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The student and the hurt feelings

February 24, 2013 by 10 Comments

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.

Filed Under: Education, Lame, Students, Things that bother me

Do your time first, hero

February 18, 2013 by 8 Comments

I can remember the day I first started in EMS like it was yesterday. It was a brisk November morning about 15 years ago. I was really excited to save lives and be a hero and get on the news, and all that. I had a fancy stethoscope that I bought at the College’s bookstore (for like $10! What a deal!) around my neck, a neat black glove pouch on my belt, and a nice trauma shear/bandage scissor combo that I had in my right leg pocket.

I was a hero.

I was also too young to buy alcohol, so cut me some slack, okay?

As I strode into the station, I admired the sharp creases that I had spent countless minutes and an immeasurable amount of starch ironing into my patches. Then I saw him: my new partner.

He was about six-three, and easily weighed three hundred pounds. And it wasn’t necessarily “fat” pounds, either. This guy was built like a defensive end. And his face was mean, too.

“Damnit. Another new kid! They always put me with the new kids.” were the first words out of his mouth. He sounded, in a word, angry.

“Hi, I’m C” I introduced myself in an effort to break some ice.

“I don’t care who you are, or what you think. Keep your mouth shut and do what I say, and you will do just fine.” was his reply.

While his reply was gruff, I listened to it, and heeded his advice. I kept my mouth shut, and I did what he said, and we got along great. He taught me a lot, and I am grateful for his tutelage. I didn’t get my feelings hurt, and I wasn’t offended by his manner. I was really okay with it. He was the veteran, and I was the rookie, so I knew he could teach me a thing or two, perhaps even three.

But nowadays you can’t get away with that. You have to treat the kids with the “kid gloves.” You have to be all tactful and mindful of the self-esteem of the new kids. Especially when they are kids.

Saying something like “I’ve been doing this since you were in Kindergarten, and we need to do things a certain way” can’t be said. Because the new kid runs to the supervisors and tattles on you, saying “he was really mean to me and hurt my feelings, and I need to cry about it a little bit, but he needs to get in trouble!”

There is a lot that the new people could learn from those that have been around for a long time. It’s just too bad that I have to be concerned with someone’s feelings. Especially when I have been in EMS since they were in Kindergarten.

Filed Under: Co-workers, Students

How an intern got sent home

December 27, 2012 by 17 Comments

Over a delicious, yet artery clogging breakfast, our student rider tells us his story: always wanted to be a fireman, but only has a real chance of getting hired if he is a paramedic first, finished EMT school and was signed up for paramedic school before taking National Registry, never worked a single day aside from intern rides on an ambulance, and 9 months into his 13 month paramedic program. Already got all the alphabet cards, CPR, ACLS, PALS, PHTLS, NRP, yada, yada, yada.

Slimm gives me the side-eye that tells me not to pre-judge this kid. I nod and shrug my shoulders in response, and the “okay, whatever…” message is received.

Whatever.

It’s a quiet day so far and there isn’t much for the kid to do.

Until some helmet-less skateboarder face plants after trying to jump over at least a dozen stairs.

Seriously, if it weren’t for alcohol, genetics, or stupidity…

This is a messed up skater. Smashed face, extremities angled in ways they shouldn’t be, a chest that doesn’t rise symmetrically, an altered mental status, and irregular respirations, with blood and teeth filling the airway.

“Slimm, toss me the airway bag and suction, lets check out that chest, and cut these clothes off. Kid, I need a good rapid trauma assessment” I call out as we walk up, with first responders several minutes away.

The kid doesn’t move.

“Buddy, I need some help here. Rapid trauma assessment. Cut those clothes off, please.”

While Slimm assists ventilations, the airway has been suctioned, several teeth removed, and the airway secured with an OPA while I am preparing my intubation equipment.

Kid is still standing there.

“Cut this shirt off, please” I say, attempting to convey just a little more authority in my voice. “He’s probably going to have a pneumo we need to stabilize, if not a big flail segment.”

Hesitantly, he begins to cut the shirt off, seemingly taking the time to sever each and every thread individually. Meanwhile, the tube is in, first responders have arrived, and Slimm takes over the duties requiring the shears, and confirming both a large flail segment and absent breath sounds on the affected side.

