The Job

I am guilty of complaining about my job. The rare occassion occurs
when I get to use the skills I spend countless hours maintaining.

Today, if you haven't heard, we had a rain event that produced wide
spread flash floods in the metro. I am a swift water rescue technician
and it is one the the more fun diciplines in technical rescue. I was
call in to assist with evacuations.

These are the days when I feel like I can make a difference. I
assisted with the evacuation some medically fragile people who were
trapped in high water. I am not a hero and no lives were directly
saved by me or the crew I was working with. Most of the day was spent
checking calls to 911 hours after the initial storm. Most of the water
in the areas had receded by the time we got to the low priority calls.

I would still do it all again. Today I love my job.

Bored,

I am bored with my job. I want more from my profession. I trained for two years to become highly trained in emergency medical care. Ever since obtaining my license I have been relegated to ambulance driver.

I tried to get a part-time job with a 911 service. No one in my area wants a new paramedic in their service. Yes, I said part-time job. My full time job with the fire department pays well, and there is no EMS job in this state that can come close to competing.

So I am screwed. I want to be able to make a decent living, but I also want to use my hard earned skills. I can't have both and that is sad. Do we need to let EMS in the US fail so we can have a better system? The gang over at EMS garage have another lively discussion on this very topic. Every week they get together and talk about EMS, often how bad the pay is for our workers. They never find a solution and I am not sure anyone who runs EMS wants a solution. Listen to their shows and email them with ideas. We need to all be on the same page, in the same room and stand up for decent wages.

Why are YOU here?

What is the reason you got into EMS? I ask most new EMT and Paramedic students this question. I really want to know the motivation behind their entry to this profession.

Me? I wanted a career change. Like most people I thought EMS would be a 24/7 adrenaline rush. Saving lives and gathering praise from the families of the patients. I had been in the fire service as a volunteer for nine years before committing to my EMS education. Firefighter are always getting positive attention (unlike police officers), they have the public fooled, kids of all ages, races and sizes want to be a firefighter at some point in their life.

No one says "I want to work on a ambulance when I grow up". During my EMT class we all thought our future jobs would be similar to a firefighter, saving lives. My first job was with the fire department, we ran in a tiered system with third party EMS. I did not work on an ambulance until a few years later.

My paramedic friend convinced me to apply for part time work with a private service ambulance company. The government EMS service had just gone through a merger and my new job was covering trucks for the local 911 service. Just like the fire department we made only 911 calls. I learned a lot, including how to get to all the area hospitals. Eventually the city got their act together and no longer needed private service to cover for them. Being an EMT-B I was sent to a BLS transport truck. This began my true education in EMS. Gone were the days of driving with lights and sirens, rapid assessment of patients and having a paramedic to do all of the paperwork. Gomers and Chuck runs are all I saw for a few months with the occasional stint with a part-time paramedic.

I left that company, they treated EMT's like dirt and were not afraid to tell you exactly that (in fewer words). I went the second largest private ambulance service in my area and worked there part-time. I am still working for the F & B ambulance company as a part-time paramedic. I wish I could say that the EMTs and Medics are treated the same, but you know that is not the case. EMT's are still dirt and medics are a precious resource (unless there are six medics, then you are just meat in the seat). I try not to use this to my advantage or abuse my status. F & B actually fired a part-time medic recently for several reasons, but mostly he was an arrogant jerk and actually told a facility that they would never fire him, because he was a medic.

I advocate for the patient. We have older ambulances and sometimes things break. I try to return only when it is a safety issue or it would interfere with patient care (like the A/C in the patient compartment not working on hot days). I enjoy working the streets and helping new EMT's (and not so new) learn how to properly assess a patient, take vital signs, lift with their legs and improve their bedside manor. I remember being the Basic who always had to take all the runs and the medic just wanted to drive (lazy medics, we all know some) no matter the patient condition.

