Probie To Practitioner

My AEMT class is big. Probably around 40 people in it, if I had to guess. All I know is that we had students perched on window sills during the last class because we were out of chairs–and this isn’t a small room either. And of those 40, I’d say almost a quarter do not work as EMT’s.

Call me ignorant, but I had no idea how hard it was for some people to find work as EMT’s. Apparently I live in a nice, cozy, little bubble of happiness. I had a job secured on the EMS division of the fire department when I was still in First Responder school. The only conditions to my employment were that I became a licensed FR, and that I turned 18 years old. I knew I was lucky, but I didn’t realize just how lucky until this class.

Many of the students in my class are working at Walgreens, or Dunkin Donuts, or Chili’s, or whatever. They haven’t been on a truck in ages. Some haven’t ever worked on a truck. During that first night of class, one by one, we have to stand up and give our name, our hometown, who we work for, and why we want to be in class. Several students said the reason they’re coming to AEMT school is because they can’t find work in EMS as a licensed basic. So they figure an ALS ticket will help them get a job.

For their sakes, I hope they’re right. I worry about my ability to perform as a provider, and I’m on a truck nearly every day. I might just be driving, or it might just be a simple BLS transfer, but at least I’m in my environment. For me, there was a bit of a learning curve between what I learned in EMT class and what I had to do out in the field. I’m not saying that we throw the book out the window when we respond to calls. But there are some things you just don’t learn until you actually do it. Like listening to a blood pressure while bouncing down roads riddled with frost heaves. Like crunching ribs when you do CPR. Like seeing what a truly sick person looks like and remembering what to do.

I’m trying not to sound like I’m judging these EMT’s that can’t find work. If you can’t find work, you can’t find work. I suppose doing this is the most that these EMT’s can do. And who knows, maybe they’re naturals at this. Maybe they can leave for a while, and get back into the swing of things in no time at all. But I worry for them. I hope this works out for them, really. In the meantime, I’m going to try to not take what I have for granted. It seems I’m luckier than I realize.

We were all standing in the kitchen, chit-chatting about this and that. But standing still and talking doesn’t last long in a firehouse. We’re all fidgety individuals. So, we start going through the cupboards, looking for God only knows what. We come across a little cookbook, and start flipping through the recipes, pointing out names and making sarcastic comments.

“‘Randy’s World Famous Spaghetti Sauce.’ Huh. I’ve lived in the world a long time, and I have never heard of Randy’s spaghetti sauce. Anything that advertises how good it is in the title is an automatic no-go.”

“Orange zest and barbecue sauce? No. Nope. You’ll never sell me on that.”

” “Wow, this will taste absolutely amazing!” Said no one, ever.”

And somewhere in the middle of this, we come across a recipe for “Mongolian Ski Beef.” What?? The recipe itself makes no sense, but it’s really the title that grabs us.

“Ok, ten bucks if you can slip the phrase ‘Mongolian Ski Beef’ into the next call. Twenty bucks if you can slip it into a patch to the hospital.”

Game on.

She wavered on edge of consciousness; sometimes barely focusing on her surroundings, but usually not. You could blame that on all the pain medication the doctors had given her, in an effort to make sure the last feeling she would have on this earth was something other than pain. Her body had been fighting for years, but it ultimately was a losing battle. That’s why she lay there on my stretcher, bundled under so many blankets, on our way to the hospice.

I looked at the paperwork we had been given. The number printed beside the word “AGE” didn’t seem to match up with the human being before me. Both the treatment and the disease had etched deep wrinkles into her skin; wrinkles she shouldn’t be old enough to have earned.

I hated myself for even having to take a set of vitals on her. She’d had years of being poked, prodded, scarred, and hurt in the medical field. Can she not be allowed peace and rest even as she dies? I apologized for disturbing her as I wrapped the blood pressure cuff around her arm. I silently cursed the protocols that made me do this, even this minor non-invasive procedure. I just wanted to let her be. “What will taking a set of vitals do for us?” I thought bitterly as I inflated the cuff. “There’s nothing we can do regardless of what they are. Regardless of what level provider is in the back of this truck. Regardless of what tools they have in their arsenal.”  At least she didn’t seem to mind too much. I’m just one more person in a medical uniform to her, I suppose.

Her bloodshot eyes remain half-open, unblinking. Her respirations are so shallow, I had to watch her intently to make sure she was still breathing. There are no more than a few days’ worth of beats left in her heart, I’d been told.  My pulse quickened, as if to make up for the both of us, as the thought runs through my head: what if her heart gives out before we make it there? A cardiac monitor would be nice right now, at least so the green peaks on the screen can give me the comfort of knowing her heart is still and constantly beating. But without one in this BLS rig, I make do. I take her hand in mine, rubbing the back of her hand with my thumb, and grasp her wrist with my other hand. Her pulse thuds gently against my fingertips. I take comfort in the quiet, steady rhythm; hoping that it doesn’t stop before we arrive. I keep my fingers on her pulse for the remainder of the trip, each thud taking her a little farther away from the world.