The rest of the trip is a whirlwind of activity with a paramedic from the fire engine riding in back with myself and the kid, and the now unconscious patient. It is a short trip to the trauma center, and the hand off is smooth.

“What was that back there about, man? We needed some help, man!” asks/exclaims my trusty partner. “Where were you at?” Slimm is typically very quiet, and raising his voice is very out of character for him.

“I’m just here to watch, man.” is the kid’s reply.

“No, you aren’t. You are here to learn and take care of patients with us.” is my reply.

“Who told you that you were here to watch?” is the quizzical response from the thin, short, obviously irritated partner of mine.

“That’s just what I’m here for. I don’t really want to be a paramedic, anyway. I just want to be a fireman.”

Slimm turned and walked away. He had nothing more to say to the kid, but says to me: “Back to the station, man. We are going back to the station.” It was a quiet ride, with Axl Rose providing the soundtrack to the tense situation.

Next stop: the station, to the parking lot, more specifically.

 

 

Filed Under: Education, Students

Things that bother me: Lazy students

March 12, 2012 by 4 Comments

I loathe the lazy student. Seriously, education costs money, be it is your money or money belonging to someone else.

Students should have more respect for themselves and/or others.

Every once in a while, about 10 percent of the time, I will have a student third rider who doesn’t want to do anything. They don’t want to start an IV because they “don’t want to miss” or they are scared to touch people.

That’s what we do. You can’t get good at starting an IV if you never miss, and you can’t be any sort of competent provider if you don’t touch people. A large part of what we do is learned through trial and error.

Anyone else remember MAST trousers, or the blind administration of bicarb, or atropine in asystole?

The students who come to me for tutoring that are lazy bother the crap out of me as well.

Without fail, the lazy ones never studied in school, and usually don’t care. I usually get the same story time after time:

“I failed National Registry, and have to pass the next time, or I don’t have a job.”

Then they balk when I give them reading assignments and tests to take home. Like they can’t find 12 hours over the next 7 days to dedicate to studying.

I know that studying takes time, and lives are busy these days. People have full-time jobs, and kids, and other responsibilities, but if you can’t make school a priority, then you shouldn’t be surprised when you fail.

I have a house, and a full-time job, and a part-time job, and two children, and a wife, and I run a business as well. I make studying and reading a priority because it is important to me to be the best paramedic that I can possibly be.

If you can’t put your education near the top of your priorities, how can you expect to have any notion of a successful career in the back of an ambulance?

Filed Under: Education, Students, Things that bother me

ACLS megacode fail

October 21, 2011 by 5 Comments

Recently, during a private ACLS class for a few members of a local ambulance service, I ran into a scenario which I had never seen before.

I’ve been teaching ACLS for about 4 years now, give or take a few months. I am in the (admittedly bad) habit of using the same scenario for my mega-code. It is the same scenario which my paramedic instructor used the first time I took ACLS.

A husband (or wife, or daughter, or boy/girl friend) was driving his/her wife (husband, father, mother, lover, landlord) to the hospital because he/she was complaining of chest pain. They find your ambulance/fire truck at an intersection/fire station, doughnut shop, and pull up to you. The driver states the patient suddenly became unconscious while enroute to St. Elsewhere. “Go!”

The first few students went through the scenario, and miraculously saved the patient’s life. Well done, ambulance technician, well done. The last two were remarkably different. Once “go” had been uttered, it got strange.

“Okay, lets get him out of the car, and on to the ground. I have my gloves on. Is the patient breathing?”

“No, he is not breathing.”

“Okay, lets put in an oral airway and begin bagging him with 100% O2 at a rate of 14. Call for backup”

“Ventilations are being delivered. Additional help is on the way.”

“Does he have a pulse?”

“He does not have a pulse.”

“Okay, let’s start chest compressions at a rate of no less than 100, 2 inches deep.”

“Compressions are being done, and a pulse is palpable at the carotids with each compression.”

“Let’s put the AED on the patient and press ‘analyze’.”

“The AED is on the patient, and after analyzing, it says “Shock advised.”

“Deliver the shock, and re-check the pulse.”

“The shock is delivered, the AED says ‘no shock advised’ now, and the patient does not have a pulse.”

