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.

Someone Has To Be The Bad Example

I was bad this morning. I had to stop for gas on my way home from work. There's a Love's truck stop just off I35 at my exit, so I pulled in there. Their gas isn't any more expensive than anybody else's in town, which is, as most of you already know, really unusual for a truck stop on an interstate. Love's also apparently has a corporate policy that only pretty girls are allowed to work the register, which may or may not have influenced my decision to stop there. They also have a Hardee's, which is the REAL reason I got my gas there rather than the place on the other side of town. The other place has biofuels, which I approve of, and a Scooter's Coffeehouse inside, which I also approve of. (Usually more than the biofuels. My Explorer is a flex fuel, and I burn E85 as much as possible, but I will bypass the environmentally friendly fuels in favor of good coffee every time. sorry.) The downside of the other place is that it's usually staffed by people that look like they just left their real job as stars of "People Of Walmart", or "Faces Of Meth". I'm already foggy from lack of sleep and lack of caffeine, I really don't need to see that on my way home. Sets a bad precedent for the day.

Anyway, I fed my truck, then fed myself. I have to admit to an addiction to fast food breakfasts. Mainly because bacon, eggs, and frozen biscuits are pretty hard to screw up. It can, of course, be done, but it takes a degree of effort most of the folks on the morning shift aren't willing to expend. Besides, they've been sucking down industrial grade coffee for four or five hours by the time I get there, so they're wired enough to take the time to deliver perfectly flat bacon and egg served on a biscuit split precisely along the equator. I appreciate the effort. Now, as a health care provider, I know that even the best of the fast food breakfasts is horrendously bad for you. That's why I rarely eat them. I tried to behave at Hardee's today, I really did. I ordered cinnamon raisin biscuits. No egg, no cheese, not fried, just two fluffy lumps of sugar coated happiness. I haven't had them in a long time, and they were good. I was not the only customer, of course. There was another guy at the counter, ordering a "Monster" biscuit, which comes with a sausage patty, ham, bacon, cheese, and egg. It looks REALLY good in the pictures. He also ordered a large hash browns, and "the biggest coffee you have". I went to the next register and ordered, then looked over. What I saw made me chuckle a little, and when he realized why, he did, too. I paid, got my food, and as I was leaving, told him, "I didn't see a thing. See ya in the cath lab, doc." Cardiologist. Someone has to be the bad example.

Public Education Pamphlets They Should Write

Good morning, all! Yesterday at the station, I flipped through a catalog of REALLY generic public education materials. I'm sure you know the ones. They have titles like "The Police And You", "Mindless Obedience Can Be Fun", and "Trust Me, I'm With The Government". They have poor quality drawings, contain no real substantive information, and are sold by the bale to be handed out at public education events. Most people that take them do so just to be polite, or because they are running low on kindling for their fireplace at home. The poor selection of EMS related literature got me thinking that they really need to add some new materials that may be a little more useful in our education efforts. So, without further ado, here are ten suggestions I came up with, in no particular order:

1) A Hangnail Is NOT An Emergency
2) You Can Still Wind Up In Triage, Even If The Ambulance Brings You In
3) Stupid People Should Not Drink
4) Don't Eat That
5) Why Did You Stick That In There?
6) Darwin Was An Optimist
7) There Is Nothing Wrong With You That Losing 200 Pounds Wouldn't Fix
8) Don't Call 911 If You Want Sympathy
9) In Fact, Don't Call 911 At All
10) You Are The Reason I Will Never Let My Daughter Date

21 Years

I did some figuring, and at the time I'm writing this, I've spent the last 23 years and 6 months to the day in uniform. I started out in a green one as a Marine. I reported to boot camp at MCRD San Diego on August 23, 1988, and graduated on November 9th of that year. (One day early, so we could celebrate the Marine Corps' Birthday as Marines, and not recruits.) I'm immensely proud of my time in The Corps, and my experiences there are a big part of why I'm the person I am today. Like the cliche says, you can take the Marine out of the corps, but you'll never get The Corps out of the Marine.

On this date, February 23rd, 1991, Operation Desert Storm began. Coalition forces had already bombed Iraqi positions for 38 days, in preparation for a massive ground assault to liberate Kuwait. The Marine Corps was tasked with breaching an enormous minefield and staging a diversionary attack on Iraqi forces, while Army units drove forward into Kuwait. The Marine assault was so successful so quickly that it became the main focus of the liberation. In 100 hours, Kuwait was free of Iraqi control. The operations of Task Force Ripper and Task Force Papa Bear will go down in history as examples of how an armored assault is supposed to work.

Today, American troops are still in harm's way in Iraq and Afghanistan. it's looking increasingly likely that Iran is next. I won't comment on whether or not any of those wars are right or wrong. I don't know if any war can ever be described as "right", anyway. That's probably a question for philosophers, not me. My job is to stay out here on the front lines, ready to respond when the call comes. Someone else can sit back and think about it. I'm busy.

There are a lot of brave men and women that put their lives on the line every day for complete strangers. Some are deployed to trouble spots all over the world, hunting down those people that want to destroy our nation. More are right next door to you, in police cars, fire trucks, and ambulances. We're out here 24 hours a day, 7 days a week, 365 days a year. None of us are doing it for the money, or for the glory, and it's sure as hell not glamorous. Most of us are doing it because we genuinely want to make a difference in the world. We're out here because for a lot of us, doing nothing is far worse than anything we could run into out on the streets. So when you see a veteran, or the local police officers, or firefighters, or EMT's, remember that. Come on up and say hello. We don't need parades, or monuments, or any of that stuff. The best award I've ever gotten was the day a guy walked up to me and told me, "You saved my wife's life last year. Thank you." Nothing can ever top that.

To my fellow Marines, keep up the good work. you've made this old jarhead proud. I'm glad to see that The Corps is in good hands.

Greater love hath no man than this, that a man lay down his life for his friends. -John 15:13

Tube Me, Or Not Tube Me...

That is the question. And the answer is "Not".

The call came out just after midnight for decreased level of consciousness. I hate hearing that, because it's a pretty generic complaint. Decreased LOC can mean anything from drunk to dead, with a whole lot of stops in between. It always poses a diagnostic challenge, because the patient can't really answer your questions. If the family isn't there, or doesn't know all the details, I get to play "House", and start throwing assessments at the patient until I get lucky and identify a correctable problem.

So- today's patient is a 55 year old female, and a medical train wreck. Multiple abdominal surgeries, back problems, celiac disease, fibromyalgia, migraines, and a laundry list of other issues. There's an equally imposing list of medications including amitriptyline, methadone, a fistful of blood pressure meds, and an SSRI antidepressant. For my non-EMS folks, methadone is not at all an unusual pain medication. It's normally reserved for either exceptionally severe pain, or pain that isn't responding to other medications. The normal methadone patient has either been on pain medications for a very long time, or isn't able to tolerate the dosages of other meds that would be required to manage their pain. Usually this means a cancer patient, someone that's had extensive orthopedic work done, or a long-time fibromyalgia patient that's not responding to other therapies. Most people think of methadone as something used to wean people off of heroin (An exceptional analgesic in its own right, with a horrible image. It's legal for terminal patients in some other countries, I wish it could be used here.), and not as a tool for pain management.

Presentation is a little unusual. The patient has been seated on the toilet for approximately three hours, which isn't entirely unusual for her. She's slumped forward, sleepy, and drooling a little. Blood pressure is 80 by palpation, heart rate is 80. Blood sugar is fine at 94. There's no history of recent acute illness, no new meds, none have been discontinued, and no dosages have changed. Because the patient is in an upstairs apartment, the stair chair is used to move her to the ambulance, parked right outside. When she's laid flat on the cot, she becomes more alert as blood flows northward to her brain. So far, we're considering a cardiac dysrhythmia, CVA (stroke), or medication reaction. Mainly because those are the three most likely diagnoses. Keep it simple, right?

