Bystander Training

OK, OK, it's been nearly a month. I haven't had any good ideas, so I haven't posted. Deal with it.

As I write this, it's the first day of EMS Week 2012. All across the nation, responders are receiving an array of poorly manufactured consumer goods with this year's lame-ass slogan on it. This year, the theme is "More than a job. A calling." Generally, I agree with that, but if you really want to give me something nice for EMS Week, STOP calling. Just for a few days. I have enough hats, t-shirts, penlights, and other garishly colored trinkets. Give me a break. I need it more.

Other places, and my agency has done this in the past, use EMS Week as an opportunity to increase public awareness and for public education. As much as I dislike trinkets, I hate meaningless public education events even more. Puh-leeze, no more tours of preschools at the station. No four year old has ever gotten anything out of a station tour. They just want to see the fire trucks, hear a siren, andget back to school in time for snack. So do I, come to think of it. However, if you insist on doing the public education thing, I have some suggestions for presentations with a greater potential benefit to all involved than the typical "Meet the Medic" show:

1. "Ambulance or Taxi?" A discussion of what constitutes a genuine emergency and what is something better dealt with by your own primary care physician.

2. "So You Think You Can Tuna Dance?" You aren't fooling anybody with your fake seizure, so stop it. We all know what's real, and what's not. All you're doing is embarrassing yourself and entertaining us.

3. "Pain of 15 is NOT on The 1-10 Scale." I specified 1 to 10 for a reason. If you are with it enough to tell me your pain is a 15, you are obviously tolerating your pain well enough to wait until you get to the ER, and they can get you some Tylenol. You aren't getting the good stuff and the accompanying paperwork from me. Plus, I can easily tell by your vital signs if you're actually in pain or not, so I always know when you're BS'ing me.

4. "How To Count Your Drinks." Two beers? Right. That explains the case of empty cans in the back seat.

5. "There Are Lots Of Pink Pills." Seriously. Make a list. Not only does it prevent you looking like an idiot when we show up, if you are ever unable to give us your medical history, we can usually figure out the high points from the meds you take. so make a list, and keep it somewhere it's easily found.

6. "Going To The ER Means You're Still Under Arrest." Really, it does. Except going to the ER means hours longer in handcuffs AND bills from EMS and the hospital, so think about it before you play that card, K?

7. "Get The F#$% Out Of The Way!" And I don't just mean when you're driving. If you see us rushing into Wal Mart with all our equipment, don't follow us around. We're trying to work, and need a little space to do our job. If you insist on crowding around us, please have the courtesy to shower and brush your teeth before doing so.

8. "Never Do Anything You're Too Embarrassed To Explain To The Paramedics." It's amazing (Or at least it used to be.) to me how often this happens. Those of us in EMS are shocked by verry little, so you might as well give us the whole explanation about how THAT got stuck THERE. But by all means, feel free to leave out the details about the weasel. Some things really are better left unsaid.

9. "Drunks Are Fun." If we get called to see you, and determine that you don't have any particular medical issues at the moment, we will almost always take the opportunity to play with you for a while. It's fun to watch you try to make your brain work.

10. "No Exceptions." No matter who you are, where you are, how much money you have, or what the problem is, if you call us, we will come running. Every time. Even though most of us are volunteers working for no pay, even though those of us that are paid don't make a lot of money, even though we've been up all night, even if it's the middle of the storm of the century, WE WILL BE THERE. Hmm... maybe it really IS a calling.

Happy EMS Week to all my fellow responders. Stay safe out there!

The 5:30 Rule

Something I learned from my first partner was that there are times it doesn't pay to try to go back to sleep. The agency we worked for at the time, along with the one I work for now, say in their policies that crews have to be awake by 7 AM for shift change at 8. There are people that complain about this, but I'm not one of them. I live quite a distance from work, so my normal wakeup call is sometime between 5:30 and 6. I get to sleep an extra hour at work. Most of the time.

