i am not broken

Four days ago, I was looking through Twitter when I couldn’t sleep. This is a pretty common thing for me to do, and then I’ll switch to listening to podcasts. At least 70% of my Twitter feed is medical, and I usually an interesting thread, or something funny. Because let’s be honest, we medical folk are pretty damn funny.

That night though, I came across something that usually would give me no problem. It was a tweet about airway management, which is always a fun topic. I couldn’t quite read the slide though, so I enlarged the picture. The pictures were of patients with various degrees of facial or neck trauma. As soon as I saw the two pictures on the left of the slide with the two patients with massive facial trauma, I felt the hair stand up on my arms, felt my breath catch in my throat, and my heart start to race. I think that if I had been more prepared, I wouldn’t have an issue with this.

But that night, it caught me off guard. I knew immediately that I would be having nightmares that night, and probably for the next few nights to come. Maybe some olfactory or auditory intrusive memories, too. You see, the call that affected me the most psychologically in my career involved this kind of facial trauma. I’ll write about it eventually, but not tonight. Suffice to say, this was enough to push hard on that part of my brain to release all those same chatecholamines and stress hormones, even though I knew I was safe at home in bed, with the dog sleeping, and house safe.

I wanted to share this tonight, because this afternoon, I took a nap and for the first time, had no nightmares. It took a solid four nights of knowing that each time I fell asleep, I’d be feeling something like A Nightmare on Elm Street. Each time I’d lay down in bed, I would dread the inevitable time my eyes would close and there was nothing I could do to prevent it.

I also knew well all the reasons this would happen. I understand (to a decent degree) the reason my brain reacts like this. I know that its a limited process that I have no choice but to go through, and I know that when I do experience these moments that I will survive them. But there’s one thing that I also know that trumps all of these…

I still have to go through the darkness.

Once this process starts, once the first dominoe falls, there is nothing I can do to stop it. So instead, I choose to face it head on. I will let friends know and be intentional about not isolating myself. I will exercise and eat well. I will remember the good things in life, and feed my heart with music and good books and people. And I won’t give up because I also know that I am not broken, even though I am bruised.

Image from Creative Commons

Lessons Learned in EMS: The Final Five 16-20

Here are the last five lessons of the 20 lesson series. I hope that you’ve found these both interesting and helpful.

15: Learn who to share with, and what to share with whom

This is another lesson about mental health and processing the things that we see every day at work. I would venture to say that this applies not only to the things that haunt us, but also how we share the day-to-day traumas and tragedies that we are called to. I would think that this would not only allow us to process effectively, but also protect those we love outside of our professional environments.

I have found that sharing comes in two different ways for me. First, I share and process (or debrief, if you like that word more) the technical and graphic things with co-workers. I will tell them the gory details of a call, such as how a patient was found, or the extent of injuries. I will process with them things like my thought process on how or when to decompress someone, or the difficulty managing a crashing CHF patient. My brothers and sisters in public safety have the unique ability to understand what I am talking about. They too have managed these challenging scenarios and comprehend the fear, the rush, and the pride of a job well done. I want that space to vent about things like this safely and with people who don’t understand. I want this space because it feels safe and not like people are voyeuristically trying to see what our jobs are like or what “the worst thing you’ve ever seen” is. They are just family, able to understand our unique living environment.

Speaking of family, we do have those real people in our lives that we go home to at the end of a shift. They might be a spouse, significant other, or roommate. We might have to come home from a horrific call and then figure out quickly how to integrate back into “normal” life. For this, I suggest pre-establishing ideas about how to take time when you get home to switch gears. I also strongly suggest to people that they not share the gory details of your shift, unless the person you are going home to is also on the job somehow. Alternatively, I suggest that you share with these people the emotions of the job. While they might not understand the emotions of fighting to save a patient and then watching them die, they will understand if you can reframe that experience into asking them to think about something like a job they fought for and then weren’t hired. They might be able to understand the idea of fear when one is processing being assaulted if they have ever been in a car crash before. There are always similarities in emotions. To be honest, the only universal human emotion is probably sadness, so this shouldn’t be a huge step. This also protects these individuals from unnecessary trauma hearing about the horrors, but allows them a place in our healing, which is as good for them as it is for us.