In the unit, the monitor is applied, as well as a 12 lead EKG. Normal sinus rhythm, with no ectopic beats, and no ST segment changes. Normal. IV access is established, and a Cincinnati Stroke Screen is negative. That leaves us medications. Pupils are constricted at 3mm, and sluggish. Now I'm pretty sure we're overmedicated. The respiratory rate is slow at 8-10 per minute, but oxygenation is good, with a room air saturation of 95%. O2 is applied at 4 liters by cannula anyway. I opted to not give naloxone (A narcotic reversal agent.) since the patient was oxygenating well. No need to overwhelm pain meds she obviously needs just to wake her up for the ride to the ER. She's awake enough to maintain her own airway, and that's good enough for me. Naloxone has a greater affinity for the opiate receptors in the brain than most narcotics, so when it's given, the patient can potentially spend hours in pain waiting for the receptors to open back up so the narcotics will work again. I don't believe in torturing patients, so I didn't give it.

Transport was uneventful. I gave a fluid bolus of normal saline. Breath sounds were clear after 250 cc's, but blood pressure remained low, so I continued to run the IV wide open. After about 400 cc's, the patient began having wet lung sounds, so the fluid flow was stopped, and the head of the cot was elevated slightly. When I called report, the RN I talked to , who happens to be a former paramedic himself, agreed with my assessment and my decision to not give naloxone. Unfortunately, he was not the nurse that had the patient in the ER. The nurse that had the patient zeroed in on the pulmonary edema (Wet lungs.), and completely blew off the possibility of overmedication. Never mind that the pulmonary edema is possible with narcotic overdose, slow respiratory rate, shallow respiratory depth, and excessive IV hydration, all of which were possible. Her excitement spread to the doctor on duty, who began wondering if there was some other acute issue. He's got a lot of experience, and tends to not get excited easily, so I began wondering if I'd missed something.

The patient was moved to the major room, and there was some discussion of intubating the patient. This really concerned me, because I'd pictured something more like admission to a monitored bed, maybe ICU, an apnea monitor, and let the patient sleep off the meds. Intubation and a ventilator would certainly protect her airway and keep the patient well oxygenated, but it would also dramatically increase the risk of pneumonia in an already fragile patient. The former paramedic and I both thought a small dose of naloxone would probably do the trick, and he was able to convince the doc to let him give it. Lo and behold, after the naloxone took effect, the patient's level of consciousness improved, respiratory effort improved, and she was able to cough forcefully and clear her lungs. Everyone calmed down, and the doctor made the comment that he shouldn't be afraid to try reversing the effects of meds if the alternative is intubation.

In emergency medicine, we have so many new and cool toys that we often forget to start simply. Our desire to fix the problem can cause us to take a very aggressive approach to treatment of things that will usually clear up on their own if they're given enough time. Obviously, there is a definite time and place for an aggressive resuscitation, and when you get there, you shouldn't hesitate to use every tool at your disposal. The rest of the time, you need to remember the very first thing you're taught in paramedic school. Primum Non Nocere. First, Do No Harm.

Don't Reinvent The Wheel

This past weekend, I was looking through the Sunday ads when I commented to my wife that we should run to Staples and pick up some toilet paper, since they had an unusually good price on it. She looked at me funny and laughed, asking, "Staples?!?" Well, yes. I explained to her that it's an office supply store, and since offices employ people, you need stuff like coffee, toilet paper, cleaning supplies, snacks, headache remedies, and so on to run one effectively. After all, as Napoleon has been quoted as saying, "An army marches on its stomach."

The U.S. military understands this. It's often been said that the primary reason for U.S. troops being so successful in combat is due to our ability to maintain a supply chain anywhere in the world. I disagree. I think training is the main reason, with logistics coming in a close second. Case in point: me. I served in Operations Desert Shield and Desert Storm. when I deployed, the only desert camouflage uniforms available had been previously issued on an as needed basis for training. there weren't any new ones. OK, no problem. We can work with that. They were already in the system, and new uniforms began showing up pretty quickly. When we got to the Gulf, we learned that the standard black leather combat boots were useless in a desert environment. Sand is incredibly hard on boots, and they would just disintegrate, as well as being almost unbearably hot during the summer. The then common green canvas jungle boots were more comfortable, but the brass vents that made them appropriate for a tropical environment let a lot of sand into the boot. So something else was needed. The military, in a remarkable display of speed, fast-tracked a tan suede copy of the jungle boot with no vents. It was light weight, breathable, and held up really well under desert conditions. So a critical problem was solved virtually overnight. We got our desert boots eight months after coming home. A solution is meaningless if you can't implement it in a timely manner.

I don't want to bash on the Army (It's too easy.), but they're the service that had the lead in the development of the original desert boot. Fast forward a bit, and we find the Marine Corps (Oohrah!) changing to the now familiar MARPAT uniforms. Headquarters wanted a new, more functional boot to go with the new, more functional uniforms. Was there a huge research project? No. Were millions spent on reinventing the combat boot? No. Were the end users in the ranks happy with the product as delivered? Yep. How, you may ask? Simple. The Marine Corps sent a letter to boot manufacturers specifying what they wanted the boot to do, how they wanted it to look, and how much they were going to spend on it. Want the contract? Meet the specs and pass our quality control tests first. If you want the contract, YOU eat the R&D costs. Guess what? Every manufacturer already had a boot that met those specs in their catalog. Every single one. All they had to do was flip the leather over so it was rough side out and sew the boots together. No long wait, no committee meetings over the number of eyelets, nothing. Box 'em up, and kick 'em out the door. Lesson learned- if you've got a problem, ask someone else if they've already solved it for you. They probably have.

EMS is in a similar situation. Every time you turn around, there's some new innovation out there that's claimed to be the greatest thing since the invention of the ambulance. That's all well and good, but remember, we only have so much space on the unit, there are only so many hours available for training, and your agency only has so much money to buy new toys. Sure, the set of joint specific, semi-customizable splints looks great in the catalog, but the case is the size of a dishwasher, and they don't do anything that can't already be done just as well, if not better, by a SAM splint and a roll of Kerlix, and for a hell of a lot less money. Ankle injury? Substitute a pillow for the SAM, and go to the hospital. Nothing works better. You spent all that time learning to tie a sling and swathe in First Responder or EMT class for a reason. It works. Every time. The fancy splints don't, and if your patient isn't average sized, they won't fit no matter how hard you try. The combination pulse oximeter/carboxyhemoglobin meter sounds like a great idea, and it is. It's also expensive, and not used all that often. Here's a thought: if you run a CO alarm call in the middle of the night, and your patient doesn't feel completely normal, take them to the hospital. They've been exposed, and need at a minimum a couple hours of high flow O2, and potentially hyperbaric therapy. You can't realistically do either one in the field, so just take them somewhere that can. Great tool for an ER, or to have in a dedicated fire rehab unit, but not especially handy for day to day operations. Both of those examples are overly complicated answers to simple questions.

Chances are, if you're faced with an unusual situation out in the field, you already have the solution available. If not, EMS providers are notorious for creative problem solving on the fly. Take a minute to think things through, and an answer will usually present itself. If all else fails, keep the patient breathing, plug any unnecessary holes, throw them on the cot, and go to the hospital. Save the fancy toys for your days off.

Oops, I Fixed You!

Author Frank Herbert wrote, "The most consistent principles of the universe... are accident and error." He was right.

It's happened to all of us. You get on scene, the patient is genuinely sick for once, and despite your best efforts, they get better. I don't mind that they get better, of course, but if I'm going to look smart in front of the ER staff, I'd really prefer to do it because I actually AM smart.