I am here to help. The patient, my partner and the company I work for (in that order mind you). I like what I do and I wish others (general public, government officials, allied health care providers) would respect my career choice and treat us all like the professionals we are.

08:34am

Shift starts at 09:00. I like to arrive early, check my truck &
equipment. The adage when I worked in theater was 'early is on time,
on time is late' as it should be even for emergency services.

Dispatch supervisor greets me at the supply officer's desk. "How soon
can you go available?"

Me: "I just walked through the door, my partner is not here, I don't
know what truck I'm assigned to and I have to check my equipment &
supplies. After that I'll be available as soon as possible."

DS: "Methodist Hospital has a vent patient who is crashing and the
other medics are on runs."

Me: "Find me a partner and give me a minute to check my truck."

I am sensitive to emergent runs and meeting requirements of our
contract with the facilities. If someone needs my help, I want to meet
that need. I notice a paramedic graduate who was in my class and I
asked if she had a partner yet. The scheduler screwed up and did not have her on for the day. I told her I needed a partner immediately (get schedulers permission) for a priority 1 run. I grab the ventilator (LTV 1000) do a quick once over on my ambulance and we head towards Methodist Hospital.

The CCU unit was a flutter with activity. Nurses racing around trying to get orders. The patient's nurse told me that the patient coded last night, they got her back after 20 minutes and she is being paced TCP (trans cutaneous pacing). We are transporting the patient from Methodist to Metro Hospital CCU for pacemaker implant. Levophed drip, Epi drip, Sodium Bicarb drip ventilator and TCP. A lot going on with this patient. First trick was to switch from their pacer to our pacer. Could have been easy, but we did not have the same brand and the connections are all different. Three people helped, lift the patient, turn off their pacer, my partner slapped our pads on the patient and I started pacing again. I studied the lifepack 12, looking for signs of capture. Finally got capture. The nurses combined all the drips to one multi pump, and we transferred the patient to our stretcher. I set my LTV and transferred to my ventilator. After a minute or two of letting everything settle, and checking to see if the patient was stable, we headed for the ambulance.

Code 3 to Metro Hospital, luckily it was less then 3 miles away. We arrive, give report to their CCU nurses and reverse the procedure. The had the same brand of monitor/pacer making that transfer easier. Vital sign check BP 86/52. Very not good. At this point the patient is in the care of the nurses I offer to help in all ways I can. Unit secretary places STAT pages for the patients doctors. I am released by the nurses, I leave the room to complete paperwork. Several minutes later they get a doctor to the floor and he is not happy that the patient was transferred in this condition. My partner, after cleaning our cot & monitor, watches the activity inside the room. She comes over to me and tells me that Doc has taken the patient off the pacer four times to see the underlying rhythm. Easy guess, it's asystole (didn't take me long to figure that out). I finish writing, get my signatures and head towards the elevator. We stepped on the lift with one of the CCU nurses, going to pick up a patient from the ER, and hear "Code blue CCU, Code Blue CCU" to the same room we just left.

Preception of perfection

Only two dialysis transports do far. The A/C in the cab of the truck
was not working well, the 85 degree atmosphere was heavy. My partner was edgy, waiting to get results from the NREMT-P (National Registry of Emergency Medical Technicians) written test. She was waiting for an email, I told her to just check the website. Her eyes, widened, and she read aloud the statement of passing the test. She even made me read the results, just to be sure that she had not misinterpreted what she read.

Dispatch: "Medic 42 copy priority 1 to Farthest Nursing & Rehab for respiratory distress"

I have seen more respiratory distress patients in the months I have been working than any other kind of ALS patient. We head over to Farthest, code 3. The pager stated that the patient was to be transported to St. Other end of the County Hospital. This is mostly the patients family making these decisions in written form for the nursing home. I always keep the option to transport to Closest ER when necessary.