16: Practice doesn’t make perfect, perfect practice makes perfect

As I was walking out of the ED one night to get back in the ambulance, I told my intern that, “Practice makes perfect!” I was quickly rebuked – in a wonderfully respectful way – by a physician that I knew well. He ran after us and pulled us aside, and said, “Tim, I heard what you said… But remember, practice makes habits. Perfect practice makes perfect!”
What a gift that this doc gave me. It was insight that I hadn’t put words to, and yet seems to be an easy thing to understand, even if its really hard to accomplish. To me, this meant no short cuts. Do things the right way, every single time. From personal preparation (ambulance, equipment, and protocol knowledge) to the phycho-motor skills of something like intubation (i.e., opening the mouth, gently inserting the laryngoscope, viewing the epiglottis, then the glottic opening, etc.), deliberate and consistent action, rooted in deliberate and consistent practice, allow for perfection.

And let’s be honest for a second: we will never be perfect. It’s the fruit just out of reach, the mountain we just can’t climb. (Wasn’t there a Howard Jones song about this?) Does that mean that its not worth striving for? Not at all… Get after it and never quit trying to improve either your knowledge or skills to create as close to perfection as possible in your practice of paramedicine.

17: Make use of your time at the hospitals between calls

There is always the temptation for people after a patient is dropped off to sit in the ambulance bay and check Twitter or Facebook. Or, lets be honest, to take a nap. Some of the best times of learning that I ever experienced though were during those long hours at night in between calls, and visiting with the hospital staff. This is similar to my suggestion about asking our brothers and sisters in law enforcement and the fire service to teach us. I learned about pediatric codes and tricks to neonatal resuscitation. These lessons were critical in my career and directly affected the care I gave to so many critically ill children. I grew in my understanding of EKGs by having physicians go over 12-leads with me, learning the minutia of the bumps and squiggles. I distinctly remember sitting in the trauma room with the attending surgeon, who graciously took her time explaining more of the kinematic of blunt trauma to the flank, and the concerns that mechanism raised for her.

There was a secondary benefit to all of this as well. These relationships paid off more than anything I could imagine. It gave me credibility to bring patients in to the hospital and be deeply trusted by the staff. They knew that I was serious about my medicine, and they knew that what I said to be true about what I saw in the field, absolutely was.

The perfect example was the gentleman who called for diffuse abdominal pain, but was pink, warm, and dry, with vital signs that would be typical for a calm, healthy man in his late 20’s. I don’t know what triggered it, but all of a sudden I asked the crew to increase the patient’s oxygen to get it above 96% SpO2, and to start two large IV’s, and do serial 12-leads. We were only a few blocks from the hospital, and I had my partner call them and tell them we were coming in lights and sirens with a critical medical patient. When she asked why, I told her to tell the ED that I just had a bad feeling about the patient. We wheeled in less than five minutes later, and the attending met us at the door, a little frustrated with the lack of information. I think she was looking to chew some paramedic butt out for the nonsense of a reason for a critical patient, but when she saw me, and I said I just had a bad feeling, Dr. K paused and said, “OK, thats odd, but its good enough for me… Take him to Trauma Bay 1 and let’s work him up.” There’s no better feeling than knowing you are trusted. (Turns out, the patient had just had gastric ulcer surgery, and while I thought he might have an MI, he was actually hemorrhaging massively internally. He ended up crashing during a bronchoscope, losing about 1.5 L of blood from upper and lower ends, and died in the ICU after the trauma surgeon tried to salvage him.) This just goes to show, that even though my diagnosis was way off, trusting one’s gut instinct, coupled with the respect of my hospital colleagues, meant the patient had the best chance he was going to get. That vote of confidence from Dr. K still sticks with me to this day.

18: As a paramedic, train your partner if they are an EMT. If you are an EMT, learn all you can from your paramedic

I find this to be so important. The relationship between partners is probably the most important thing to develop each shift. Investing in this relationship really is a force multiplier when it comes to patient care. I always took the time to park somewhere when we weren’t running calls, I would sit in the back and go over things like doing 12-lead EKGs with my partner. I wanted them to understand not only what we did, but why we were doing it. I wanted to make sure that they knew how to set up pediatric drip sets, or all the things that I would need to incubate someone. Again, the dividends payed off so much for my patients by doing this.

A hunter and his friend were lost and trying to drive to the hospital after a night of boar hunting, and saw the ambulance parked behind the fire station. The driver pulled in and came knocking on the door almost at shift change at 0700. My partner and I casually walked out, thinking it was just a random person asking directions, and he said the passenger in his truck might be having a heart attack. As soon as we opened the door to the truck and we saw the passenger, we knew this was a very sick individual. He was ashen and profusely diaphoretic. My partner, Jon, ran to grab our monitor and bag and hit the siren to get the firefighters out to help us. In under 90 seconds, Jon and I had a nasal cannula on the patient, SpO2, a blood pressure, 12-lead, and aspirin and a first dose of nitroglycerin.