“Okay, I’m going to have my partner attempt an IV or establish IO access to the anterior tibial tuberosity.”

“IO access is obtained without difficulty, and with good flow noted.”

“Okay, how far away is my backup?”

“Your backup is 4 minutes away.”

“Okay, let’s continue BLS until they get here.”

 

At this point, I am literally speechless. This is a person with a paramedic license, mind you. I have delivered this scenario literally a hundred different times. Had this scenario been run the way it virtually always is, they would have seen pulseless ventricular tachycardia on the monitor, defibrillated, seen asystole, given epinephrine 1:10,000, then seen ventricular fibrillation, defibrillated unsuccessfully, pushed 300mg amiodarone, defibrillated, then seen a sinus rhythm with a pulse at a rate of 70, then they would have hung an amiodarone infusion, and the patient would have awakened on the way to the hospital. But, alas, that was not done. And the hypothetical patient had a hypothetical bad outcome.

 

“I’m sorry, could you show me in the ACLS textbook where they advocate continuing BLS until firefighters arrive?”

“Oh, it probably doesn’t say that in the book, but that’s how we do it where we work.”

“Interesting. Unfortunately, I cannot pass you, and suggest that you read the textbook again, and obtain your ACLS card elsewhere.”

I am interested to know where, or if, this student actually passed ACLS, and am also interested to know what the student’s supervisor/training director would have thought had they been there to witness this horrible ACLS failure.

Filed Under: Education, Lame, Oops, Students

Old-school assessments

October 20, 2011 by 5 Comments

When I first started this field, we didn’t have the luxury of a pulse oximeter in the field. The concept was hardly new, as it was being used frequently in emergency rooms and operating rooms.

Now, it has become the “sixth” vital sign, along with pulse rate, blood pressure, respirations, mental status, and blood glucose.

We used to actually assess the patient’s work of breathing, skin color, temp, and moisture, along with capillary refill time. Does anyone else remember “CRT is less than 2?” You know, squeezing the patient’s fingernail, or touching their forehead, and counting how long it took for color to return?

CRT, skin, and work of breathing can tell you a whole lot more about a patient’s status than a pulse-ox ever could. And don’t even get me started on using the pulse-ox to count a pulse.

I rarely use pulse oximetry to guide my application of oxygen. If I have a patient with a known history of emphysema, breathing 20 times a minute, with no distress, with clear breath sounds, and no accessory muscle usage, chances are that patient does not need a non-rebreather simply because “their O2 sat is 90.”

I am much more concerned with the end-tidal CO2 on the emphysema patient than I am with the pulse oximetry.

Using pulse oximetry can be valuable, but all too often, it is used in place of a good assessment, and that’s just plain lazy.

Filed Under: Co-workers, Patients, Students

How to be an EMT student

October 3, 2011 by 1 Comment

We all had to do intern time, third rides, student rides, ride-alongs, whatever you want to call it. When I was doing my third rides, we had a 4 hour class devoted to how we were to present ourselves and behave during our rides. Obviously, students these days do not go through a similar orientation. So, allow me to give upcoming students some hints.

 

Several points for students:

 