Occasionally, that does happen. I was once dispatched for chest pain. Routine call type, right? First responders get on scene and triage the patient "Red". That may or may not indicate a Type Red patient, of course. Our first responding agencies tend to overtriage patients, which is the way to do it. I would much rather go in expecting a Red and find a Green than the other way round. Ruins your whole day. This night, the patient was as red as red gets. OK, OK, he was really grey, rapidly turning blue. And sweaty. And short of breath. And clutching his chest. Which makes sense, considering he was having a BIG anteroseptal MI. (For those not fluent in Paramedic, he was having a heart attack localized by the EKG to the front portion of his heart, as well as the septum that divides the ventricles. It's commonly referred to as "The Widowmaker". This particular type of heart attack can easily spread to take out the heart's built in pacemaker nodes, leading to a lethal arrythmia. If a paramedic is ever going to get nervous about a patient, this is the one. These folks die with depressing regularity.) The good news is that we can actually do something about that. So, I did the normal stuff. He chewed four baby aspirin (Which judging by his expression was far more unpleasant than the chest pain. Again for those unfamiliar with the treatment, aspirin is administered for a couple reasons. First, it acts as an anticoagulant, which can prevent the clot that may be blocking an artery and causing the heart attack from getting worse. Secondly, as an anti-inflammatory, it can help minimize the damage done by the lack of blood flow to the heart. So everyone should have aspirin around the house all the time. It saves lives.), we started an IV, and hit him with nitro. The nitro dilates the coronary arteries, increasing blood flow to the heart. If an artery isn't completely blocked, this can often relieve the chest pain by restoring blood flow to areas that need it. It will also cause one hell of a headache if you don't need it, which is why the inmates that claim chest pain in an effort to get out of jail rarely do so more than once. I gave morphine, and we rolled for the hospital. Our closest cath lab was about 20 minutes down the road. During transport, I continued with the nitro and morphine, and by the time we got to the hospital, the patient was pain free. And had a normal looking EKG. And normal cardiac markers. Yep. Stopped it dead in it's tracks. I had transmitted the EKG, so the cath lab folks were waiting for me. When they saw the patient, they asked if there was another ambulance coming. Nope. This is your guy. I fixed him for you. They cathed him anyway, and found that the LAD, the main artery to the front of the heart was 98% blocked. He was, as we phrase it in the field, circling the drain. Everything fell into place somehow, and we managed to get him in and out of the hospital in a couple days. The cardiologist told both the patient and me that I had definitely saved his life. All in a day's work.

The second one was somewhat less of an ego boost. Similar start, dispatched to a chest pain. The patient is on the third floor of an apartment building with no interior hallways, just catwalks and exposed stairwells, and it's COLD out. Figures. We begin our assessment, and find that the patient is in SVT, with a heart rate of 180. OK, uncomfortable, but an otherwise healthy person can sustain it for a while. It's easily fixed with a dose of adenosine, one of the more dramatic drugs we carry on the ambulance. Think of adenosine as a kind of chemical circuit breaker. When it's given, it travels to the heart and stops it briefly, giving the electrical system a chance to reset itself. After that, in an ideal world, the heart then restarts itself in a normal rhythm. Once that happens, the paramedic's heart then restarts, because it stopped as you see that period of flatline on the monitor. The longest I've seen was six VERY long seconds. Most of the time, it's less than a second, followed by a big burst of electrical activity accompanied by a patient yelling "Oh, shit!", or some variant thereof. (The whole stopped and restarted heart thing is kinda painful.) All of that keys on gaining IV access, which we didn't do. Three of us tried for almost 15 minutes, and we got nothing. This poor lady had nothing for veins. Finally we decided to implement Paramedic Emergency Procedure #1: If all else fails, put the patient in the back of the ambulance and take them to the hospital. Vagal maneuvers (Bearing down like you're trying to overcome the worst constipation you've ever had.) hadn't worked, maybe cold air would. Both of those stimulate the vagus nerve, which can slow heart rate. Sometimes that can put you back into a normal rhythm, other times it just makes you pass out and causes your panicky family to call 911 so we can tell you to eat more fiber. It can also kill you if you have a really iffy heart, so don't go overboard, OK? And eat more fiber. Or, there's always option "D", which is it doesn't do anything. That's what our patient picked. So we carried her down three flights of stairs in the stair chair, got her to the cot, and made our way to the ambulance. The OSHA approved way to do that was probably to walk down the sidewalk to the handicap parking space, and use the ramp there. The Fire/EMS way is to take the most direct route, regardless of obstacles, in this case a four inch curb. I lifted the foot end over the curb, but apparently "Hey, watch out for the curb!" doesn't translate into Firefighter. So the head wheels dropped four inches, jolting the patient, who promptly exclaimed, "Hey! I feel better. Do I have to go to the hospital?" A quick look at the monitor, and sure enough, she's in a normal sinus rhythm. Not one to look a gift horse in the mouth, I told her her heart was beating normally again, but she still should go and get it checked out. She agreed, and that was us on the way to the ER. They always love it when we deliver a patient with no complaint, no symptoms, and normal vital signs. Here you go. Fixed her. Whoops.

Never argue with results, I guess.

So You Think You Can Ambulance?

There are quite a few good EMS related pages on Facebook. Too many to list, but the one I seem to be following the closest is "Paramedics On Facebook". It's not just for medics, of course, but it's a catchy title. You should check it out if you have any interest at all in the EMS community.

Anyway, I've noticed that there's been a slight bump in the number of "What's EMS REALLY like?" posts in the past few days. A lot of good links have been passed along, but I'd like to add my two cents worth, so this one's aimed primarily at those folks that are contemplating crossing over to The Dark Side, or just want to know a little more about the warped world of the EMS provider. Enjoy.

Over the years I've been in EMS, I've had the opportunity to speak to a lot of junior high and high school students at various events. These are really the only PR events I look forward to, because they're by far the most interesting. Most of the time, they're pretty predictable. We show up, talk briefly about what our job is like, show off some of the equipment, then do a Q&A session. Inevitably, the same three questions get asked over and over. (And over, and over, and over....) "How much school does it take?" "How much are you paid?" And everyone's favorite, "What's the worst thing you've ever seen?" The first two are easy. In Kansas, becoming a paramedic means you're going to have to either get an Associate's degree out of your training program, or have a Bachelor's before you start. Simple and straightforward. How much are you paid? Depends on where you work. In general, paramedics in my part of Kansas start in the neighborhood of $14 an hour, maybe a little more if you're a fire medic. EMT's are $10-$12 an hour, depending on where they work. That doesn't necessarily seem like a lot, or even enough, for a job that's consistently rated as one of the five most dangerous in the country. If you factor in the overtime I get, I actually bring home somewhat more than the average in the area. so no complaints here. I wouldn't turn a raise down, mind you, but I think I've got it pretty good. And the third one... that's a toughie. Not because I don't know. Not by a long shot. My personal worst is seared into my brain, and no matter how hard I try, I will NEVER be able to forget it. The problem is, it sounds so crazy that everybody thinks I'm making it up. Believe me, I wish I was. No human being should ever have to see that done to or by another person, ever. So I usually make something up, or tell a different story. I'm trying to encourage people here, not scare them off.

The made up story works most of the time. The class acts all shocked, the bell rings, and they move on. Except for one. There's always that one. It's normally a student that's been sitting there the whole hour without saying a word. They hang back as everyone leaves the room, then start asking their questions. Those questions are normally intelligent ones, and worthy of a serious answer. Stuff like "Where's the best place to go to school?", or "What should I focus on in high school to get ready for EMS training?" You can tell they have a real interest, so they get a real answer. Especially when they ask what it's REALLY like. They deserve the truth.

So what's it really like to work in EMS? Well, it's a job you'll love and hate, often simultaneously. You'll find yourself expected to perform difficult, stressful tasks perfectly the first time, every time, under conditions that should make those tasks impossible. And you won't even notice those conditions, because there's someone there that NEEDS you, and that's the only thing that matters.

You'll spend endless hours in the station in training, cleaning, maintaining, and inventorying your equipment. You won't even have to think about how to use it, because after thousands of repetitions, that's going to be second nature. When the time to use it comes, you'll find yourself wishing you'd practiced more, so you could move just a little bit faster and more surely.