My old partner/FTO told me very early on that if you were up at 5:30, it usually didn't pay to try to go back to sleep when you returned to the station. The logic is simple. You've been up forat least an hour if it was a transport, a little less for a patient refusal. If you get back to quarters right at 5:30, you have about 10-15 minutes of paperwork to finish up (Get run times, log the call, PROOFREAD!), then if you're like me, you need  to pee. Now we're up to 5:45 at best. If I try to lay down, I can rarely go right back to sleep. I usually toss and turn for a while, especially if I had a really sick patient. I tend to replay every call in my head, trying to decide if I could have done anything differently. So now we're probably looking at 6:15 or so. My alarm goes off at 6:45, so that leaves me half an hour to sleep. I firmly believe that if you can't sleep for at least an hour, you shouldn't sleep for more than 20 minutes. (Normal sleep cycles support this. Much over 20 minutes, and you drop into REM sleep, which you really don't want to interrupt if at all possible. That first sleep cycle lasts about an hour or so.) So, since less than 20 minutes isn't really worth it, and I wake up groggy if I'm inside that 20-60 minute window, I don't bother trying to sleep at all. That's what coffee is for.

Corps Curriculum

Over the past few days, I've been able to reconnect with a lot of folks from my Marine Corps days. Mostly, it's been a bunch of people I served in Desert Storm with, that I haven't seen in the last 20 years. It's funny- all it took was a couple of people on Facebook, and the cascade began. This guy knows that guy, who knows someone else, who knows a couple other people, and so on. Before you know it, the friends list is expanding rapidly.

I know that most of you reading this are mainly in the EMS community, with some innocent victims from my life outside work thrown in for good measure. I enjoy writing about my life in the wacky world of EMS immensely, but it was my time as a Marine that really shaped who I am and how I operate today. I'd really like to pass some of those lessons on, but it's all stuff that can be learned, but not taught. I'll try to pass a little of it along, though.

Lesson 1: Always remember the 6 P's.- Proper Planning Prevents Piss Poor Performance. It seems obvious, and can be summed up even more simply. Set yourself up for success. That means that you need to take stuff like checking in the ambulance seriously. Check that the laryngoscope is going to light up when you need it to. Run a test strip on the monitor EVERY MORNING. Open the nitro bottle to make sure there are some tablets in it. As you pull up to a scene, figure out your egress route. Simple stuff that can make or break your day in an instant, all preventable with a few seconds' thought.

Lesson 2: Time spent in reconnaissance is never wasted. Neither is time spent eating, sleeping, or peeing. On every scene, take a minute to look at your surroundings. Is there something that poses a threat to you? I once responded to a difficulty breathing call at an upscale residence. My partner took the paramedic student in to the patient, followed by several firefighters. they assessed and treated the patient, loaded him on the cot and were heading out to the ambulance when one of the fire guys finally saw the .357 magnum revolver next to the patient's wife on the coffee table. I saw it when I looked around the room as we entered the house, and made a point of getting between the wife and the gun, then asking if I could make sure it was unloaded. I could, and did. Nobody else had seen it.

Lesson 3: One is none, and two is one. Carry at LEAST one spare of everything. Murphy's Law dictates that if you only have one of any particular item, you will lose or break it at the exact moment you need it. Especially pens. Never buy pens in less than a 4 pack, and carry as many as possible with you at all times. We still use paper reports, so I have a banged up aluminum clipboard that rides with me. It contains at least a half dozen pens at any given time, along with a dozen reports, two dozen EKG mounting sheets, two accountability tags, and a handful of paper clips. Every time I get on an ambulance, it goes with me. I have a cheap plastic clipboard back at the station, just in case. (Irrelevant side note: My aluminum clipboard is older than my current partner.)

Lesson 4: Never eat the MRE chicken ala king. Or the sweet and sour chicken from the hospital cafeteria. Both things look, smell, and taste like someone already ate them once. And the fruitcake makes it rain. (You 9th Comm people will remember that, I'm sure.)

Lesson 5: Nobody gets left behind. If three of you go into a scene, you better make sure all three come back out before you transport. Everyone that's been in EMS any length of time can tell you horror stories of the hoarder house with the rotten floor that someone fell through and got their foot stuck, or the wreck where someone slipped and slid into a ditch, or any of a million ways you can get into bad trouble on the job. So watch out for each other. Not just physically, too. If you've been on the job a while, you're going to be seen as a mentor, and the hard learned lessons need to be passed on. I'm a firm believer that only the painful lessons stick, but it's OK to forewarn the new kids so they don't get hurt as bad as you did.

I'm sure there are more, but I have a short attention span tonight, so I'll stop there for now. Stay crazy, my friends.

Sick Day

My daughter stayed home from school today, sick. Nothing major, she puked a couple times last night, barely slept, and still felt bad this morning. Nobody else was sick, so my son went to school, my wife went to work, and I'm on days off, so I stayed home with her.