90 seconds. The only way we were able to accomplish that was communication and training. I taught Jon everything I thought would help me out if we were ever with a really sick cardiac patient on our own. When he didn’t know something or understand a concept, we would stop and take a break, working through it until we flowed. It can be done, but it does take work on both ends.

19: Don’t give in and be the lowest common denominator at work. Fight to give the best, most creative care possible to your patients.

It has been my experience that there is often a tendency of older paramedics and EMTs to talk about how things have “changed, and not for the better,” or how “its not as good as the old days.” I have two thoughts on that.

First, its never as good as the old days. It’s been proven in studies that our perception changes over time, and that the old days had just as many problems as our current situations. Let that sink in. Don’t be fooled by that. We tend to block a lot of the negativity out of our systems.

Secondly, we have the absolute power to control our attitude. In the immortal words of Michelle Obama, “when they go low, we go high.” I have worked with some really negative people. It is my choice if I choose to feed off them, or I work deliberately to make them have a good day. When assigned with a negative partner for one day, I’ve bought coffee, engaged in conversation, and made them engage with me. When I’ve been assigned with someone for six months or a year, I have done all the same things. I have fought deliberately to include that person in time around the table at the station after dinner, and treated them as well as humanly possible. I also communicate explicitly to them that I do not want to be negative and hate my job. I love my job, and will continue to, so we might as well have fun. And in every case, I have ended up converting that partner’s attitude and we have had a great time.

Finally, learn your protocols as well as possible so that you can raise the level of care in your agency. It is tempting sometimes when you are tired to not push hard, and to just do what the line items say in the policy manual. I remember being dispatched to a nursing facility for someone with acute COPD exacerbation. We had just gotten magnesium sulfate on the ambulances to use in cases of severe pre-eclampsia or eclampsia. Knowing that the magnesium is used in hospital for severe shortness of breath also, I decided to contact my base physician when my patient was having such incredible difficulty breathing. The mag was in our scope of practice, just hiding in a different protocol. I explained my thoughts and rationale (always present a problem along with the solution!), and he agreed with me and let me give the mag, even though it was slower acting. Knowing a I had a long transport and a sick patient, i was able to elevate the level of care given because I was well aware of my protocols. Never give up pushing that attitude, because with that, comes pride, and pride in yourself and your medicine makes having a good attitude so much easier!

20: HAVE FUN

That is the perfect segue to my last thought. HAVE FUN. We have the most unique opportunity to help people on a regular basis. We are able significantly impact multiple people’s lives every day. We work with some of the most selfless and amazing humans, who will risk everything for strangers. We are given tremendous responsibility, but also incredible autonomy. We are living little kid’s dreams, and we should never forget that. We are doing a job that for most of us, we identify with much more than just way to earn a paycheck, but something that is deeply fulfilling at the level of our souls. We are given everything we need to create, at least in our down time, to have a perfect day, almost any day. I believe that a lot of this has to do with our expectations. For example, one of the best pieces of advice I ever received was to expect to be held over on a late call. If I had the expectation that I wasn’t ever going to get off “on time,” then I could change my perspective to that of when I did get off on time, which was more often than not, I could really celebrate an extra hour or two of freedom (or sleep). Simple things like reframing our situations contribute to this. Remember that our job exposes us to how quickly life can change. We all know this. Don’t forget to appreciate all the little things each day. Take time to laugh hard, to love hard, to be present with the ones we love.

 

These are my thoughts on the most important 20 Lessons I’ve Learned in EMS over the almost 24 years since I received my EMT. Thank you again for all who have read, and for all who have inspired these thoughts. You have made my career absolutely unforgettable and I couldn’t imagine better people to work with.

Lessons in EMS: 11-15

Well, my plan had been to publish one of these each Friday. I’m not sure that’s the best day to do that, so its a work in progress. Also, this past couple weeks has been intense in physical therapy. I had a really significant neck/shoulder/back injury a while back, and the last few months the neck pain has been out of control. In an attempt to avoid another round of steroidal epidurals, or a trip to the neurosurgeon, I’m doing PT a few times a week, for about three hours at a time. While that might not seem like much, it has wiped me out. I’m seeing results, but just didn’t have the capacity to write last week. All that to say, it feels good to sit back down at the keyboard, and if I can, I’ll start to get ahead on posts so that, even if I’m having a rough week, I’ll still be able to publish an entry.

Time to jump back into the Lessons Learned in EMS!