You'll learn to love the sound of the siren, even as it's destroying your hearing. You'll wish the damn thing was louder, so the drivers around you could hear it that much sooner, and move the hell out of your way. You're only going to save a life, God forbid you delay them on their quest for junk food and poorly manufactured consumer goods.

You'll have a partner who will be as close to you as your spouse, or your brother or sister. You'll learn to depend on each other completely, and you'll trust each other absolutely. You have to.

Your first responders will become your lifeline. They'll clear a path for you, guide you to your patient, and keep an eye on you while you're working, so you can do your job. Most of them will do it for no pay. They've left their homes and families in the middle of the night to respond. Remember that, and never, ever forget to thank them for all they do. Chances are, you'll be the only one that ever does that.

The patient is going to depend on you. Completely. You owe it them to try your hardest to fix their problem. Sometimes we can give medications and make things better. Sometimes, they really just want someone to listen to them. That makes things better, too.

You can't always help. It happens, and it sucks every time. You don't get used to it. If you do, it's time to go. You won't remember the success stories, but I guarantee that every single failure will stick with you. Learn from them.

Someday, somewhere, a stranger will walk up to you in the gas station, or the post office, or just on the street. They'll look you in the eye and tell you that last year, you saved them, their wife, husband, child, mother, father, or a complete stranger that they just happened to see collapse. That's a great feeling, and a helluvan ego boost. Then again, someday, that same stranger may walk up to you, and you'll remember that you COULDN"T save that family member. They're going to thank you for trying. Moments like that are why you'll KEEP trying.

We are privileged to see people at their best, and at their worst. We're present for the beginning and end of life. Sometimes we can make things better, and sometimes all we can do is just not make things worse. The trick is to figure out when to do which. Think you're ready?

Snow Big Deal

It's the 13th of February, and we've just gotten our first measurable snowfall of the winter. A whole inch. It didn't even cover all the grass in the yard. Frankly, I'm disappointed.

Surprisingly, we didn't run a ton of wrecks this morning. Didn't have any, in fact. Normally the first real snow of the winter results in absolute chaos on the roads. Generally, nobody gets seriously injured, but there are a lot of aches and pains from sliding into the ditch, or trying to fight the steering wheel in an effort to keep out of said ditch. A few slideoffs this morning, but not too bad, all things considered.

I expected a lot worse, considering how snowy roads are usually managed around here. I grew up in northwestern Iowa, so I learned to drive on ice and snow. The rules are actually very simple: Slow down, think ahead, then slow down some more. Follow those, and you'll generally get where you're going. All you need is a little extra time. In Iowa, most towns won't plow snow, especially the heavy wet kind we got here this morning, until there's three or four inches on the ground. The wet stuff doesn't blow around all that much, and once there's been a little traffic on it, it either turns to slush that most tires can squish out of the way, or packs down and refreezes, which gives you a surface a lot like wet pavement to drive on. Most towns spread a little sand at the intersections so you can get traction to stop and restart, but that's about it. Everybody KNOWS it's gonna be a little slick, so they slow down and go about their business.

Around HERE, however, if more than four snowflakes accumulate on any road in the county, crews are out spreading brine and rock salt, and scraping every road they can get a plow truck onto. Never mind that the only thing they're doing is moving snow that tires can grab traction in to the side of the road and leaving a thin skim of water that instantly refreezes to a glasslike surface. That road is now CLEAR. It's dangerous as all hell, but the pavement is visible, and that's the goal. So people go flying down the road, and wind up in the ditch. Then we get to take the ambulance, which handles with all the precision of a cow on ice on a GOOD day, out to the middle of a slippery highway, stand on the side of the road for twenty minutes, all to have someone tell us face to face that no, they aren't hurt, and don't want to go to the hospital. They all tell us the same thing. "It looked OK, so I went for it." I know. It happens every winter.

But I don't mind. That inch of snow out there has made everything clean and quiet. I'm sitting here typing, sipping a cup of coffee, with the dog snoozing on the couch next to me. Out the window, I can see a couple of deer walking across my hill. It's warm in the house, and it's quiet. At least until the kids get home from school. Let 'em plow the roads unnecessarily. I don't care. It's no big deal to me.

Dents And Dings

Those of you that have been reading this blog regularly will probably remember that I wrote about rolling my ankle at work a week ago today. I am pleased to report that it STILL hurts, stiffens up at night, and has now turned a delightful shade of purple. Once again, I have managed to injure myself for no apparent reason.

I'm long past complaining about it. After all, I voided my warranty a long time ago, so there's really no point. At last count, the toll is up to two broken toes, almost all of my ribs have been cracked or bruised, a broken finger, torn rotator cuff, no cartilage in my right knee, hip bursitis, several black eyes, a radio frequency burn to the hand that is absolutely the single most painful thing I've ever done to myself, two bulging discs in my lumbar spine, countless cuts, scrapes, and bruises, a scratched cornea, various dents and dings, and the thing I am most proud of, a formal letter from an ER doctor forbidding me to play soccer further than 100 yards from an emergency room. (I'm pretty sure he was kidding, he was chuckling when he handed it to me. However, since he was a full Commander, and I was just a Lance Corporal, I did what I was told.)

I'm a firm believer in the theory that if you aren't occasionally injuring yourself, you probably aren't trying hard enough. Something I learned in boot camp is that pushing yourself out of your comfort zone and past your self-imposed limits is one of the best feelings in the world. The scars you carry are proof that you aren't afraid to take a chance at living a real life. I haven't coddled myself over the years. What fun would that be?

I'll pop my Advil, rest my ankle, maybe even see a doctor if it keeps hurting. Then, when it's all healed up, I plan on going back to doing what I was doing. It's only pain, after all.

Veterinary Mode: On

I took the dog and both cats to get shots today. It was less traumatic than I expected. Meaning, of course, that I only required a few stitches and two units of packed cells after trying to get the cats into the carriers. I don't approve of declawing (Because it's the equivalent of trying to keep your fingernails from growing by clipping the fingers off at the first joint. Barbaric.), but sometimes I regret not having done it. On the bright side, the cats yowling on the way there DID drown out my five year old son's constant mindless chatter. Does the kid ever inhale?

My mother-in-law belongs to a sorority that sponsors the shot clinic we go to, so it wasn't our regular vet tonight. No problem, this guy is a good vet, and as a paramedic, I have an instant rapport with veterinarians. If you think about it, we have very similar jobs, so vets are probably the medical professionals EMS providers have the most in common with. After all, we both frequently have to diagnose a patient that just can't tell us what's wrong. So, we start poking and prodding, and when the patient either yelps or tries to bite us, we treat that area. I have also often felt I was working with an entirely different species out on the street. It's hard to fully explain it to someone that hasn't been out there for a fairly long period of time, but let's just say that to most paramedics, Darwin's theories do, in fact, remain wholly unproven. (OK, I'll concede the point that Darwin did NOT actually promote survival of the fittest as the basis of evolution. Most biologists will tell you that survival of the most adaptable is why we aren't still swinging from the trees.)

Animals are also very forgiving of people that try to help them. Our dog acted like nothing had happened after her shot, and was ready to play as soon as we got home. The cats? Well, they were acting like cats. The best any human can hope for is tolerance from a cat. That's part of why I like cats. Our younger cat, Pepper, was just a kitten when I found her under a bush in front of our old house. I thought she was the neighbor's cat, but they told me she wasn't when they got home for work. So that was us with a second cat. We took her in, cleaned her up, fed her, had the vet check her out, and generally kept her from either starving or freezing to death. Do that for a puppy, and you have a friend for life. A cat, on the other hand? To this day, Pepper looks at me like I'm an idiot every time I speak to her. But that's OK. I can respect anyone that will accept my charity, then turn right around and despise me for doing it. I appreciate the honesty.

We do have a lot in common with veterinarians. We have difficult, noncommunicative patients, we get clawed, scratched, and bitten regularly, and the most common gratitude we get from our patients is to be treated as if we're invisible as soon as the problem is fixed. Yet we keep doing it. Because it's all worth it to see a family taking every single member home at the end of the day. I can live with that.