When the rig stops, and the parking brake pops on, her eyes open and focus. She looks around the ambulance slowly, briefly. “We’re here,” I offer with an uncertain smile. What expression should you wear when you essentially tell someone you’ve brought them to the place they will die? She looks out the window at the carefully manicured landscape.

“Oh well,” She says, smiling for the first time all transport. There’s a twist to that smile; a bitterness, a sadness, a resignation? It’s nothing I can place, nothing I can describe in a word.

What do you say to that? What is there to say to that?

Later that night, I reflected back on the events of the day. How I looked into the face of a woman dying. How there was nothing I could do—or anyone could do—to change what she would soon face. How I had so little in my power to make her any more comfortable. Wondering if there was such a thing as dying with complete dignity. How an hour before I’d met her, death and dying were the farthest thoughts from my mind. And suddenly, it was so forefront, so nearly tangible. I sat, blinking, thinking, not sure how or what I feel.

My phone buzzed in my pocket. A text message from my pregnant friend, “I hope Little Wiggly One is this jumpy tomorrow night so you can feel (or SEE!) her!” I’m even more uncertain how to feel. My hand was holding onto someone so close to the end of her life only a few hours before. And a few hours from then, my hand would be resting on someone who hadn’t even began her life yet. It’s all a circle, and it’s all so out of my control.

She sat on her living room couch. She kept her head down, her light brown hair shielding her from our presence. Her mother stood in the hallway, her outward expression revealing anger, disgust, frustration. But her red eyes, wet eyelashes, and occasional sniff gave away her true internal emotions of sorrow.

Our patient held a dishtowel to her forearm, which I slowly removed. The bleeding from her lacerations had mostly stopped, only leaking a little. I tore open a 4×4, wiped away the blood, and taped it to her arm.

We talked quietly to one another. She spoke only when necessary; she was too lost in her grief to do anything that wasn’t immediately required. Her heart had been broken that day for the first time, by her boyfriend of one year. Silent tears rolled down her cheeks, and she stared at the floor. This was the worst day of her sixteen years of her life; the worst thing that had ever happened to her. And she was in the throes of the emotion that anyone would feel on the worst day of their lives.

I could’ve told her so much, but I knew she wouldn’t believe any of it. She would probably nod, and offer a weak, polite, transparent smile. I’d had a boyfriend when I was her age, and after much emotional turmoil, he’d broken up with me too. I thought my heart had been broken beyond repair. We were supposed to be forever, my boyfriend and I. We were sixteen, but, like most puppy loves, we’d had our whole lives planned out. Just like I’m sure she and her boyfriend did.

Absentmindedly, I tucked her hair behind her ear, probably just like her boyfriend had. And–although I know she wouldn’t believe me–just like her future boyfriends would. She raised her eyes to meet mine briefly, before returning her gaze to the floor.

It hurts. I remember. You remember. We’ve all been there. That first broken heart hurts on a level you previously thought unimaginable.  And right now, there’s nothing I can say that will change that. But I can offer a ride to the hospital. I can offer an unbiased ear, and a shoulder to cry on. I can give her privacy in a little mobile box. In the ambulance, the walls are blank. There are no corkboards, tacked full of ticket stubs, photobooth pictures, and still-frames of the cheery couple, to remind her of what used to be. There are no dresser-tops with vases of flowers. There are no memories and reminders of what was, and what she thought would be forever. Sometimes, that’s what you need; just to get away for a bit. But that’s the very thing I hope to remind her of, as I keep my arm around her, gently guiding her to the ambulance. She needs to get away for a bit: not forever.

As we take our ride to the hospital, a tone goes off for a second call. It was something that sounded gory and dangerous. Like “hero’s work.” Like “a real call,” or “a real emergency.” I sat there, holding her hand. Between sniffles and coughs, she began verbalizing what had hurt her so much. To her, at this moment, this was “a real emergency.” This was painful. This was real. She needed help. And at that moment, despite everything else that was going on in the world, my help was needed here. Not on my knees in some car wreck, shattered glass and blood around me, shouting above the roar of the Jaws of Life, with TV crews pulling in not far behind us. No. My place was here, with her hand in mine, passing her 4×4′s after we’d run out of tissues. This was where I needed to be.

As I’ve said like a jillion times on this blog already, our fire department has changed a lot. A few months ago, we had two regular paramedics that were available 3 days a week for very specific hours. This means many of our calls were run at BLS level. Sometimes we called for “ALS intercepts,” not “paramedic intercepts,” because we knew one wasn’t available. And even then, sometimes EMT-I’s weren’t there, and we’d bring in some serious calls with a crew of basics.