11: Learn to feel the emotions

I think that everyone, whether in public safety or not, that our job is emotionally taxing. No one ever calls us to invite us to a party, at least night for a good reason. The crucible of working in the public eye, of being judged by unreasonable expectations thanks to Hollywood, the long hours and physical strain, and the toll on the body of boredom to extreme stress is not something everyone can do. In fact, I used to be really uncomfortable when people would say that to me, Now, after all these years and time spent as an instructor and preceptor who has had to fail people, I think that is actually accurate. We do a job that not everyone can do, even if their heart is in the right place.

With that in mind, I wanted to talk a bit about how to deal with the feelings that will come up in this job as an EMS provider. It’s not so much a question of if, as much as a question of when. If you want, you can search #itookhome and get an idea of what I mean. This is another mention of the idea of PTSD, and I’m certain it won’t be the last on this blog. My thought today is less typical than you might here. I don’t know if I’ve ever heard it expressed before, so please, if it doesn’t sit well, find someone to process through these moments with.

Some of these calls will stick with you, and haunt you the rest of your life. I have my share, and I’m going to share some of those in later posts. There are some though, that even though people are shocked that it doesn’t bother me, I just don’t have the same emotional response to.

Some of the calls that haunt me are absolutely understandable. They are the ones that we all think of as “the worst call possible”… A bus load of pregnant, hemophiliacs crashes into a glass building and catches on fire. That sort of thing. But a few are just holding a child as they process their illness, or an older man who reminded me of my dad, who was himself on the cusp of entering hospice. There was one call for a child who drowned that didn’t bother me at all, not with nightmares or flashbacks or intrusive sights or sounds. I absolutely felt bad that this had happened to this beautiful girl, but I was actually really proud of my crew, and the firefighters and police officers that responded. We ran as a cohesive team, providing excellent care.

A couple people told me I “should” feel bad about that call. No! I refuse. As a pediatric advanced life support instructor I never told my students that a pediatric call would be more or less stressful or emotional than any other. I prepared them as best I could to handle whatever situation came at them, as calm, cool professionals. I think to some degree, we set ourselves up for struggle if we assume that a certain type of call will absolutely be our triggers.

When you feel bad about a call – ANY call – feel bad. Embrace the emotions. Talk about it. Find healthy coping mechanisms. When you don’t feel bad about a call – ANY call – don’t force yourself into that emotional space, and certainly don’t let anyone else force you into that. Be aware that it may come back at a later time to bite you, and be ready for that. The emotions and the adverse effects of this job are all too real. Don’t run from them, but don’t force them on yourself either.

12. Learn from other public safety professionals

Some of the best lessons I’ve learned as an EMT, then as a paramedic, came from our brothers and sisters in other branches of public safety. In our modern era of responding to mass shootings, cars driven intentionally into crowds, or even the most basic call of a possible intoxicated individual on a bus bench (I’m certain this call is a universal one), our physical safety is most important. Ask a police officer to teach you the proper way to search someone for weapons. Ask them to show you the easiest and best compliance holds for someone’s wrist. Ask the firefighters to show you where they keep the medical equipment in the engine. Learn how they store their gear. Even go so far as to ask them if you can learn how to pull hose, because there is a technique that works.

I know that people have made fun of me for this at times in my agency. However, the numerous knives and four guns I’ve pulled off patients tends to get people to laugh a little less. I also have been enroute to major structure fire and had the winds shift on the cul-de-sac that we were in, and while some firefighters were pulling the hose from the front of the engine, the driver/operator handed me a hose bundle and told me to run it to the hydrant because we needed water for our own protection.

My point is that sometimes, we just don’t have the ability to foresee how quickly a scene can change from safe to not safe. We need to have as many tools, even if they are simple ones, in our mental kit, to help us adapt to those changing dynamics and to overcome them and go home safe at the end of our shift.

13. At some point, start to learn above your comfort level

One of the best things that I ever did for myself, after I had my feet pretty well under me, was to stop getting paramedic-level CE’s. I’ll admit, I was really nervous the first nursing conference I went to. It turned out to be such a great experience! Not only were there incredible opportunities to network and build professional relationships that benefit me to this day, but the clinical education was amazing. I know medicine is a profession that no one can ever learn completely. There is both too much knowledge and too much craft to it. To be honest though, paramedics really only scratch the surface. I choose a flight nursing/ED/critical care conference to attend. The first time I went, I probably only understood 50% really well, and conceptually was able to track at about 85%. I then started buying nursing textbooks. (The one that I love most is called “Critical Care Nursing: A Holistic Approach” and I have no financial ties to that book or publisher.) Now I had a tool – other than the Google and Wiki – which allowed me to cross-reference my notes and dig deep. I also noticed that the nurses who had attended the conference loved having a paramedic there! They were more than willing to answer my questions – and I had a lot of them! – and offered to continue to mentor me after the conference was over. I was now able to do more thorough and in-depth history and physical assessments, and I began to conceptualize what the hospital treatment would be for my patient. This meant I could make better decisions about where to transport a patient.