Stay crazy, my friends.

Time On My Hands

I'm constantly amazed by the number of EMS providers I see that aren't wearing a watch. A watch is one of the most basic tools of our trade. You need one to get a pulse rate, count a respiratory rate, note the times of interventions on a call, and generally be on time.

I understand that we have a whole generation (More than one, probably.) that are dependent on their cell phones for telling time. Hell, they probably can't even read a REAL clock. Their world has always been digital. That is a fact that is NOT calculated to make those of us with analog brains happy. I still like clocks and watches that look like clocks and watches.

If you just want to know what time it is occasionally, your cell phone is a perfectly good way to check that. It updates itself every time it pings a tower, so it's more or less accurate at least half the time. I use my phone as an alarm clock at work, but that's the ONLY time I treat it like a clock. Other than that, I wear a watch all the time. If you need frequent time references, that's the only way to go.

If you're one of those phone people, let me ask you this: What do you do when your hands are wet, dirty, or full? Does digging a phone out of your pocket sound like a good idea now? I didn't think so.

Let's talk about checking a pulse. I don't know about your phone, but mine doesn't have a seconds readout unless I work my way through a couple menus to get to a clock app. Doable, sure, but I can also just tilt my wrist and watch the second hand sweeping around. Much easier. And what if it's a trauma? Do you want to dig into your pockets with bloody gloves, just so you can count a pulse. You'd better count one. Trauma centers hate guesstimates. A pulse can tell you a lot of things. Is it strong? Weak? Present at the radial? Carotid only? Regular? Irregular? You can't tell, because you're still trying to figure out how to get your phone out without sliming either it or your pants. I have already moved on to the next step. I'm counting respirations. You're trying, but since you're using a cell phone instead of a watch, the 15 seconds you used to count a pulse have eaten into your backlight time, and the screen just locked up on you. Sorry about that. I'd help, but my patient's only breathing six times a minute, so I'm bagging him. I can do that, because I have both hands free. I'm wearing a watch. You aren't, and you just dropped a $400 smart phone into a puddle of puke composed mainly of cheap beer. I don't think your warranty's gonna cover that.

Technology is a great thing, and it's made our jobs a lot easier over the years, but new isn't always better. Sometimes you just have to stick with what works. Put the phone down and go buy a watch.

Intermission: If looks Could Kill

The kids have eaten dinner, and the countdown to bedtime has begun.

Brendan is playing with a little rubber bouncy ball on an elastic band. I think it broke off some crappy cheap paddleball toy he got from the allergist's office. Anyway, he's swinging it around, and it's hit him twice, once in the face, and once in the chest. Both times, Claire has laughed at him, and he's gotten mad about it. He told me "She's laughing at me, and it's not funny!" My response? "Yes it is."

I think he learned that look from his mother.

Ibuprofen, Youbuprofen, Weallbuprofen

So I rolled my ankle at work the other day. Nothing major, but it hurts. I'd love to say it was in the course of doing something stupidly heroic, but it wasn't. I just missed a curb and pretty much tripped over my own feet. The only upside, if there is one, is that it was dark, and nobody saw me do it. Unlike the last time I did something like that. I'm still bitter about the score from the East German judge, too.

Anyway, my left foot and ankle now hurt. The arch and the outside of my instep. Weird place to hurt, and the ibuprofen I took didn't do anything. I think I'm probably immune. I've been using it since my Marine Corps days, when the battalion aid station handed out baggies of giant orange horse pills (Motrin 800) like they were candy. If you were really lucky, you'd have something long term, and could get the 250 tab pharmacy bottle. It was always nice to have a stash. God only knows what we did to our kidneys, considering how many of those things we popped. I remember there was an official warning from our battalion surgeon at one point. Didn't stop us.

I celebrated the day Ibuprofen went OTC. I STILL pop it like candy, but I pay a little more attention to dosages now. No, I don't follow the label directions. They tell you to take 200, wait an hour, and if it doesn't work, take another 200. I don't do that. I take 800, wait eight hours, then take another 800. And so on. I'm not exceeding the prescription dose, so no problem. Until it quits working. I have, over the years, managed to dent and ding myself countless times. Knees, right hip, right shoulder, most of my ribs, left foot, couple fingers, you name it, I've probably broken, torn, strained, or sprained it. Even if I weren't currently out of warranty, I probably voided it somewhere around 1993 or so. It all means I've taken a lot of ibuprofen over time, and now it doesn't always work for me anymore.

It's gotten to the point that if I go see my doctor for anything pain-related, she more or less automatically writes me a script for something stronger. She knows I hate taking pain meds, so if I come in asking, it must be serious. It usually means I've been maxed out on NSAIDs for a week or two, and they aren't helping any more. I always feel like I'm whining when I go for pain, and I really hate drug seekers (Occupational hazard.), so the pain control visit usually involves some chitchat, followed by a lecture that ends with me promising to actually fill the script and take the damn pills. Sometimes I even keep that promise.

I'm not at that point yet, even though the ankle is really stiff and sore this morning. I can still walk on it, so it must not be too bad, right? Besides, I took this amazing wonder drug for the pain. One that fixes almost all pain, prevents, cancer, prevents blood clots, and can even save your life if you're having a heart attack. All this, and you can get a 100 tablet bottle for a dollar. Aspirin.

It worked.

Festering Ambulitis- Scourge Of The Streets

Recently, the International Institute of Real Doctors released a warning to EMS providers worldwide regarding Festering Ambulitis (FA), an illness reaching epidemic proportions among ambulance crews worldwide. We here at Med in Kansas Enterprises (MiKE) would like to provide the following information not in the hope of curing an incurable disease, but in the hope that all of you out there will at least have something to blame your crankiness on, thus absolving you of guilt for your inevitable antisocial behavior.

FA is a disorder of insidious onset first identified sometime in the mid 1970's. It is primarily confined to the ranks of EMS providers, although some isolated cases have been identified in ER staff populations. The general public so far appears immune to FA, even though a random sampling of the people at the gas station this morning indicates that virtually all of them are carriers. The reason for this immunity is unknown, but appears to be related to some sort of naturally occuring stupidity barrier at the blood/brain interface.

Transmission of FA remains a mystery. It appears to only be transmissible following repeated exposure to carriers. There is a theory that this may be the world's only psychically transmitted disease, based primarily on ancedotal evidence of some victims becoming symptomatic when finding themselves within a 50 meter radius of an identified carrier. No effective personal protective equipment has been identified so far. It appears that carriers are no longer contagious after death.

The exact pathogen responsible for FA has not been identified. Ongoing research has indicated that it appears to be related to the organism responsible for various other disorders including, but not limited to, the following: Acute Handcuff Induced Incarceritis, Hysterical Female Syndrome, Shift Change Delirium, Hypoxanaxemia, Haldol Deficiency, Alcohol Related Assholia, Dontwanna Syndrome, and Terminal Stupidity. There are others.

The incubation period of FA appears to be remarkably short, often to the point that onset of symptoms is nearly instantaneous following exposure. More virulent strains of FA have been known to become symptomatic as much as 12 hours prior to exposure, although this is most common in long time FA sufferers.

Symptoms vary widely from victim to victim, and may resolve then reappear seemingly at random. some of the more common symptoms include short temper, indigestion, cynicism, bleak outlook, inappropriate humor, brain/mouth filter dysfunction, inability to distinguish between "inside" and "outside" the head voices, profanity, compulsive caffeine ingestion, and a tendency to eat rapidly at mealtimes. Some of the more UNcommon symptoms can include exuding an aroma of stale coffee at all times, immunity to bad coffee, cold food tolerance, and a tendency to drive every vehicle as if it were stolen, while still slowing or stopping at every intersection, regardless of traffic control devices. Additionally, in a significant number of cases, blackening of the soul may be observed.

