We've all been there

The job is for an 'altered mental status' at a local nursing home. The BLS gets there first and radios us to set up in the back of their bus. As they're coming down the elevator, they again radio us that this "could be cardiac related."

Relaxed, my partner throws a few new stickies onto the 12-Lead wires, and I continue scribbling the location details on the chart. As if by magic, the EMTs appear when they throw open the rear doors. "Nursing home staff found her this morning at 10AM, but they thought she just wasn't speaking because she was in a sullen mood, I couldn't feel a radial pulse or get a blood pressure" the quite petite and quite cute, young EMT tells me: Mr. Medic.

I glance at my watch: 4PM.

My partner puts the EKG leads on, and we both look at the monitor at the same time -- idioventricular beats only, at a rate of 20 bpm. Not good. In case you haven't guessed yet, this patient is completely unresponsive. Here we have the 85 y/o female who waited six hours for medical attention, and all of a sudden, now we are all springing into action. My partner and I move with the certain speed and grace that only a life hanging in the balance can instill in a man.

Oxygen. Intubation. Intraosseous Access. Assisted Ventilations. Fluids. Atropine. Pacing.

Our first line medical treatments... not a dent, not a change. We've run out of Standing Orders.

We call the doc and and let him know what he's about to get hit with. By this time we're racing away with every light and every siren blinking and yelping at full bore. "DOPAMINE!" the doc yells over the din. Barely time to look at the drug and we're pulling into the ER. A flock of nurses, a young, quiet Attending, us - the medics, a mass of people. More medical procedures the do, more hands flying around in a blur. Then calm. Order sets in. The routine kicks in again...
A nice stable blood pressure gradually sets in. The ventilator is hooked up, blood work gets sent, the medics go on their next job.


The following day I speak with the quiet young Attending physican. " A Save!" says he, but to what end? Only a stopgap in death. A crumbling levee against the tide of the inevitable. The doctors, can't wean our patient off the dopamine. Physically, she's probably moderately strong, but too long a hypoxic brain. Too much injury. The family makes their grandmother DNR. Six hours.

Green Medic

This just in! New medic in town! Oh baby, going to hit the streets!

After a year of classroom study and clinical rotations, I am a fully certified and rip-roaring, ready to go, brand-new Paramedic. The new gig is a very busy urban EMS system in the most densely populated county of the most densely populated state (New Jersey). I started last week and tomorrow is the last day of orientation. Since I'm a per diem, my first official tour of duty will be six days from today.

Now, you may ask, "Why cross the mighty Hudson River from your beloved City of New York for a job? You have five years experience as an EMT in your fair city, and trained as a medic in the same?" The most honest answer is "Uhhhh...?" So, with that affirmation in the hopes that I know what I'm doing, I embark to work in the Garden State twice a week; and for twelve hours on each of those days, 'County of 1,000,000 people': I will be one of the only six paramedics here to come at your call (assuming the dispatcher decides you need ALS attention!). Good luck crazy county, to the both of us!

Ho, crap!

Wow, what happened!


Paramedic school really beat the piss out of me. But at least I can now call myself Polarbear, NREMT-P!

With medic school over and done with, I think it's time to get back to this blog. New posts coming soon!

Old and Crusty

Anyone who's anyone in this game has seen "Bringing Out The Dead," starring Nick cage and directed by Scorsese. The movie is based on the book by Joe Connelly.

I found out when starting my medic class that one of the characters in the book is based on someone who currently works as a Medic at one of the places where we do ambulance rotations. There are lots of stories about this man, who we all know only as Marcus. Most recently, I heard him described as a "curmudgeon." I had spoken to him in the past about non-EMS related things and had thought that this was a fair description of his personality. We just didn't see eye-to-eye on things.

This past weekend I worked my first ever tour with this man, and was delightfully surprised. He was a pleasant enough individual, and true to the movie, some of the qualities portrayed shone through quite clearly. For instance: he drives sllloooowwww. Case in point: On our response to the Unconscious, I'm pretty sure we didn't exceed 7 mph.... with a clear path ahead of us... and our lights and sirens going.........! I just have to say... I understand being cautious,... but why stop at the green lights?

All in all, we only did one job, so I reserve whatever judgment I have on his performance as a Medic and a teacher... though I'm sure of this now: whatever criticisms I may have of him, he will never find out. There's only so much you can disagree about with a person who's been working the streets since 1978.

A real Paramedic?

It's funny, isn't it? At this point in time, I'm just about nearing the halfway point in Medic school. An odd accomplishment. The novelty of going to class and working the rotations has pretty much worn off. We've lost a number of students, so that the room where we have lectures is only half as full as on Day One. I've been the the NYC Morgue, the Operating Room, NYPD's Central Booking, and a number of other places where I didn't think I belonged a mere five and a half months ago.

