Lame excuses

My employer runs a paramedic program. When I say that the company runs a paramedic program, what I want you to take away from that is that the company supplies a physical location for a paramedic program, and students to fill the chairs.

But, they attached the words “EMS Academy” to it, so maybe it is sorta-kinda-official.

Whatever. It’s a moot point.

My employer runs a paramedic program.

Being one of the company’s Field Training Officers, I get to see the aftermath of the paramedic program, when the newly graduated paramedics spend several shifts riding with me. Some of them aren’t prepared, but most are.

I was having a talk with another FTO, Tony, while at the hospital a few days ago. This must have been early in a shift, because I actually cared about the topic.

Tony mentioned that he rarely sees the same paramedic student more than twice, and that each student does at least twenty rides at our company. He thought it would be wise for a student in our paramedic program to be ‘assigned’ to an FTO for the duration of their preceptor rides.

While we’re on the subject…our program is putting paramedic students on ambulances for their preceptor rides after three months of school. They don’t know how to read a monitor, and they aren’t allowed to perform any ALS interventions. What the hell is the point of riding for twelve hours on an ambulance if you can’t do anything?


Tony made a good point. After ten rides or so, there should be a pretty good rapport between an FTO and a student. They should be able to communicate openly with each other, so the student can get the most out of their classroom time, and their ambulance time. After twenty rides, any bad habits should be corrected, and the FTO can feel confident in his evaluation of the student. Alongside the FTO’s confidence in his evaluation, the course director can feel confident in the evaluations he gets from the FTO.

But instead, the students just ride whenever, and wherever. Rarely more than once with the same paramedic, or even with an FTO.

So Tony and I brought it up to the director of the program.

“Assign each student to an individual FTO. We have twenty-five students, and eighteen FTOs. Surely we can come up with a list of seven competent medics to fill the roster of needed FTOs. Once a student is assigned to an FTO, that student does all of their rides with that FTO. It only makes sense.”

We got a reply:

“Well, that would just be too hard, and we don’t want to make it any harder on the students.”

This is why I don’t care.

Lame-ass excuses.

These people got lights and siren responses

These are calls I have heard dispatched over the radio, or ran myself in the past few weeks or so since the implementation of the new policy that requires an “emergent response to all requests for services generated through the 911 system.”

  • A male with CHF who just got out of the hospital and wants to know how to take his meds.
  • A female with a swollen knuckle who can’t get her ring off (the ring isn’t stuck, her knuckle is just swollen.
  • A female who is depressed and ‘wants to talk to someone.’
  • A male in the waiting room of the emergency room who has been waiting too long and wants to go to another hospital.
  • A female who ‘has anxiety and witnessed an accident and is now having a panic attack.’
  • A male who ran out of gas on the interstate and is demanding PD drive him 40 miles home, but now PD wants EMS there.
  • A  very elderly male who is dead in bed, cold to the touch and stiff, with family refusing CPR instructions.*
  • A female who wants her blood pressure checked.
  • A school bus with 14 children on it was struck by the arm of an apartment complex gate. There are no injuries on the bus.
  • A male who was in a fight last week, and now has a swollen hand.
  • A male sitting behind a strip mall, dirty, and talking to himself.

There were others, but these are just the highlights.

But we want people to take us seriously.

*I sort of understand this one, but in reality, this family just needs a coroner.

“Yeah, but…”

I’m doing an ACLS check-off for a group of physicians as part of their biannual renewal. It is some of the easiest work I have ever done, and I have a blast doing it.

I give the delightful gastroenterologist his scenario, a middle-aged male who is waking up from his lower GI study. He doesn’t feel good, and it is only going to get worse from here.

Doctor Endoscopy asks for a set of vitals, and learns the patient is hypotensive, bradycardic, with pale, diaphoretic skin, and very weak.

“Okay, I want to put him on the cardiac monitor.”

“Sure thing. That’s what you get when you turn on the monitor” I say, as I press the button on the rhythm generator that hints it will display something resembling a a complete heart block.