Then we hired about 10 paramedics from out of the area. All of the ones I’ve worked with are amazing and very talented at what they do.  We’re also doing interfacility transfers now, which has allowed for some really cool and special opportunities to work alongside paramedics on some very sick people.

But there’s still a disconnect between the old fire department crew and the paramedics. And I really wish there wasn’t…I’ll get into that at a later date. Most of us get along great! There are some learning curves and misunderstandings to be had, sure. But we work through them, and we’re respectful of each other.

Well, mostly. Until this little exchange the other day.

“Hey, so I’m going out to Big Medical Center on a transfer,” Paragod says.

“Oh cool, have fun. Be safe,” I reply, going back to writing a report.

“But that means you guys are going to be without a paramedic for 5 hours…what are you going to do if you get something serious?”

“We’ll just have to run it with what we got. You guys forget, we used to do that all the time. It’s no big deal.”

“Right. I can’t imagine what a shit show you guys must have been before we showed up. Now you’re like a real ambulance service.”

What?

That’s when you change the pronunciation of “paramedic” to “par-AM-a-dick.” No, as basics, we don’t get to do much. But that’s not to say that we don’t do our jobs well. Believe it or not, we’ve run some nasty calls as a BLS crew. What’s more, we’ve actually had some meaningful saves. Yeah, without a paramedic. Can you believe it? Apparently he can’t. Just because we weren’t able to stick people full of holes, and push drugs through their veins doesn’t mean that we were “a shit show.” And we were a real ambulance service for many years prior to your arrival on EMS, and probably even prior to your arrival as a human being on this earth.

I joke about how I’m useless as a basic. But that’s just it—I joke. Because it’s not true. I’ve gone on a tangent before about this, and I’ll probably do it again (just not now…this post is getting lengthy and unruly enough as it is…). I don’t know if his inflated ego was taught to him, or if it seeped into him from the cultures of where he’s worked before, or if he was just born that way. But, contrary to his thoughts, the “B” at the end of “EMT-B” does not stand for “bitch.” Quality patient care is not specific to higher level providers. Anyone at any level can do it. And if you know any arrogant jerks like this paragod I described, ignore his derogatory crazy talk. You are better than that. Remember that.

(Firstly, thanks to CCC for inspiring this with his series of “Things That Bother Me”. If you haven’t read his stuff yet, you probably live under a rock, and should go check it out.)

I don’t know about you guys, but where I work, our first-in bag is freaking huge. I wish I had a scale at work so I could weigh it, but, no dice. It’s designed to be worn like a backpack. When I wear it, it extends from about C5 to my sacrum. And the bag easily doubles my depth (if that makes sense…the line from the anterior of my body to the posterior). It’s also a good 3 inches wider than my shoulders on each side. The bag is absolutely packed with equipment and supplies too. You have to muscle the zipper a little to convince it to close back up.

In addition to our traditional first-in bag, we also now have an “airway bag,” which contains everything we could possibly use to manage the “A’s” and “B’s” of ABC. This bag is a bit smaller than our first-in bag, and at least has a narrower profile. The bag we bought is the same that is used by emergency medical helicopters. So it holds A LOT of stuff while taking up as little space as possible. That being said, it’s about the size of a hiker’s backpack…you know, the kind with the aluminum frames and whatever?

We’re supposed to take these two bags with us to every scene. Frankly, I think that’s a little ridiculous. Every scene? When was the last time you were called to a house where space wasn’t an issue? I’m almost convinced that the wider your hallways, the less likely you are to ever need 911. Most of the time, we always could use at least a few more inches of room to make our lives a bit easier. So why are we adding two hefty bags to people’s backs? It makes it that much harder to navigate the narrow spaces. It also limits our range of motion until we find a place to set down the bags.

And that’s the other thing that kills me. A good chunk of the time, that’s all that’s done with the bags: they sit there. Rarely is there a time where I need anything out of the first-in bag, other than a BP cuff and a stethoscope. And maybe the occasional 4×4’s.  I have yet to need anything out of the airway bag, seeing as we keep a couple NRB masks and nasal cannulas on the stretcher. So, we bring out these bags, take up room, further limit space, and bring them back to the ambulance. Because we are told we “have to.” Well that seems logical.

To be honest, I’d like to have the blessing to use my discretion as to what I might and might not need. I’m lucky to have competent dispatchers who almost always are capable to convey the severity of calls, even if the chief complaint is sometimes a little off. That, combined with the learned (and always learning) skill to size up scenes, I think we have a good idea as to when we should be bringing in equipment to stabilize a patient before transferring him to the ambulance, and when lugging in so much stuff is unnecessary. We literally have at least one of everything that’s on the ambulance in our first-in bag and airway bags. It seems, at times, a bit excessive. Are there times you need a lot of equipment right then and there? Sure. And that’s when the first-in and airways bags are convenient. But most of the time, basically bringing the entire ambulance inside the residence with you seems a little over the top.

I don’t know. Just my two cent