I've learned a load of skills that I had only dreamed about performing, once upon a time, and actually done them on real people without any real harm (at least, no permanent harm). I've now started countless IVs, taken EKGs, and finger sticks. I've intubated people, paced and defibrillated people. I've carefully carted my City's poor, homeless, and hunger, to a safe place off the streets, where they could get a warm meal (and put up with the derogatory banter from everyone they came in contact with).

And yet, though we've studied Anatomy, physiology, pathophysiology, patient assessment, pharmacology, airway management, trauma, and pulmonology, we still sit on the cusp of cardiology and still have another six months of class to go.

One of my friends, who I know from school and from a volunteer ambulance corps, is a BLS provider. He asked me the other day, whether I was starting to feel like a real Paramedic? The truthful answer to this question is: No. I don't. I feel like an EMT who now can start IVs and intubate, etc.

A few weeks into class, one of my classmates came to lecture wearing a borrowed paramedic job shirt. He had just got puked on during a rotation and didn't have any extra clothes. Our instructor riped into him. "Do you really think you're ready to wear a white patch! Do you?!" he yelled. At first I thought this uproar was about paramedic pride. An elite group of few who protect their rank with indignant honor. Yet now, I think differently. I realize that the white patch is as much an journey of self, as of just completing the Paramedic course. The thinking is different from a paramedic as from an EMT, just as thinking is different from an EMT to a lay person. I can only assume that sooner or later my thinking will shift from BLS provider to ALS provider. But, until that time, I'm still just an EMT.

Sorry Boys.....

Note to self: Do not try to drive ambulance down steps in Central Park!

68

I wonder what it's like to wake up on a normal, beautiful, sunny and crisp winter day, go to a restaurant with friends for a bit of lunch, step outside, trip on a grating on the street, then fall into a coma and die?

As a paramedic student, I've been spending an awful long time in the Emergency Room lately. Mostly I'm there to help out -- you know, start IVs, do EKGs, take vital signs, etc., but also to observe. Thus I find myself observing a late-afternoon scamper as a notification from an ambulance comes in for a person falling from standing height, unconscious, being manually ventilated.

Doctors are literally pouring out of the woodwork. "Notify the trauma team!" screeches one MD, "Call neurosurgery!" yells another, "Does respiratory know?" asks a third. These people haven't even seen the patient yet, but already beepers and pagers are going off all over that block in Greenwich Village.

Finally, red and yellow flickering lights can be seen through the opaque doors of the ER as we all watch from the trauma room down the hall. Thirty seconds passes, then a minute. A doctor starts to walk towards the entrance, when... swoosh!... it slides open. Two medics are calmly and carefully pulling their stretcher towards the sea of green scrubs. The one at the head gently squeezing the bag at the patient's head every few seconds. They wheel him into the room and transfer this man onto on the hospital bed. A whirl of activity ensues.

Clothes are cut off. The medics are grilled by one doctor. Another nurse starts an IV and draws blood. Another doctor makes the decision to RSI (Rapid Sequence Intubation) the patient, a portable X-ray machine is suddenly in view. One doctor gets a brainwave: "This doesn't look like a trauma! There's no sign of external injury! Someone call the stroke team!" Ten doctors all working on one patient. Some independently of the others. How they know what another is doing, I don't know. Maybe they don't....

The decision is made to transfer the patient off the longboard and take off the collar protecting his cervical spine. I've moved outside the trauma room to talk to one of the medics who brought this unfortunate soul in. He asks me, "What do you think?" I shrug. The he asks me the question that's really bugging him: "Do you know why they're taking him off the board?" Again, I shrug -- they don't think it's a trauma I tell him; but I agree with him, if this were my patient I would leave him on the backboard. Both of us are powerless to stop the mass of doctors.

The process has finally reached an end. The patient is carted out for a CT of his head and any other body area they can think to irradiate. The show is over.

About an hour later I notice that the patient has returned. He's now in the main treating area, lying in bed, next to another patient, looking just like the rest of them, only this patient is on a ventilator. I ask the attending physician if I could look at his imaging. The CT isn't good. I massive bleed on the left side of his brain with midline shifting. On of the ventricles on the right side is empty. Essentially his whole brain is being squeesed through the only place where it can go: down through the hole which the spinal cord passes. I start to form a question, but the attending already knows what I'm going to ask.

"This was probably caused by his fall," he says, "There's nothing we can do. It's only a matter of time."

68 years old on a beautiful, sunny, crisp winter day.