It’s uncomfortable to surrender what “expertise” you may have garnered and feel like the awkward new kid again on the first day at a new school, but the payoff is absolutely worth looking a little foolish for.

14. Choose who gets to speak into your life

Speaking of those nurses offering to be mentors to me, here’s an important thought about which voices you listen to. In public safety, everyone is a critic. I admit that I am. I will place myself in a scenario and wonder how I would have handled that case. I think people have a tendency to express those opinions also, for better or worse. Actually, its for worse. Armchair quarterbacking can really shake one’s confidence and lead to paralysis-by-analysis. Even more detrimentally, it can cause someone to take responsibility for something that might have been out of their control in the moment, and cause unnecessary mental anguish. (The subtext to this paragraph is: Don’t armchair quarterback!)

To counter this, I found a very successful strategy. I chose five people who are widely respected at work, and who I personally respect a lot. One is a physician, one is a nurse, and three are other paramedics. I have talked with these people ahead of time, and treat them as mentors and our conversations as miniature Morbidity and Mortality Rounds. I will proactively come to them with cases that I struggled on, that I am unsure of how I handled myself, or that I am receiving pushback on from other providers. In my mind, I go into it with the clear goal of identifying if there are any system issues, cognitive issues, or scene issues that contributed to how I ran the call. I do this really informally in the conversation, but these are my clear personal goals.

These five people have a free pass to say anything they want to me. They can critique me, ask any question, offer any suggestion, or any encouragement. They can also ask me to look further into something, and I take that as homework and treat it seriously.

With this team assembled and a phone call away, I feel that I can then ignore the rest of the voices chirping in my ear. Everyone else can say whatever they want. I am not responsible to those people or their opinions. I choose to submit myself though to the opinions of my team, these other well-respected people. This holds me accountable, teaches me, and keeps my inner dialogue and critiques in a healthy perspective. I absolutely credit these people with making me the thinking paramedic I am today, and believe sincerely this is one of the best pieces of advice I can offer anyone.

15. We don’t get to choose the war we fight, we fight the war we are given

Expectations can lead to so much disappointment. I know this sounds kind of cynical, but its a pragmatic approach to working and to the work environment that has kept me calm while others are about to be sent for alone time in a padded room.

We have very little control of our lives at work. We come and go and are sent at the time of another’s choosing. We operate under agency policies, protocols, and state and federal law. Even things such as sleeping and eating are often interrupted because of someone else’s decisions. When we arrive on the scene of a call, we rarely get to control our environment or the people on the scene. When it is time to go home, we all know how disheartening it is to get that late call and be held over.

What we can control is our level of expectation. I am solely responsible for my attitude. The vast majority of the time, I can combat a negative turn in a attitude by realizing this is all out of my control. Maybe this is why I like having a clean truck and uniform, because in those things, I can express my own control. I can choose fun music, I can choose to be a good partner, I can choose to be polite. In doing all of this, I find myself enjoying work more than I did when I was new and got frustrated not being able to do what I wanted, when I wanted. I think that was a huge sign of me maturing as a human being, not solely as a paramedic.
Not sure when the next post will be, but I imagine it will be either Tuesday or Wednesday. Thanks again so much for reading and for the kind words and support! This has been a great experience putting these thoughts to paper!

Lessons Learned in EMS: Lessons 6-11

Here is the second installment in the series on my lessons learned in EMS… You can find the link to the first post, Lessons 1-5, here.

6: Be consistent

This one has to do with both the professionalism that I believe so strongly needs to be deeply held by those who practice EMS, but also pays huge dividends in patient care. I think it is important to have routines. This applies to preparing to go to work, equipment maintenance, and patient care.

Preparing for work: The day before work, realize that your responsibility to be effective at work means that you act like a responsible adult the night before you have to be on duty. Again, drawing on my friends in the Navy, the rule that they live by is “12 hours from jigger to trigger.” That means that the night before you have to be on duty, don’t go out and get plastered. There is no excuse to come in hungover. When I started, this was more common behavior, but now seems to have fallen out of fashion, for the better! Also, sleep is of critical importance. The US Army includes sleep as one of three components in its “Performance Triad,” with the other two being nutrition and activity. Lack of sleep decreases cognitive abilities, one’s stress resilience, and can even increase one’s susceptibility to post-traumatic stress reaction and disorder. We all do so well running at a constant level of sleep deprivation, but that one night when we know we are heading in the next morning, there really is no excuse to not start your shift rested!