Now, I take care of sick people for a living, so why is taking care of a kid with a mild virus such an undertaking? It's not like she needed a lot of care. She spent most of the day sleeping, after all. When she was awake, she was kind of whiny, but she didn't feel good, so I expected that. I warmed up some chicken noodle soup for her lunch, but that's pretty much all the care she needed today. So WHY did I feel like I spent the day trying to keep up with her?

She's better this afternoon. No fever, no puking, and she told me she's hungry. Back to school in the morning.

And can someone tell me, has kids' TV always sucked this bad, or is that something new?

They Said What?

So US News & World Report has declared EMS to be one of the top jobs of 2012. Even though EMS was classed as one of the ten WORST jobs of 2011, growth in the field, relatively decent pay and "excitement" all played into the decision to move us to the "A" list for this year. I'm thinking that magazine researcher might also be a good choice. It apparently doesn't require any particular effort or knowledge of the subject you're "researching". I don't want to scare anybody away from the field. I love it, after all, but the article paints a wildly inaccurate picture of the field. Let me give you a more accurate picture.

First off, if you're looking for excitement and glory, try pro sports. Sure, we have our moments. Some calls really ARE exciting, but most aren't. Let's face it, we very rarely get the chance to really save a life. Most of the calls the average ambulance runs are nowhere near "emergencies". We get a lot of calls from people that simply got scared, and just didn't know what else to do. Are they sick? Sure they are. Is it an emergency? Not really, but it could be if they don't do something about it fairly soon. That's where we come in. It's not that we can actually fix the problem, but we can reassure the patient while we take them to the hospital, where they CAN fix it. Seeking glory? Stay away from me. Those people are the ones that get themselves or their fellow responders killed. If you see my picture in the paper, it means I didn't see the photographer in time to duck behind a firefighter or hustle the patient to the truck. I like my anonymity, thank you very much. The glory hounds don't last long, for some reason they think hosing puke out of the back of the truck at 3 A.M. is beneath them.

Money? Right. Now in all fairness, my agency pays at the top of the scale for Kansas, so I don't have any real room to complain. Would I like more? Of course. But if you're looking at the field as a career, you need to remember that the vast majority of EMS providers in the United States are volunteers. They either don't get paid at all, or receive a small (VERY small.) payment for responding to calls. Sure, volunteering is a great way to build up experience and/or get noticed by the full time agencies, but there are a lot of areas that haven't got any full time ambulance service. Private services tend to pay poorly. My first job as an EMT paid $7.50 an hour, and we ran our asses off for that money. Public agencies tend to have the best pay and benefits, but you need to remember that you're dealing with a fixed budget every year, and a lot of government agencies have been forced to implement hiring and pay freezes recently.

Something the U.S. News article didn't mention is the conditions we work under. Most people have no idea what our job is like. TV either depicts us as incompetent bunglers, or as sociopathic burnouts. Occasionally, the burnout is allowed to experience some kind of redemption, and show some emotion in the form of that one subtly macho tear rolling down your cheek as the closing credits roll. It ain't like that, folks. There are days you'll see stuff that makes you want to puke, or scream obscenities with your middle finger extended to the sky. We deal with things that no human being should ever have to see. And when we're done, we clean up and DO IT ALL OVER AGAIN. No time outs, no commercial break, no fortuitously timed appearance by the world renowned brain surgeon who just happens to know the one obscure technique that causes the patient to miraculously make a full recovery. Nope. In the real world, that patient dies. And we get to stand there and watch it happen. Helpless. And then we move on to the next one. Every time.

Given all that, why the hell would anyone EVER want to do this for a living?

Because it's really a great job. Your coworkers will become like family to you. You'll laugh, cry, and everything else together. You get paid to hang out with your friends. If you look at the hours we get paid for versus the amount of that time we actually spend working, it seems like really easy money. Out of a 24 hour shift, we probably only actually "work" 4-6 of them. People respect you. They want to see you around, and they're glad you're there. Every so often, you get the chance to really make a difference. I've had quite a few people come up to me at the gas station, or in the grocery store, or in Walmart, and tell me that they remember the day I saved their life, or their child's life, or even a complete stranger. I don't remember it, of course. It's just another call to me most of the time, but it makes quite an impression on them. And that's a good thing. It means they'll tell that story to anyone that will listen, and eventually the whole community will know that no matter who they are, or where they are, or why they call, they CAN call, and we'll come get them.