The patient's room was filled with staff members (and they even had their crash cart out), they had the patient on oxygen 8 liters per minute via a non rebreather mask (I didn't know nursing homes had these things, they always give nasal cannula). I could hear the fluid in the patients lungs from down the hall. LPN reports the patient has an axillary temperature of 103.4F bilateral Rhonchi SpO2 77%. The patient looks pale and moist. I'm told that he has become this way within a few hours. He's definitely hot to the touch and not looking well. We scoop him up, get the paperwork and head out to the truck. I like to do my work in the ambulance when I can. His pressure was 118/60 heart rate 110 (ventricular pacemaker) restorations 34 shallow lungs bilateral rales (NOT Rhonchi). First thought, I need to breath for this guy, my partner gets the BVM (bag valve mask) and begins assisting restorations. I prepare to nasally intubate the patient. I have already decided we are going to Closest Hospital, will have my dispatch notify the patients family. First attempt, sounded good, looked promising, not good (damnit). Bag the patient for a little bit, get new tube and try again. Second attempt, no good, screw it, let go I'll just bag him (we are 3 miles from ER).

We roll into the ER, give report, the nurses do their work up, get IVs, respiratory arrives. The Doc takes one look and says Aspiration Pneumonia. Patient has a PEG tube (and a foley cath that looked like mud, a PICC line that had not been flushed in days). Doc orders Etomidade, Succinylcholine and intubates the patient. Sure would be easy if I could have done that. RT suctions out the ET tube, and the contents look a lot like feeding tube goo.

Minor Leagues

Today I feel like I am in the minor leagues, trying to make it to the
majors. I work for a private ambulance service as a paramedic and a
rural 911 service as an EMT-B. A former class (paramedic class) mate
of mine was recently 'upgraded' at the 911 service to medic.

I was happy to see that he got his due, he works for an ALS fire
department full time. A few people have encouraged me to speak to the
operations person at the rural service about getting upgraded myself
to medic status. I have only had my license for a few months (January)
and I'm just not sure if I'm ready for the major league.

What are you reading?

I have been following a large variety of medical blogs. Most of them are related to emergency medicine, but a few are not. Here is my current list of medical blogs I follow (and so should you).

Crass-Pollination Nurse K is absolutely funny, and very sarcastic. You can follow her on Twitter also @ernursek

A Day in the life of an ambulance driver Funny and insightful, he has recently published a book called En Route .

The EMT Spot a great learning resource for all levels of prehospital medicine. You need to subscribe to this one.

Paramedicine 101 I shouldn't really need to describe this blog, it is exactly as the name states. Very useful information here. Read daily.

Street Watch: Notes of a Paramedic I really blame Mr. Canning for my interest in EMS. I read his book Paramedic back in 1999. I am also from Connecticut and I knew the areas he was writing about. You really need to read both of his books.

Rouge Medic This guy knows his science. Don't try to argue a point without your facts and the foot notes to back up your statements. Excellent use of science based medicine.

Doctor Grumpy in the House Dr. Grumpy is a neurologist. His patients are freaking hysterical. I had not idea people could be this senseless. Make a friend, bring the good Doctor a diet coke.

Random Acts of Reality a Paramedic from across the pond, Tom Reynolds has a very interesting outlook on life. His first book Blood, Sweat and Tea, was a gem. His follow up should be available any day now More Blood, More Sweat and more Tea.

On the Clock moving stories from an English major in college who also enjoys the thrill of riding in the back of the ambulance. She really is a good writer.

That's all for now. It might take you a few days to read enough of the blogs to get a feel. I'll add them to my 'Blog Roll' and more when I get a chance.

Do we need Paramedics?

I was listening to the EMS garage podcast #27 the other night, when they got into a heated discussion about Columbus, OH looking to be a Basic Life Support (BLS) only service. San Antonio Fire Department in Texas has just started running six BLS only ambulances in addition to their thirty two ALS (Paramedic) ambulances.