New Year's Eve on 7W

After completing the first phase of our clinical time December 1st, I took a few weeks off to rest and prepare for the Holidays. Unfortunately, when I looked more carefully at the work I need to finish by April 1st for the second phase, I realized I was starting to fall behind. Thus finds our brave hero walking into the Medic room at ten minutes to 4PM on December 31st for the eight hour tour leading into 2008.

I would have preferred not to be working, but this is medic school after all, and sacrifices have to be made. I should be counting my blessings since I was able to at least get up to see my grandparents and family over Christmas. I know at least one person who was doing tours over that holiday.

Prepared for the worst, I knew an ALS tour in Greenwich Village on New Year's Eve could turn into hours of responding to the "Unconscious," aka people who indulged on too much Champagne. Also, the possibility existed that we would spend the entire tour in the throng of partygoers chasing ghosts in the crowds at Times Square, a mere 30 blocks north from our assigned station.

Lady Luck seemed to be with us however and by 7PM, we were just starting to head to our first job for the "Internal Bleeding" of a 95 y/o women. Pretty uneventful call. It wasn't even too stinky considering her chief complaint was a GI bleed. I couldn't get the IV on my one attempt (also my first attempt in the field), but I think that was more luck (and not so great veins) than lack of skill on my part. In fact, after doing about fifty or so in the ER, I'm starting to feel more confident with sticking people. Her B.P. was pretty low and one of my preceptors got the line in the pt's other hand to start administering fluids on the way to the hospital.

Hours passed until we got our second job. This one was for the unconscious, but on arrival, the pt has already disappeared. Seems like there were some ghosts haunting the City after all. I actually don't mind chasing after phantom patients. I prefer to be working than idle (or as it was, studying my trauma textbook in the back of the rig), but it amazes me how many resources go into this one 911 call. For example, this was a street job, and more than likely, someone walked passed someone lying on the sidewalk. They then flipped out their cell phone, hit the magic buttons, and next thing you know, I'm on my way, along with another BLS ambulance, a FDNY engine company, and a police car going to another scene where everyone is gone by the time we get there. Oh well, this is the age we live in. Cell phones are everywhere and people have just enough scruples to call this an emergency, but not enough to walk over the person lying on the concrete, shake their shoulder, and find out if their alright.

Returning to the medic station, we find the street we're traveling down blocked by a fire engine. We weren't assigned to this job, but the firefighters wave us in. We call ourselves flagged down to dispatch and enter the nice, quiet restaurant. At least it was quiet until six firefighters, two Paramedics, one medic student, and two cops barge in.

The patient is a middle aged women. Cool, pale, diaphoretic. History of MIs and COPD. Appears weak, and slightly AMS. Bystanders report a near syncope as she was eating her dinner. FD has her on O2, so we make our quick, ninja-like exit with the stairchair to the back of our bus. I've noticed that the medics are staring to trust us students a little more, so I have the responsibility of hooking her up to the 12-Lead, and getting IV access. Both completed successfully (22-guage in the right AC! -- Woo hoo -- first line in the field!). Her rhythms look good and the field diagnosis is vasovagal near-syncope. we dish her off to the hospital without any problems and it's 11:00 PM.

No more jobs for the rest of the night, but a couple minutes to midnight we all start to gather on the sidewalk outside the ER. Nurses, doctors, staff, medics, and students stand at 7th Ave and 11th St. in Manhattan. We can just barely see the ball, but when the fireworks go off, we all cheer and hug each other. A few quick minutes of celebration and everyone soon returns to care for their patients.

What a great way to bring in 2008!

National Politics of EMS

Fortunately, this is not a political blog, and the last thing I'm going to do is write a politics post. However: with all the presidential nonsuch beginning in just a few short weeks, I thought I would start looking into a few things...

Namely, I was surfing around looking at the different candidate's webpages and came across one that mentioned firefighters. Hmmm, I thought. Interesting. The next logical progression was to start looking for candidates that stated on their website that they were supporting EMTs and Paramedics. Unfortunately, if you were to do the same thing that I did, you'd be quickly disappointed.

So I systematically went through the websites of all the presidential candidates from the two major parties (as listed on washingtonpost.com) and checked to see what the candidates stood for:

The following candidates explicitly mention standing for Firefighters and Police Officers:

Joe Biden (D)
Chris Dodd (D)
Bill Richardson (D)

The following candidates had no mention of firefighters, police officers, or EMS:

Hillary Clinton (D)
John Edwards (D)
Mike Gravel (D)
Dennis Kucinich (D)
Barack Obama (D)
Rudy Guiliani (R)
Mike Huckabee (R)
Duncan Hunter (R)
Alan Keyes (R)
John McCain (R)
Ron Paul (R)
Mitt Romney (R)
Tom Tancredo (R)
Fred Thompson (R)




Now, as a member of the EMS community, the fact that no presidential candidate mentions anything about EMTs or Paramedics explicitly on their website (some say 'other first responders' -- but come on, what does that mean?) is troublesome to me.