  • Getting to your scheduled third ride on time is probably the most important thing you can do. I know this is early in the morning and all. You had all weekend to prepare for this ride. Perhaps you shouldn’t have stayed up to watch the Jets beat the Ravens. We show up 15 minutes prior to our shift time, so we can check our truck off and restock as needed. More on that in a minute.
  • Please don’t show up with your shirt untucked and yawning. This is a serious business, and I’m not going to take you seriously if you look like crap. I know you are tired from watching the aforementioned Sunday Night Football game, but suck it up and wake up.
  • Don’t show up here with a cigarette in your mouth. We aren’t allowed to smoke on company property, or hospital grounds, for that matter. Which means you will have precious little time to smoke your cigarettes. So give it up for a day.  As a former smoker, I know how tasty cigarettes can be in the morning.  But people won’t take you seriously if you smell like an ashtray.  Just don’t smoke.  It’s 12 hours.  You can do it.
  • Help my partner and I check off the truck. If I ask you for the nasal airways, I need you to know which cabinet they are in. (The answer is cabinet 2, by the way.)  We don’t necessarily like checking the truck off, but it’s a necessary part of the job. Your willingness to help will go a long way.
  • Bring your book. Or notebook. Bring something to read aside from some wrestling magazines.
  • Shave. ‘Nuff said.
  • Don’t butt in to my assessments and conversations with patients, family members and other first responders. I didn’t ask when the last time the lady who twisted her ankle ate, because I don’t care, and it’s not pertinent. Especially not before we determine the extent of her injury.
  • Perform your own assessments. Our patient’s won’t mind if you ask them the same questions I already have. They tend to know that you are a student, usually your big name badge that says “EMT STUDENT” gives it away. Performing your assessments on your own, and obtaining your own vitals (like, acutally listening to vital signs and blood pressures) will only reinforce your routine, and make you better once you finish school.
  • The time to discuss the call, why things were done, or in a certain way, is after the call. I promise, I will answer all your questions, and we can discuss anything you want. In the back of the ambulance is not the best time to ask what valacyclovir is used for. (She’s not so cute now, is she?)
  • Talk to your teacher about rescheduling your third rides. I understand that you have only 9 months to get your rides in, but that is a big part of the problem, and you are only contributing to it. There is absolutely no reason for your to come to a third ride before you can perform the most basic of EMT interventions. For paramedic students, you should have CPR, ACLS, PALS, and PHTLS cards before you schedule a ride.
  • Help my partner. When we turn over a patient, I have things I have to get done, such as obtaining signatures, and some minor documentation. There isn’t much reason for you to shadow me while I do these things. Slimm has to prepare the stretcher for the next call, restock the supplies we used, and generally tidy up the truck. Go help him, and he will teach you how to be a good EMT, and more importantly, how to be a good partner.
  • Help both of us. We spend 12 hours in this truck, and there are various things we have to restock, clean, remove or replace at the end of a shift. I know you don’t work here, but sticking a piece of paper in my face before the truck is cleaned and restocked, and demanding my signature, will only make you wait longer to be able to go home.

 

Please understand that I really do enjoy having student third riders in my ambulance. I remember fondly the third rides I did when I was in EMT school, and how new and foreign all this stuff was. I looked up to my paramedic and EMT preceptors, and I was lucky that they were kind and patient with me.  It was made perfectly clear that I was the new guy, and I was an immigrant in a foreign land. My preceptors guided me, and showed me the ropes. I will be happy to do the same, but you are going to have to at least try and show a modicum of respect for this business.

 

Let’s do better next time, mmmkay?

Filed Under: Students

Those pockets aren’t for your hands…

August 21, 2011 by Leave a Comment

So, Slimm and I had a student third rider the other day.  I enjoy having students, I really do.  They are, for the most part, sponges for knowledge, tend to ask good questions, and are generally helpful.  This one was none of the above.


I’ll call him Goofus. 


My partner and I started this shift as usual, with a check-off sheet in our hands.  Goofus had failed to introduce himself at this point, and stood about 20 feet to the side, with his hands in his pockets.  We were prepared to leave him standing there in the parking lot, but he managed to sneak in the side before we could drive off.  Then he took a nap. 


Granted, this is an early-starting shift, but beginning the shift by napping in the back does not bode well for the rest of the day. 


The day started off plainly enough, with a vent transfer from a long-term hospital to another hospital’s ICU, then with some driving from post to post, then finally, a call.  It turned out to be nothing, with no assistance from the fire department needed or wanted.  What was of note, however, was that Goofus kept his hands in his pockets.  The entire call.


The rest of the shift was utterly boring.  Some schizophrenic man with diarrhea for a week, and no shoes, a known alcoholic drug-seeker with abdominal pain and an incredibly steep and long driveway, and some other calls that were bland to the point of not remembering.  Goofus never took his hands out of his pockets, never spoke to the patients, never attempted an assessment, much less an intervention, didn’t participate in the hand off of patients to nurses, and didn’t help my partner or I put the truck back together in preparation for the next run. 


As we were handing off the ambulance to the oncoming crew, Goofus had the nerve to ask me if I would go into the monitor archives and print vitals for all the patients we had transported. 


I’m not sure if Goofus ever got his vitals, or if Goofus ever got anyone to sign his paperwork for school.  I am pretty confident, however, that Goofus will have a very short, if any, career in EMS. 

Filed Under: Students