I work for a private ambulance service in Kentucky. I am a new paramedic with only a few months under my belt on the streets. My ambulance service does not have any 911 contracts, but we have many with nursing homes and rehabilitation centers around town. Today (like many days) was extremely slow, and the three paramedic trucks were relegated to dialysis runs and doctor appointments, all of them BLS in care level. I began to think are paramedics really needed in urban service areas?

The OPALS Major trauma study as reviewed by Dr. Keith Wesley on JEMS.com showed that ALS intervention in major trauma patients had little to no benefit to survivability. Also it stated that when a trauma patient had a Glasgow Coma Scale (GCS) score of less then 9 and ALS intervened, the mortality rate INCREASED. Yes, this is only one study, but more and more studies are arriving showing that ALS procedures do not increase survivability for the patients. Trauma is the realm of surgeons (paramedic students are told that Trauma is a surgical disease, and the only definitive care is surgery), control the bleeding, apply oxygen and increase the diesel flow exponentially (all BLS skills by the way).

Cardiac Arrest, the American Heart Association (AHA) has been promoting more high quality CPR (cardiopulmonary resuscitation) and less time interrupting chest compressions while trying ALS interventions. Ok, I can hear the pundits (and old school medics) but we NEED an IV line and we NEED an endotracheal tube to secure the airway! Well, modern science along with a few industrious people have come up with several blind insertion airway devices, like the venerable Combitube or the King Airway. Both these devices are BLS level skills in many states (the number is growing and it should). Any decent paramedic, would not remove one of these devices as long as adequate ventilation are being performed (and you can even add capnography). What about electrical therapy? Semi-automatic External Defibrillators (SAED or AED) BLS skill. There is even a thought from Dr. Bryan Bledsoe in the recent JEMS magazine about giving too much oxygen. Summery, high quality chest compressions, not hyper oxygenation and a king airway with a bag valve mask (on room air of course), all BLS level skills.

Stroke (Cerebrovascular Accident, CVA), unless you work for a service that allows the administration of tPA (Tissue plasminogen activator) , you are just a glorified BLS transport truck trying to get the patient to a stroke center within the three hour time frame. Sure you can start and IV, but can you provide definitive care for that patient? If you could why would you be transporting them in the first place? Treat and release (yes I know this is extremely unlikely that a paramedic could EVER treat and release a CVA, but the question is still valid).

Asthma/Anaphylaxis, again modern science has given us the Epi Pen auto injector that many BLS services are now carrying. Even in the Metro are I live, BLS trucks administer albuterol nebulizer treatments. Then just transport them to hospital of choice.

Congestive Heart Failure (CHF), what about that smart ass? Again more medical directors are adopting protocols that involve less invasive treatments in the field, like CPAP (Continuous positive airway pressure). A BLS ambulance is trained to listen to lung sounds, they can identify ralse (crackles) and use the CPAP, during transport to the hospital of choice. Diuretic medications are also being studied closely, and some doctors want to stray away from excessive use of lasix in the field.

Angina and chest pain, Nitro glycerine (NTG) and asprin (ASA) along with a little oxygen and get thee to a hospital. There is talk in the EMS community of reducing the use of morphine for chest pain. Oh, you want to address the twelve lead ECG stuff also? Much of 12 lead ECG transmitting to ER's in my area is still in the pilot program stages. Yes, this can reduce door-to-balloon time but the study in my metro is still under way. If I can get a patient to the ER under 30 minutes and I did not transmit an ECG to the hospital is the door-to-balloon time really that much greater? We all act like transmitting ECGs to the ER is something new, but as I recall Johnny & Roy were doing that in the 1970's.

I believe that if your transport time is less than 30 minutes to definitive care in a hospital, then you really don't need paramedics in your service. Maybe I am just a new medic and I don't know what I am talking about, but the studies are out there. I became a medic to help people, and I find that I am just another ambulance driver. You can send your hate mail here: joelneild@gmail.com but you will only get a response if you can format a sentence correctly and use proper grammar.