Treatment remains an iffy prospect at best. FA does not appear to significantly impede normal function in most sufferers. Remarkably, the bulk of FA patients actually appear to ENJOY the effects of the disease. Some researchers have speculated that this is due to FA physically damaging or destroying brain cells over time. These researchers are in the minority, as most that have studied FA classify this finding as a disease induced psychosis. Symptoms can be managed relatively easily through administration of sleep, caffeine, alcohol, and/or nicotine in some patients. Exceptionally large doses of any of the treatments, often administered simultaneously, appear to be the most effective. Once again, the patients do seem to enjoy the therapies.

We hope this has been educational and informative for those that read it. Remain vigilant, and be aware that Festering Ambulitis can strike at any time. Thank you and good night.

Night Of The Zebra

The last time we spoke, my shift was having an "interesting" evening. There were many "WTF?" moments, but I think we all handled it rather well. Every patient was well cared for, and arrived safely at the hospital. One of my patients was admitted to the ICU at our local hospital, where my wife works. I like it when that happens, because I can get a better followup than most EMS agencies get regarding a patient they've transported. Most of the time, that followup just confirms what I thought already, and lets me know how the patient is doing. Generally, that's all I really want to know. Once in a while, the answer to my question is nowhere near what I expected.

Disclaimer time. This one is going to be more for the EMS types reading this. I'll try to not leave any of you non-medical folks in the dust, but if there are questions, ask me. Just leave it in the comments below.

We get dispatched to an unresponsive person at about 1:50 in the morning. En route, dispatch gives further information that the patient has snoring respirations. I know, it's almost 2 A.M., you should expect unconscious and snoring, right? To be honest, that's what I expected to find.

On scene, the patient is found laying on the living room floor. BLS first responders and a deputy are on scene, and tell us the patient is awake. so far, so good.

The patient is a 21 year old female, no significant past medical history, no regular meds, no allergies. Earlier in the day she had complained of nausea, headache, and neck pain, and was seen at an urgent care clinic, where she received Toradol, promethazine, and diphenhydramine injections. After coming home, the patient continued to complain of pain, so took a 5/500 Lortab, with no effect. She's awake but very confused and restless. Exam is unremarkable, with no nuchal rigidity. While we're on scene, the patient has a tonic-clonic seizure lasting about 30 seconds. She comes out of it, and is classically post-ictal. So now the picture is somewhat clearer, and I'm thinking meningitis. We scoop her up to the cot and head for the ambulance.

In the unit, we start an IV, check blood sugar and temperature, then apply an EKG and some oxygen. Sugar is well within the normal range, and there's a very low grade fever at just over 99 degrees. Pupils are equal, round, and reactive, if slightly constricted. Still thinking meningitis. The EKG shows a sinus tach, and the 12 lead is normal. Off to the hospital.

During transport, the patient wakes up a bit more, and becomes agitated and combative. I spent half the ride trying to keep her from coming up off the cot and trying to jump out of the ambulance. Get to the hospital quickly, and hand her off. The ER works her up with the usual package of labs, urinalysis, drug screen, and CT, all of which didn't really show much out of the ordinary. A lumbar puncture was performed, getting some pink, cloudy fluid with some red blood cells and white cells at 10. Yep. Meningitis. The patient gets admitted to ICU a few hours after arrival.

A neurologist was consulted, and also arrives at a diagnosis of meningitis, probably viral. If you're going to get meningitis, viral is the one you want. It just makes you sick, unlike bacterial, which tends more toward the lethal. Acyclovir, vancomycin, and rocephin are administered with some improvement in condition, and the decision was made to transfer the patient to a larger hospital in Kansas City for a stay in the Neuro ICU. Case closed, right? Nope.

The transfer was uneventful, and the patient was admitted with probable viral meningitis. The neuro team there orders an MRI. Before the MRI, all the routine screenings, to include a pregnancy test, have to be done. Patient is pregnant. And hypertensive. And seizing. Could it be...? Yep. Pregnancy induced hypertension, AKA pre-eclampsia, AKA toxemia of pregnancy. WTF? Really? Uh-huh. One emergency c-section later, and patient is better, her 24 week infant is in NICU, and we're all scratching our heads.

One of the things you're taught in paramedic school (Or any medical education, for that matter.) is that if you hear hoofbeats, you should start looking for horses, and not zebras.

But don't be surprised if one of those stripey bastards sneaks up behind you and bites you in the ass.

D-Bags, Ditchweed, and Dumbasses

I don't know if it's the unusually mild winter, something in the water, or stronger than normal waves of absurdity sweeping through Kansas that are affecting people, but I'd like it to stop, please.

Yesterday seemed to get off to a normal start. That is rarely, if ever, a good omen. I apparently NEED to drop my coffee cup, forget my pen, miss a turn, or something equally inconvenient to generate a reasonably "normal" day at work. None of that happened yesterday, so other stuff did.

Right after lunch, we had some training on our new scheduling program. It's web based, and (Unusually for a web based ANYTHING.) looks like it's actually going to be a substantial improvement over the system we currently use. It's even user friendly. No problem there. Then we get a call for a subject unresponsive behind the wheel of an SUV. Normally, this type of call is nothing. It's usually called in by some well meaning passer by that sees a car on the side of the road, with the driver's head down. About eight times out of ten, it's nothing. Normally, it's a driver that pulled over to read a text, make a phone call, or pick up a dropped item. When you're driving past, a guy digging for a cell phone looks a whole lot like a guy passed out. Those drivers are usually gone by the time we get there, so we spend a few minutes driving around looking for them, then call it "No Patient found", and go back to the station. It's a pain, but helps us pad our number of calls, which is useful come budget time. The ninth time, the driver actually has a legitimate medical emergency, most commonly low blood sugar. If you're lucky, they knew it was coming on, and managed to pull over and park safely before they passed out. As long as the doors aren't locked, no sweat. Get them out, toss 'em on the cot, go to the ambulance, put in an IV, a little dextrose and some saline, and presto! All better. Or it's something that actually needs a trip to the hospital. That's kinda what we do, so we can handle that, too. Same deal- cot, ambulance, IV, EKG, drive. Piece of cake.

Number Ten, on the other hand, can range from nothing, to entertaining, to being a huge pain in the ass. Yesterday's was entertaining. We pull up to see an SUV nose to the curb, back end hanging out into the street. It had been seen by a city street repair crew driving erratically, and when the police got there, it was still in gear. (Reverse, to be exact.) The driver was over the wheel and out cold. Just after noon, so I'm thinking blood sugar. When we got there, the driver was awake, and apparently totally normal. Vitals good, blood sugar good, want to go to the hospital? No? Great. Sign here. The officers will be right with you. We were blocked in, and there really wasn't room to to a 96 point turn around, so we sat there and watched the rest of the show. The cops drew a straight line on the street, and place the driver at one end of it. Horizontal gaze nystagmus gives us a thumbs up. Intoxicated. Now for the straight line test. Ideally, the suspect takes nine steps, turns around, and takes nine steps back to start. Not our driver. Seven steps. Pause. Sixteen more steps. Turn around. A hundred or so little bitty steps trying not to fall down on the way back. Busted. The driver opted for a breath test rather than blood. Blew a .22 in the field. You get arrested at .08. Buh-bye. Dumbass.

The rest of the afternoon was training time. I got to cut a giant hole in a school bus, so that was good. A little strange breaking a sweat and overheating on February 1, but this winter has been anything but normal, so I called it business as usual. Until evening, anyway.

This was an example of why the most frequently asked question by EMS providers is usually "WTF?"