“That is a third-degree heart block. I need someone to start an IV, and put the pacing pads on him.”

“Okay, your secretary has started an IV, and the janitor has applied the pacing pads.”

“Okay, I want to give point-five milligrams of atropine.”

“Are you sure?”


I pause the scenario, as best as a scenario can be paused. “Um, atropine isn’t going to work in a complete heart block.”

“Well, I’m the doctor, and that’s what I want to give.”

“Yeah, but…”

A conversation about plethysmography

“What’s that?” asks a student on another ambulance, pointing to my cardiac monitor.

“It is the plethysmograph” I replied, most likely butchering the pronunciation.

“What’s it for?”


After dropping my patient off, I made my way back to the EMS room where I found the student. It turned out he is a paramedic student, just finishing up his intern rides. He has a few weeks to go before he takes his exam. He has been an EMT for roughly 4 years, and by all accounts, is a good student, and a fast learner.

The fact that he asked a paramedic whom he didn’t know bodes well for him. He is engaged, and wants to learn.

We spent the next 15 minutes or so discussing the plethysmograph and its usefulness in assessing patients. What struck me most about our conversation was the fact that he had no idea whatsoever that there was even such a thing, much less that it could be used to assess patients.

We talked about how vasoconstriction can cause an increase in amplitude, and what could cause vasoconstriction. We talked about how vasodilation would cause a decrease in amplitude, and the causes of vasodilation.

We discussed how waveforms would change in a hypertensive patient with chest pain to whom we were administering nitroglycerin. The mechanism of nitro’s action, in decreasing systemic vascular resistance through causing vasodilation. It seemed to make sense how waveforms would change, and how that was directly related to afterload.

My patient happened to be septic, and I could show him how plethysmography could help confirm that diagnosis. My patient was an infirm older woman who had a mildly altered mental status, hypotension, and some mild tachycardia. The fact that she had a chronic Foley catheter with cloudy urine in the bag made the diagnosis of a UTI fairly easy, but the plethysmograph showed a very deep, prominent dicrotic notch.

He asked, appropriately, how the waveform would help me in my assessment, and I explained that the deep dicrotic notch showed me a low SVR, and there was no need to assess orthostatic vital signs.

He was receptive, inquisitive, and it was a refreshing conversation.


I’m just a regular paramedic, and nothing special. I only learned about this stuff because I asked and because I wanted to learn. I enjoy showing students, and other EMS personnel, things that I have learned along the way, and I enjoy learning from others. Our education doesn’t stop when we get that paramedic patch, it begins.

What is disheartening is the fact that a paramedic student, only weeks away from testing to become a paramedic, had never heard of a plethysmograph, a dicrotic notch, and did not understand the relationship between waveforms and vascular resistance.

We have a very, very long way to go in the education of our paramedic students.


The student and the hurt feelings

I hurt that poor paramedic student’s feelings today. Poor guy. I’m always cordial with students, and nice as I can be. But I was apparently very mean today.

First, I hurt his feelings when I suggested he get some real-world experience as an EMT before even thinking about taking the National Registry exam for paramedic. I know the commercials on late-night TV make this job look easy, and they tell you that you won’t get judged for not working on an ambulance until you have “P” on your patch, but that’s not true.

Then I hurt his feelings when I wrote in his evaluation something along the lines of “there is a lot that happens in the back of the ambulance, but this student wouldn’t know, since he spent the entire 12 hours napping, playing on Facebook, or staring out the back of the ambulance with his hands in his pockets. I guess my suggestion that he spend his time asking questions or reading his book didn’t go over too well.

I hurt his feelings once more when I suggested that he could start an IV if he wanted to, but he had to actually want to try and that it would be his responsibility if (God help us, when) he becomes a paramedic.

And lastly, I hurt his feelings when I suggested his bedside manor was more in line with someone who made a living selling used clothes on eBay.

This ain’t no Sadie Hawkins dance. I’m not going to grab your hand and tell you what to do.

Poor guy. I guess his complaint was warranted, after all.