Equipment Maintenance: Create a routine for checking out your bags, your truck, and even your personal kit. If you aren’t consistent, then things get missed. Always take the extra time to open every pocket in the bags. If you need to, create a checklist so that you know that you have all the IV sizes you need, all the meds you need, all the tubes. There really can be zero excuse for not having something on scene that should be in the bag and having to run to the rig to get something. And there should be no digging in the bags in the back of the truck, trying to find something that should be in a cabinet. I heard Ashley Liebig (on Twitter @ashleyliebig), in her talking entitled “The Golden Fleece, The Golden Hour, And The Golden Rule“, telling how on the way to a scene, she touches all the pockets in her flightsuit and vest, just to make sure everything she needs is in there. That kind of routine breeds a confidence in the provider because, no matter what you face, you know you are as prepared as possible.

Patient care: Consistency is so important here. We all learn these little parrot-phrase assessments that we are taught for NREMT, or whichever trauma certification we are trying for when it comes to the physical assessment. Over time, we develop our own questions to ask, but it is always important to ask the same questions the same way. Why? Because, as is well documented, there is a direct link of the release of catecholamines, stress hormones, and an increased heart rate, and a decline in cognitive function. I hear a lot about how calls with a patient with acute shortness of breath are so stressful, such as the patient having the acute anaphylactic reaction, or the crashing pulmonary edema patient. I agree, these can be some of the most high intensity calls. in light of that, I make sure that my assessment on the most benign shortness of breath call is the same as the most critical. I ask the same questions, and listen to the patient’s lungs in the same pattern, every single time. I assess my trauma patients in the exact same way. I take the time to visually asses them, then palpate them, the same way, every single time. Why do I do it this way? When I have the crashing patient, whether medical or trauma, I know that I won’t get distracted from my assessment. This consistency greatly reduces the risk that I will overlook something. If I have a trauma patient with a lower leg that just went through a wood chipper, I know that I will place the tourniquet, then move to my ABC’s, without tunnel visioning extremity or the patient’s screams. I have my priorities, and my assessment allows me to keep them. It’s important to remember we will always fall back on the level of our training. So practice the same way, on every patient, every time.

7: Listen a LOT

One of the things that I have always loved about being in EMS is sitting around the dinner table at the station, laughing at stories, hearing how thing were “back in the day.” It took me a couple years to learn that what I was actually hearing wasn’t just stories, it was wisdom. Sitting in a fire station, as a junior medic, I was surrounded by five people who had a cumulative experience of just under 100 years. That is a ridiculous number of EMS calls, fires fought, practical jokes (there’s good to be learned in the humor!), and people rescued. I began listening not just at the humor of it, which was side-splitting. I began to listen to the lessons. “Why do you think you pulled your crew off the roof?” “How did you know that patient was going to crash?” “What told you that line was going to snap and could have killed you all?” Sometimes people gave me a hard time, always asking “hard” questions. For the most part though, they would stop and pause, and everyone would turn and look at the person, and listen. I cannot even express how much i gained from taking the time to ask these questions. The most overlooked procedure on a call, like where to park, all of a sudden became the lynchpin in understanding what kept a crew safe. One of the greatest lessons I learned was that it was absolutely critical that I learn to trust my instincts. So often, I would hear from firefighters, chiefs, senior paramedics, and cops that, “I’m not sure… I just had this gut instinct” or “my gut just told me that..” What a valuable lesson. Be thankful that we work in a job where oral tradition is passed down, senior to junior, and that with awareness of the deeper lessons, we can learn from people’s mistakes and heroic actions.

8: Learn the inside of your apparatus

I don’t care if you work in ground EMS, fire service, or an air service, there are few things more beneficial than this. When things are going to poop in the back of the rig, when there is stress and screaming, and people working hard doing ventilations or fighting with a patient, knowing where things are is almost the most important skill. If you can’t find your surgical airway kit, your glucometer, or restraints, you have done your patient a disservice, and possibly endangered them and your crew. This might blow my cover and reveal my true level of nerdiness that I have at work, but I would sit in the back of the ambulance and close my eyes and train myself to find everything by feel. I could at least get to all of my equipment without looking. This took some time to master, but in those moments with the crashing patient, I never regretted looking like a fool in front of my partner, because I was squared away and it decreased by stress levels dramatically.