To start, a transfer call comes out. Normally, it would have been my station's turn to take the transfer, but this one came out as a STEMI. (That's an "ST Elevation Myocardial Infarction" for you non-medical readers. It's a heart attack with EKG changes, and those are one of the very few types of calls that we take seriously 100% of the time.) that means the closest unit takes it, and since Station 1 is just across the parking lot from the ER, they got it. That meant that a few minutes later, I got the call for - you guessed it- a driver unresponsive and groaning. I sense a theme. So, off we go. On the way there, we were told that an officer was on scene with our patient. That changes things, because someone has actually stopped and tried to talk to the patient. This one could be real. Our scene was just outside of town, so it took us a while to get there. While we were responding, a call for a fall came out. We run a lot of those, no big deal. Except for the fact that we only have three ambulances staffed at any given time, so now we were down to none. Sure hope nobody else gets sick for an hour or so. We pull up on our scene. WTF? There are like six cop cars here. And isn't that the drug guy? This is gonna be good. We pile out, grab our portable gear, and start walking in time to see the drug guy walking another guy in handcuffs up to the ambulance. Clearly, NOT unconscious. Get in. What's going on? Guy tells us "I'm fine." OK. The detective tells us he got caught with a big bag of weed, and when they got him out of the car, fell down and was groaning. Remember this, kids. If you want us to believe you're actually sick, try to get that way BEFORE you get arrested. It's more convincing. Guy is in baggy jeans, sleeveless t-shirt over a wifebeater, and a puffy down coat. It's 40 degrees out. I'm in a sweatshirt under my flight suit, and slightly too warm. Oh look, it's an Ed Hardy t-shirt. We're at a 10.5 on the Douchebag-O-Meter now. The guy tells us he smoked a bunch of weed, but he's fine, and doesn't want to go to the hospital. Vital signs are good, so no real reason to take him. I hate to tell him, but I think he got ripped off on his weed. He smells like burning lawn clippings, not pot. The legendary Midwest Ditchweed strikes again. Marijuana does, in fact, grow wild around here. It is definitely NOT high quality. I don't know why people insist on smoking it. The county sprays it with herbicide when it's found, so it's not exactly something you want to suck into your lungs. The last time I checked, Roundup didn't qualify as an intoxicant, you know? Besides, it's not like getting real weed is exactly difficult. If you're gonna smoke dope, I don't really care. Just buy the non-toxic stuff, and stay home, OK?

So we clear the scene. The transfer is rolling, and the boss is on scene at the fall. And calling for a helicopter. WTF? Being the nice guy, I get on the phone and call a helicopter. The ambulance coming for the fall was responding from the far north end of the county, so we're thinking we might need to light it up and head to the scene. Nope, Medic 4 is on scene. Cool. And then the unit taking the transfer comes over the air. "Code blue." WTF? They pull over to work the code and grab one of the volunteer first responders to ride with them. Much radio traffic later, they go back en route. Code Red, so that's a win in the books.

Just another day at the office.

Peace And The "Q" Word

It's Monday morning, and I'm home alone. Well, except for the two cats and the dog, but they're all asleep at the moment, so they don't count. My wife's at work, the kids are at school, and I'm on day three of my normal four days off.

About those four days.... Almost nobody that doesn't work in Fire or EMS can figure out my schedule. My agency works what's known as a Berkeley schedule. (Yes, after the city in California. No, that doesn't mean we spend our time at work smoking dope and protesting. Most days, anyway.) I usually describe it as a nine day work week, with a four day weekend. I work a 24 hour shift every other day, and after the third shift, I have four days off. So last week, I worked Monday, Wednesday, and Friday. I'm off Saturday, Sunday, Monday, and Tuesday. Next week, I will work Wednesday, Friday, and Sunday, and so on. It makes sense once you actually start working it. The point of all this is that MY weekend doesn't necessarily correspond to the rest of the world's weekend. As a result, if my wife is working, which she normally does on at least some of my days off, and the kids are in school, I wind up at home alone after the kids get on the school bus.

I don't really mind the peace and... well, that brings us to our title, doesn't it? One of the greatest taboos in EMS is saying the word "quiet". Bad things happen when someone does that. It angers the Call Gods, who bring their wrath down upon us, usually in the form of a VERY busy day, or a really bad wreck, or worst of all, the phenomenon known as "explode-a-poo". Needless to say, the wrath of the Call Gods can be minimal when compared to the wrath of the Coworkers, and EMS providers are noted for creative problem solving on the fly. Anger us at your own risk. So we NEVER (OK, almost never.) say that word in reference to our day. It's OK to use it in the generic, particularly when the topic of conversation is noise, but not when you're talking about how the day is going. So don't do it. And don't polish your boots while on duty, and don't make plans to watch a TV show you've really been looking forward to but didn't bother to set your DVR for at home, and most of all, NEVER, NEVER plan to go to bed early and sleep all night. The Call Gods hate it when you do that, and will punish you severely for your sloth.

I like my days at home alone. Once the kids are gone, I can eat a leisurely breakfast and drink my coffee in peace. I've already gotten two loads of laundry done, and the last one is about to go into the washer. The dishwasher has been unloaded, and the few dirty dishes that wouldn't fit last night are in it and ready to be washed. Meals are planned for the day, and all the prep is done. (Actually, we're having Dr. Pepper Pulled pork tonight, so it's already cooking. It's a recipe from The Pioneer Woman, and it already smells AMAZING. Go to her site, it's well worth your time.) Animals are fed. The giant mat on Zoe's (Cat #1) side is worked loose, and if she'd quit biting me, I would be able to clip the last little bit of fur holding it on. I'm showered and dressed, and last but not least, I have complete control of the TV remote.

I'm bored.

Bad Coffee! Down!

This morning, as I was driving home from what turned out to be a 27 hour shift, I was struck by a thought. (Or a mild seizure. I often have difficulty distinguishing between the two.) How much bad coffee have I consumed in my 42 years? I probably don't really want to know an actual quantity. After all, we all know that there is no beverage served more often than Bad Coffee. You can get it nearly everywhere, and there is really no way to tell without tasting it.

A couple disclaimers first. I really began drinking coffee during my time in the Marine Corps, so my personal "bad coffee" bar is set exceptionally low. Military issue coffee, like all other military issue items, is produced by the lowest bidder. As always, the bid is low for a reason. Canadian grown coffee, anyone?

The second disclaimer- I have been working the streets since I got out of the Corps in 1993, and spent a big chunk of that time working the graveyard shift. Some of those nights, the need for caffeine outweighed all other considerations. That meant gas station coffee, and I highly doubt I will ever be that desperate for caffeine again. Once more, the bar has been lowered.

It's also worth noting that EMS is a caffeine saturated profession. Think about it folks, your lives are in the hands of a bunch of at least partially burned out adrenaline junkies all jacked up on coffee, Mountain Dew, Red Bull, and any food that can be either easily reheated or eaten cold. (Preferably one handed. Easier to drive that way.) Makes you want to start taking better care of yourselves, doesn't it? On my shift at work, we've joked more than once that our official mascot should be a hummingbird.

We do occasionally get good coffee. One of the perks (Sorry, I know. It's a lame pun, even for me. Nothing else works.) of the county I work for is coffee. It's Folger's, which one of our firefighters refuses to drink. He's a coffee snob, so he brings his own from home. It's normally something good like Costa Rican Tarrazu or Sumatran. You can always tell when Dave's working, because everyone drinks the coffee. At the other end of the spectrum is the coffee made by one of our EMT-I's. You can tell when SHE made the coffee by trying to put a spoon in the cup. If it either stands up or melts, Cindy made it. It's funny to see the firefighters come in when she's working. They always hesitate before pouring coffee, then ask if it's Cindy's coffee. Sometimes, just for fun, I lie and tell them "No." Most of us are immune by now, but the reaction of the susceptible few is always fun to watch.

Perhaps the worst coffee I encounter on a regular basis is the dreaded ER Night Shift Special. At best, it's barely tolerable when it's fresh. Caffeine content seems to be the primary concern. What gives ERNSS its distinctive bouquet is nothing more than time. Normally, coffee is one of the first activities of the shift, just like everywhere else. The degradation occurs when the night rush happens. Every ER has one, especially on Thursday, Friday, and Saturday. When it hits, it hits hard, and the coffee just sits and stews, sometimes for hours. Every EMS provider knows the rest. The pot's sitting there, half empty not because anyone has been drinking coffee, but because half the water has boiled away. If you inhale deeply when walking past the pot, the airborne caffeine is enough to get your heart rate well into the 200's. By about 7 in the morning, that last little bit of coffee in the pot is sufficiently concentrated to make it the drug of choice for cardiac arrest. Hell, a couple tablespoons spilled on the floor is enough to make the tiles beat most of the time. You know the shift is over when the guy in the hazmat suit grabs the pot and heads toward the sink. Don't tell the EPA, and don't pour it into a styrofoam cup if you decide to drink it. They've been known to dissolve on contact.