This was just an observation I made that I thought I would share with you.

And by the way, if I made a mistake in looking at one of the candidate's websites, tell me about it in a comment or shoot me an email and I'll fix this post.


OK, this will be the last post I make on politics in a long, long time.

ER

In the ER today... 16 hours in the ER.

The good news: we were cleared on IV sticks this past Monday so I was able to get a lot of practice today.

The bad news: missed my first eight IV starts on real people before I got one patent line in.

(Good news again: I got five in a row after that... I'm on a streak!!)


Things were good and the nurses I was working with were very nice and very helpful. Entirely willing to teach... That is, until the end of the day, at 11:30PM when I went to get all my skills and attendance verification sheets signed by the Charge nurse... who said, "Who are you? I've never seen you before!"

Let me tell you -- If you want to beat your head against the f---ing wall, work 16 straight; performing skills and walking past someone all day and have them say that to you. I was about to deck her. She actually refused to sign any of my sheets! (I was able to get the nurse I was working with to sign me off, but technically, the charge nurse is the one who supposed to take care of that.) I really don't understand... it seems only in nursing that you find so many wonderful people doing a job, and yet... just as many bitches doing the exact same job.

I apologize for my use of profanity, but it's hard to convey my frustration to be on the receiving end of undeserved treatment like that after I spend so many hours of my Saturday (unpaid!) working my hardest to learn, doing my best to treat the patients and staff as respectfully as I can, and just generally being helpful... And all for what would have amounted to 15 seconds signing my forms.

A terrible end to an otherwise decent day.

I just hope that a good night's sleep and a day off will cure my newly instilled despair.

Something completely completely different

Found this today and thought it was an interesting read. Thanks to the original author at: http://www.math.canterbury.ac.nz/~m.steel/life.pdf

Advanced Provider

Oh my God! Oh my God! Oh my God! Oh my God!

I finally feel like a real-live advanced provider!

Tonight in class, I did my first IV stick!!!!!!!! Woohoo!!! (OK, OK, it was only on the plastic arm thingy.)



Yeah, yeah. I know all you Paramedics out there are rolling your eyes, and you nurses have already surfed away -- but to me, a lowly EMT for years on years, it seems like Neil Armstrong's 'One Small Step.' And albeit I have no idea when an IV is actually required. And I realize I have no idea what to do with it once it's in place. I also realize that there are still months and months left before I even think about considering myself a Paramedic. BUT GIVE ME A BREAK because I CAN START IVS!!!!

Pharmacology 101

Did I mention how my Medic school instructor is pretty cool. JB (as we'll call him) started the basic Intro to Pharmacology unit with us tonight (not where you memorize all the drugs, but where we figure how how drugs function).

Now if you were an instructor and decided to use a clip from a movie to show the exciting world of medication administration what would you pick?

The scene OD scene from Pulp Fiction of course!

What a great way to kill twenty minutes in class.


PS: Got a 90% on my A&P exam. Not as good as I would have liked (5 questions wrong), but who can complain?!

Tired

Whew! This was a tough weekend.

The guys at my volunteer squad back at school needed a hand with shifts on Friday night and they came to me. Since I'd been MIA for awhile, and like an idiot, I decided to help them out. Overall not a bad time, however, when it came to Saturday, I knew it was going to be trying to finish the day.

I decided I wanted some experience doing the overnight shift in Lower Manhattan, so to kill a couple birds, I took a double starting 3PM and ending 7AM Sunday morning, on a BLS truck for my clinical time. We were hopping all through day and into the wee hours. Some new experiences:

-Getting left on scene by the crew
-Sleeping in the back of the ambulance (max 35 min. at 5:15AM between calls)
-Picking up an inmate from a police precinct
-Having said inmate cry all over me
-Sort out the victims of a massive fight, including our patient, who, when asked "Would you rather go to jail with everyone else, or not go to jail?" picked "Go to jail."
-Sixth Floor walkup (is there a maximum number of floors in a walkup?)
-10 jobs in 8 hours, 16 jobs total.

Let's put it this way: when I finally walked into my apartment at 8AM, I was beat, and hit the sack. I also banged out of some tours I was supposed to do today.

Back to the day job tomorrow, and the Anatomy & Physiology exam is Wednesday night.

Let's hope I make it through the week....