9: Understand the concept of “Command Presence”

This is something I learned from my law enforcement sisters and brothers. In my understanding, this means that when someone encounters you, they can tell merely from how you present yourself, that you are someone to be respected. When I was new, I had a partial understanding of this. I thought that it meant that I spoke in a tone of voice that “demanded” respect, and I leveraged the fact that I wore a uniform to back that up. What I ended up learning was something much more subtle, and much more effective. I learned that this kind of presence started with how my truck looked, and even if it meant showing up early, I would wash it every day, if needed. I think seeing a shiny fire engine is much more appealing than seeing a dirty ambulance, and its one of the reasons that the fire service tends to get more respect. That may be splitting hairs, but its my opinion. This also might be me being a bit ridiculous, but I absolutely think that shirts should be clean and tucked in, boots should be zipped, and if possible, polished. Does this mean it’s always fighting a losing battle? Sure. However, the payoff of seeing someone looking sharp in their uniform, and not like a “soup sandwich” (if you don’t know this term, imagine eating a soup sandwich… its just a mess!) is undeniable. In an profession where we walk in and meet someone with whom we have never had contact before and ask them to trust us with their life or the life of a loved one, the more presentable you are, it might give that person or family one more reason to allow us to effectively care for our patient. I also learned that I could do this gently, without the authoritarian attitude I had early in my career. I could always default to that if I needed to, but with so many patients, I found that I could speak softly. If I addressed everyone as “Sir” or “Ma’am” with my initial contact, and then asked what they liked to be called, I could establish an amazing rapport with them quickly. This demonstrates respect, which is the sign of a professional. I addressed gang bangers, professional athletes, transients, and CEO’s all the same way. I also addressed people I worked with by their title, i.e. “Hey there Captain Flores! How can I help you guys today?” By showing respect for the police officers and firefighters I worked with, I gained their respect in not coming in with an attitude, which in turn had them treating me with similar respect. This just made it easier for the patient to see that we were all on the same team, working together in their best interest. I even demanded that my junior partners who worked with me learn to act in this professional way, and understand the concept of command presence. It was fascinating to watch those that might have had an antagonistic relationship with different agencies or hospitals see that dynamic change. They literally would see how people would interact with them change, as they started to address people with their title, and would show up looking professional. One of my favorite partners ever had such a bad reputation, and watching it transform was really a highlight of my career, as it was the first start setting him up for success as he followed his dream to be a firefighter/paramedic. I think had he not changed, his reputation would have prohibited his advancement.

10: BE GRATEFUL

In emergency medicine, we have the extremely unique privilege to not only provide transport and care for all of our incredible patients, but we are in the unique link in the healthcare chain that gets to go in to people’s houses, and see the most intimate parts of their lives. While I do not discount our sisters and brothers in the hospital, and their compassion, there is a humanization that is only possible when you see where these patients come from. Our society values our “space” as our own, with each house being our castle. Yet, when the public calls 999 or 911, they allow us in, with unfettered access. This is such a privilege, and its eye opening to see how some people live. It always gave me more compassion, seeing how lonely some were, or what they did to survive. And, we all know, sometimes they do not survive. We all bear witness to being present at the beginning of life and at the end of it. To my mind, these are sacred moments, watching a baby take a first breath, or someone take their last one. Both give me chills, and a sense of awe. The words we speak in those moments to family members will ring in their ears for decades, and they will remember even more how we make them feel. What an honor. We also get to see moments of incredible heroism, big and small, in our partners and coworkers. Sometimes, this looks like risking your life for a stranger. Sometimes, its taking your gloves off and giving someone a hug and crying with them. Never lose sight of the inspiration in the seat next to you in the ambulance, or the simple bravery of showing up. I could write forever about the things I am most grateful for in my career, but it always comes back to deep human connection and interaction. This means that even 23 years in, I still get a huge smile, knowing that I get to do a job that I would do for free. I was talking to a police officer friend of mine, and he said this: ” Some people have to force their life to fit their profession. For us, those of us lucky and blessed enough to do what we do, our profession fits our heart and soul and our life. What a gift!” I couldn’t agree more.

Thanks for reading this! Next Tuesday, I’ll post another part of my story, and maybe start talking more about lessons learned from my patients. Next Friday, I’ll post lessons 11-15.

Sincerely, thank you for the support and feedback I’ve received! It’s been so much fun to write these thoughts down!

I’ve never seen anything like that… (Or how I fell in love with EMS)

It was a dark and stormy night…

Actually, it wasn’t. Not at all. I’ve just always wanted to write that.

I had just graduated high school. I was 19 years old, having grown up in a mostly ideal home in an affluent area in the Silicon Valley. My parent’s had adopted three kids, and we were all growing up into successful and capable humans. I always struggled in school though, mostly because I was bored. I realize now that’s a lame excuse, but I was rarely captivated by any subject, but the ones that I did, I excelled in.