Good or bad, we need that coffee. It may be to keep us awake, it may be to GET us awake after a long night. Or it may just be that we need a few minutes to sit down, collect ourselves, push some images out of our head, and get ready for the next one. The coffee's just a prop.

12 Rules For Calling 911.

Tonight's post is brought to you as a public service announcement.

Most people will never interact with their local EMS providers. As a result, a lot of folks are very intimidated by the thought of having to call an ambulance. In the interest of public safety, I'd like to offer a few helpful hints that might make your ambulance call a more fulfilling experience for all involved.

1. Verify the presence of an actual medical emergency. Not a WebMD indicated emergency, I mean a real illness or injury. These can be easily recognized by the appearance of symptoms BEFORE reading the description of your condition. (You live in Kansas, the likelihood of you actually having Ebola is extremely low.)

2. The 911 operators are trained professionals that are there to help you. Do not yell, curse, swear, or otherwise abuse them. They don't have any control over how long it takes us to get there, who shows up, or what we do when we get on scene. You may only be on the line with them for a few minutes, I have to work with them every day. Please try to keep them in a good mood.

3. Have your residence marked in some visible way. At 3 A.M., I will be unable to recognize "the empty lot where the barn burned back in '76" as the entrance to your driveway. House numbers are relatively inexpensive. Go get some. I'll wait here.

4. I like dogs and cats, but pen yours up before we get there. A cold, wet snout in the back of the neck is very distracting when I'm trying to save your life.

5. We do appreciate the people that call in the car on the shoulder as they whiz past, but do you really think you should be making a phone call while you're driving? Here's a thought- pull over to make that phone call. That's what the guy driving the car you're calling about did.

6. In rural areas, "wavers" are nice. Having someone stand at the end of the (Unmarked. See #3.) driveway to flag us down is actually very helpful. Having six people standing there drinking beer and all waving at once is not. Neither is having a line of a dozen people waving us in for a landing along the entire length of the driveway. It's distracting, and you all look stupid when you do it, so stop.

7. Unlock your door if it's at all possible. We don't have a key. We DO have an axe. You figure out the rest.

8. Bathe regularly. Seriously.

9. It would be greatly appreciated if you could manage to have a medical problem I've actually heard of. If I can't figure out what's really wrong with you, I will simply treat you for something more easily dealt with. Please make every effort to develop that alternate condition before we get you to the hospital. The paperwork is much simpler that way.

10. At some point, I will ask you to rate your pain on a 1-10 scale. Don't say 12. If you are with it enough to joke, you don't need pain meds. I can tell when you're pain is real, and when it's not. Someone that says their pain is a 7 is WAY more likely to get medicated.

11. At the other end of the scale, we do not award bonus points for bravery. As stated above, I can tell when you're in pain. If you insist your pain is a 2, I will eventually stop offering you meds.

12. When we get you to the hospital, try to give the doctors and nurses the same story you gave me. It's embarrasing for me to have you tell them something completely different than the story I got, and it's embarrasing for you to get admitted on a 48 hour psych hold for the hallucinations you are clearly having. Why else would your story change so radically?

I hope these tips have aided you in your 911 calling experience. Thank you, and good night.

How do you do it?

One of the things they don't always teach you in paramedic school is that true life threatening emergencies don't really happen all that often. (Relatively speaking. Looking at the entire population, they are extremely rare. Working as a paramedic means that you get called to life and death situations with something approaching regularity.) As a result, the majority of patients we wind up transporting either don't need any particular care on the way to the hospital, or require something simple that doesn't take up a lot of time. That's fine with me, even though the paperwork is more or less the same regardless of how much I do en route, and as any of my partners can tell you, I tend to leave pretty much the same degree of mess in the back of the ambulance whether the patient is truly sick or not. (I'm getting to the point, I promise.) What all this actually means is that we can wind up with a LOT of time to kill while we're on the road. I'd even venture to say that most of the people we transport really don't need much more than a ride to the hospital with someone to keep an eye on them, just in case.

The end result of all this is that we wind up making a lot of small talk to keep the patient entertained, informed, and most importantly, DISTRACTED. Kids are easy. Being emotionally immature myself, I can relate to them. Bring up the finer points of Spongebob, start talking video games, and draw a face on an inflated glove, and you're golden. Keep them occupied until you get to the ER, and you're three quarters of the way to fixing them. Teens and adults, on the other hand.... Not so simple. They keep asking intelligent questions that demand real answers. Most of the time, they just want you to reassure them that everything's going to be OK, which it usually is. Sometimes you're worried about them, and you really need to be honest with them about that, too. They don't want to hear it, but the truth is your only option. Fortunately those folks are the minority, and a subject for another day.

The largest group is the not all that sick folks, and eventually they all ask the same question: "How can you do this every day?" Good question. So good, in fact, that even after doing this for years, I still can't answer it to my own satisfaction. I usually come back with something along the lines of "Well, they keep paying me, so I keep coming back." Most people are satisfied by that, even if it IS a cop-out. The truth is that most of us keep doing the job because we can't NOT do it. EMS has become what's termed an "ego investment profession". Put simply, the job becomes not just your job, but your identity. If you ask me what I do for a living, I'd never tell you "I work in EMS." I'm more likely to tell you "I am a paramedic." See? There's a difference. The job is psychologically addicting. Deep down every one of us in the field is an adrenaline junkie to a certain extent. We still get a rush when the call comes in, and it's still fun to go tearing through town with lights and sirens. It's a huge ego boost to show up on a scene and have your first responders tell a patient that everything's going to be all right now, the paramedics are here. It's exhilarating to watch someone that was nearly dead a couple minutes ago open their eyes and look at you with gratitude. I still get a kick out of having someone walk up to me in the gas station and tell me that I saved their life, or their spouse's, or child's life five years ago. I probably won't remember it, of course. Only the failures stick with you. But even if we can't save them, someone ALWAYS comes up and thanks us for trying. That's a good feeling, too.

So how do I do this job every day? Easy. I love it.

Opening Day

OK, let's try this again. I've attempted a blog in the past, and just couldn't stick with it. After reading many EMS related blogs over the past few months, I decided that my earlier problem was a lack of focus. So I'm taking a new approach, and sticking to a subject I know well enough to fool someone into giving me a job.

Since this is the first post, an introduction is in order for those of you that don't know me. (Lucky you!)

My name is Mike Hasty. I'm 42 years old, married to an ICU nurse, with two kids. (Girl, 8 and boy, 5. More about them later.) We live in rural Kansas, where I work for a county ambulance service, and Cassie, my wife, works for a local hospital. I've been a paramedic for the past 10 years, and have been with my current employer for the past 6 1/2 years. That time on the job actually makes me one of the senior paramedics at this agency. I'm a USMC veteran, and served in Desert Storm. (The OTHER Gulf War.) I can be sarcastic, cranky, and intolerant of other people's stupidity. I hate politics, but generally consider myself a somewhat left of center independent. Deal with it. Or not, it's not my problem. (See? I TOLD you I could be cranky.)

I have stories to tell. Some I want to tell, and some I NEED to tell. You may or may not be able to pick out which story is from which group. I probably won't specify. I hope people will read and comment. I love to hear from others, and let's face it- the EMS providers that read this stuff can probably use the group therapy. We are not generally recognized as the most psychologically stable group of people out there, and can use all the help we can get. Especially if it's free.

So, sit back, relax, and enjoy the ride. The road could get twisted...