I don't really care what some magazine I never read says about my job. I don't care if I have one of the "top" jobs in the country. That label, like most labels, is ultimately meaningless. What I know is this: This isn't a job, it's a calling. If you want in, you have to get in all the way, or you won't make it. It can be tough, and it WILL change you. But it's rewarding in ways most people will never be able to understand. so is it one of the top jobs? No. It's THE top job in my book.

Drama Activation

I'm often asked how many of the calls we get are legitimate. That is, how many people that call 911 actually NEED an ambulance? If pressed, I'd estimate that somewhere between 40 and 50 percent of our calls are true medical emergencies. The other 50 to 60 percent? Everything from nursing homes no longer wishing to deal with a difficult patient, to law enforcement officers covering their asses by calling an ambulance for the newly arrested person with the sudden onset of vague symptoms (Known in the business as "acute incarceritis" or "handcuff allergy".), to patients that just want someone (Not necessarily us.) to pay attention to them. The third group is by far the largest.

Chest pain and/or difficulty breathing are the afflictions of choice for the dramatic. Those two things don't necessarily produce visible symptoms, and thanks to years of public education, everybody takes them seriously. OK, almost everybody. To EMS providers, all calls are assumed to be bullshit until proven otherwise. We can usually tell in less than a minute or so if your complaint is real or not. We'll still do a thorough exam, of course. We ARE professionals, after all. But the whole time we're checking you out, we probably already know what the results are going to be. So seriously, don't try to bullshit us. We can see right through it. If you manage to fool us, you'll never fake out the cardiologist, and very few of them have a sense of humor to start with. Plus, they bill more than we do, and if we think you're faking it, by the time a doctor sees you, we've already told them you're probably not sick. You might wind up getting a very large bill for little more than sitting all by yourself in a room with no TV for six hours.

Fake seizures are also popular, and far more entertaining for us. We've been known to applaud a particularly good performance. REAL seizures produce some predictable symptoms, so if we don't see those, we assume it's not actually a seizure. Little hint- if you're trying to fake a seizure, wet your pants. Nobody ever thinks to do that, and it's actually relatively common in a real seizure. If you can arrange to lose control of your bowels as well, I'd probably go ahead and give you the valium, just as a reward for authenticity. Plus it'll keep you from doing it again, at least until I get you to the hospital and the drugs wear off.

Fainting or being "found" unconscious is popular among the younger melodramatic patients. It's not all that uncommon in the actually sick, and the number of things that cause it is astronomical, so finding a 16 year old passed out doesn't necessarily register as obviously fake. Most of the time. But when it's obvious, it's REALLY obvious. Again, we can tell if you're truly out in less than a minute. Flickering eyelids and purposeful movement are dead giveaways. If you try to hold your eye closed when I go to check your pupils, I know it's fake. Really unconscious people tend to go totally limp and don't resist being moved. So if you fake unconscious, we'll find out. The common way to do this is to check your reaction to noxious stimuli. Meaning pain. Like a knuckle rubbed on your sternum. Or the same knuckle on the mastoid bone. Or take the first joint of the pinky finger, bend it down in it's natural direction, and squeeze hard. Hurts like hell if you do it right, and can also be used to unobtrusively encourage troublesome spectators on a scene to go find something else to do for a while. If you insist on playing this little game out, it's entirely possible we're going to cut your clothes off you so we can do a thorough exam. Someone that's legitimately unconscious for an unknown reason has to be assumed to have a hidden traumatic injury until we've definitely ruled it out. That means we have to go hunting, which means it's scissors time. Unless you're wearing a down jacket. EMS Rule #2- Never cut a down jacket unless you absolutely have to. Cut one, and I have, and you'll be sweeping feathers out of the ambulance for weeks afterward. Don't worry, we WILL cover you up eventually. And no, we don't have to pay for or replace what we cut. You probably should have thought of that.

I don't know why people call 911 expecting sympathy. In the paramedic dictionary, "sympathy" is nothing but the word that appears between "shit" and "syphilis".

Actual Conversation

Patient (Who is obviously way high on meth.): "What is it? What's wrong with me?"

Me: "I'm not sure. We'll probably have to wait for the autopsy results."

Patient: "How long will that take? I have to work tomorrow."

From my very first ambulance job, in Independence, Missouri. At the time, it was the methamphetamine capitol of the world. Since that day, I have viewed tweakers and other obnoxiously intoxicated people as playthings put on this earth purely for my amusement.