skills and tighten up my IV skills. I’m working hard on delegating tasks to the EMTs and other medics with me. These guys and gals want me to run the scene and they’re poised, ready to jump when I say the word, all to help me succeed. I just need to tell ‘em what I want. And that’s a little hard, when sometimes I don’t know myself. But I’m getting better.

I made some mistakes over the past few days. I’m moving fast. Sometimes too fast. Going down the checklist in my head at a chest pain call at 2 in the morning…

“Okay, Tom, let’s get this gentleman on the monitor and some O2… Dave, can you grab me another set of vitals while I get the aspirin and nitro?”

Tom, my Medic preceptor, hops right to getting the patient on the monitor and some Os flowing on a cannula while Dave, the Firefighter EMT that’s with me, looks up from his BP cuff and says, “As soon as I’m done here, I’ll go spike a bag for you and set it up in the truck. I’ll make sure to set the nitro next to your IV roll.”

“That’s great, thanks Dave.” I mouth a silent “thank you” in his direction. He winks back.

And don’t think that Tom didn’t catch that. On the way back to the station after that call Tom asks in the headset, “So, how’d you do?”

I review the call in my head before I answer. I had a great rapport with the patient, we were laughing and joking on the way to ED. I did an great Q&A. Got a 12 lead in the first 5 minutes in the door, got ASA on board quickly, got an 18 gauge in the right AC while we were en route…

“Well,” I start.

Before I could go any further, Tom says, “It was pretty nice of Dave to save your ass with the Nitro, huh?”

“Yes. Yes it was.” I answer slowly.

These guys aren’t out to bust my balls. They’re working to make me the very best medic I can be. And I appreciate that. That’s why I don’t mind helping with chores around the fire house or cleaning up after dinner. These guys don’t get paid to teach me. They like teaching. And I appreciate it.

And yeah, I wasn’t gonna give that guy any nitro ‘til I had a line. I know better than that. But Dave was there to back me up.

I love riding with these guys.

I wake with a start when the red light in my bedroom flicks on and the tones blare from the overhead speaker.

“Medic 22 with Medic 11, upgraded ALS response for a traumatic fall…”

I hop from my warm bunk and stuff my feet into my still warm boots and walk out to the bay and climb in the medic unit. I settle in the back and put on my headset. The captain turns to look at me through the pass through.” This is for you, ya know. 11s doesn’t need the help, but they know we have a student so they called us in.”

As we speed down the quiet streets, the radio mutters updates in my headset. “Bagging the patient.” “We need your C-Spine gear.”

We show up to a mess. The patient is a 50ish year old guy who had either been assaulted or had a standing ground level fall. Either way, it doesn’t matter. He’s in bad shape. A mushy occipital fracture, decorticate posturing and an airway full of blood means he is getting a tube.

The medic on scene finished starting the IV, lookes up at me and asks, “Can you go set up my truck to RSI this guy?”
“He looks to be around 150 pounds?” I guess.
“Sounds about right.”

The firefighters get to work packaging the guy on a board while I run over to Medic 11 and grab the intubation roll. I set out a 7.5, a mac 3, and  pull the bougie from the airway cabinet and lay it within reach on the bench. Then I start drawing up the drugs. 140mg of Sux, 20 of Etomidate, the Vec, the Versed. I label all of the syringes and carefully place them in order on the counter next to the head of the stretcher. Suction? Set. Vent is out and plugged in. I am as ready as I’ll ever be.
The stretcher comes crashing and rolling into the back of the rig. The Captain is bagging, the guy is seizing. A firefighter I don’t know is holding the man’s arms to keep him from pulling the mask from his ruined face. 11’s medic asks me to get a BP as he pushes some benzos. As I pump up up the cuff I hear the medic tell my preceptor, “No, you can go, I’ll just take your student.”
Monitor on, pulse ox, capnography showing a good waveform.
Down the road we go. Blood everywhere. The suction thrums, slurping in the guy’s mouth.

The medic asks if I think I can get the tube. I tell him I’d give it a shot.
“This is going to be a hard one,” he says. “He’s got a bunch of facial trauma, his airway is full of blood, he’s in a C-collar…” He trails off, looking at me expectantly.
“Well, no time like the present,” I say.

He smiles as he pushes the Etomidate and Sux while I pick up the laryngoscope in my left hand.

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.

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.