Push

Finally... after nearly 5 years as an EMT, I get to push some drugs!

Doing some ride time for the clinical component of my Paramedic class, we get an Altered Mental Status (read: probably drunk), in a homeless shelter. And while after only two and a half weeks in class, I still don't really know squat, I saw the ALS AMS algorithm being worked. More importantly, the Medics I was riding with let me push the meds. OK OK, so I didn't have to think about anything and all I was doing was pushing plungers on the stuff that the Medics were handing me, but it was still a learning experience.

Here's what we did:

25 mg Dextrose (D50W, 50 mL)

followed by

Thiamine, 100 mg (100mg/ml)

and finally,

Naloxone 0.5 mg


After all was said and done, we talked about what we pushed and why. I also looked up the protocols, and sure enough, that was exactly what it said to do. One of the Medics, who is a 25-year veteran and usually based in the South Bronx (read: YIPES!) drilled in the Six Rights of medication administration, and scolded me for initially not checking what I was pushing.

Right Patient

Right Route

Right Dose

Right Time

Right Medication

Right Documentation


Overall, a great learning experience... and I'M EAGER FOR MORE!!!

Week 1 Done, and walking in my apartment door at midnight

Completing tonight's lecture marks 1 week and 1 day of Paramedic class over. Tonight was the first night where we stayed almost all four hours and got out at 10:15 PM. Previously we've been released between 8:30 and 9:00 PM.

We only covered Medical-Legal issues tonight and while the review was useful, it seemed really repetitive from EMT-Basic class. Though this time, instead of the instructor throwing out scenarios that we, the students, might encounter in the field, we instead asked the instructor if the actions we took while encountering those scenarios were legal. A few highlights from tonight's discussion:

"I'm a volunteer and we took a patient to the hospital on our rig. The ER was packed and we were waiting forever in triage. Since I had to get to my real job, I hopped a ride with another truck from my agency and left my partner at the hospital with the patient. Is that abandonment?"

"Our medical control physician works 8AM-4PM, so we don't have online medical direction outside those hours. Can I administer a med that usually requires online control and let the doc know the next day?"

"We got in a fight with the police, and after they Tazed my patient, they refused to allow us to take her to the hospital. The police threatened to arrest us. Do we have liability if the police take her away and she has a heart attack?"

"Can parents consent for their children over the phone? How do we get them to sign the form?"

"I can't believe how hard it is to RMA someone in New York, back in Jersey if the patient can move the pen, he can RMA. Is that cool?"

The Road of 1000 Miles Begins with the First... Day

The first day of Paramedic school is over. Things were pretty low key. We talked about course policies and procedures, expectations... and the insane amount of work: clinical and didactic coming up in the next year. I can't say I didn't expect it though.

We had today off in memory of 9/11 (this class takes place in Manhattan after all), and Day 2 starts at 7PM Wednesday!

Can't wait to actually start learning stuff!

If case you're wondering, you can see exactly which program I'm a part of here.

The Long Road Ahead...

Good Lord! PARAMEDIC School starts this Monday!!!! Whoa! Aaahh! Help!

Another Map

While existing as a bored, empty shell in my present state of insomnia, I created yet another map. This time, Google gets all the credit for the software and instead of charting all the Manhattan Hospitals, I have plotted the only the trauma centers for the Five Boroughs.

The map is available for your perusal here.

A short hiatus...

The past several weeks were hectic. During this time I took a break from writing here, but also had final exams and GRADUATED COLLEGE!!! You didn't miss much since EMS-wise it's been pretty laid back -- sans the job where I found out 'mostly but not completely - unconscious' patients don't like having NPAs applied.

However, I'm out of NYC for a short while and back in my little town in Upstate New York. One of the more interesting happenings in this suburban locale was the 80+ y/o female, driving her car along one fo the town's roads and managed to wedge it nicely between a hill and the utility pole she cracked. My FD was called for an extrication, but essentially all we had to do was open the passenger door and yank her out, easier said than done since the car was pointed downhill at about 70 degrees. Not so bad, the pt wasn't injured but after she told us she was "trying to avoid all the mud all over the road..." (I turned my head and not only was there no mud on the road, but it was dry and clean as a whistle), we decided to ship her off to the ER. No harm done and the power company replaced the damaged pole. The next day (I KID YOU NOT!), we're toned out for a PIAA (personal injury auto accident) on the same road. Turns out it's the same pole struck. Let's just say the power company wasn't too happy. No injuries noted, but this 80+ y/o woman is c/o back pain, so she gets boarded and shipped out.

I hear new telephone poles are going for $1500 these days. I wonder if Medicare covers...?