Like most young kids, I had zero idea what to do when I “grew up” and needed to choose a career. There are always the outliers, like a good friend of mine who wanted to be an officer in the Marine Corps since the day I met him in sixth grade. That was not me. I was floating, and had no ideas or direction. Having played soccer and lacrosse in high school, I had spent a fair bit of time with our athletic trainers, and after graduation, the trainer was allowing me to hang out with her and learn basic treatments and therapies. This was great, because it was awakening in me a further desire to do something helping people, something tactile, and something out of a traditional office setting. I loved the anatomy and physiology she was teaching me. I decided to investigate this further, and realized it would be a lot of schooling. Knowing that I would have to pay for the vast majority of college, the trainer made a passing suggestion that changed my life.

“You know, Tim, you should take an EMT course. It’s a good job, the hours would fit around an academic schedule, and its always good to know how to do CPR.”

“EMT? I have no idea what this is. Oh… A quarter of college to get my basic level certification, and then I could work in the hospital or on an ambulance? That sounds fun. Wait. I’ll have to be social? I’m super shy though. Yes. You’re right, if I want to work with athletes and people as a trainer or PT, then I guess I have to learn some time.”

Fast forward almost a year: I had just gotten off of my normal 10-hour shift. I was doing BLS hospital transfers at the time, as there were no EMT basics on the 911 ambulances. One of the paramedic crews that worked out

of the same station had been asking me for a couple weeks if I wanted to do a ride along with them. I had been dodging this for a while, because again, that would have meant meeting more people and talking with more people. As I was heading out to my car, they were getting toned out on a call and asked again if I wanted to join them. I said no, and they basically said, “HEY! Get in the back of the ambulance!” I guess their command presence worked on new kids as well as once scene. I hopped in quickly, and we were off.

I will never forget that moment. The gate to the station opened, and I was watching the sunset, and the lights starting to reflect off the building in front of us. I remember hearing the piercing of the siren, the first time I’d heard it from inside a moving ambulance. I still can hear the dispatcher advising us of the specifics of the call. “324, Code 3 (lights and siren) for a stabbing at the corner of Second and Reed, scene not secure.” My heart rate must have jumped through the roof, and I remember thinking, “I can’t believe I am actually doing this!”

We got to the scene and it was chaos. Police officers were shouting and running trying to set up a perimeter, and the suspect had possibly been spotted. Firefighters were stressed, as the patient was screaming and was in a lot of pain, but also very sick. He had been stable multiple times in the left upper chest, and was having progressive difficulty breathing.  The two paramedics I was with grabbed the gurney, and the small bag used for rapid treatment of trauma patients. We walked into the fray, and from that moment on, everything else was a blur. They evaluated the patient, rarely speaking to each other, years of working together allowing for anticipation and slow, smooth, steady flow. People fed off of their energy. The patient became more calm, listening to their strong, steady words, describing what would happen and how. The firefighters stress level decreased, knowing that these guys were so good at what they did, and soon this patient would be on their way to the hospital.

They asked me to go spike two 1000cc IV bags, which I did completely wrong, because I was so overwhelmed. This wasn’t school anymore. I could smell the blood and alcohol, mixing together in a unique scent that I would become so well acquainted with over the years. I just ended up sitting behind the patient, thinking over and over, “I’ve never seen anything like this before! And I have no idea what just happened or how it happened, but I want to do what they did and be that good at it.”

That simple thought fueled me over the next twenty years. That hour, watching those two guys respond to, manage the scene, treat the patient, provide amazing care, and deliver the patient to the awaiting trauma team was one of those “before:after” moments in my life.

Before this, I was lost, floating and unsure of myself. After that moment, I felt I found my calling, my purpose in life. I had no idea what that would actually mean, what I would learn, and what it would cost me. I am so thankful for those paramedics, who became friends and mentors, and the opportunities this profession has offered me.

The First Five (Lessons in EMS)

This post was inspired by yet another person on The Twitter – @jessandra111! She’s a new paramedic graduate, heading to start her career in a big and busy city. She had asked the question of what lessons one who has been in the field might pass on to a new medic. While I don’t claim my experience to be definitive, these are some of the lessons about EMS that I have learned in my time. As I keep scribbling more notes to myself, I realize this instillation will be probably the first of four, broken into five thoughts at a time. There are so many lessons that I’ve thought of. Thank you, Jess,  for carrying the torch into the next generation of pre-hospital excellence! Hopefully, I can act as the Sensei above, sharing my learned experiences and things that have brought me success and safety in my EMS practice.

1: Always prioritize your personal health.

The first and most important thing is personal health. This includes the physical, psychological, and spiritual/emotional facets of who we are as complete human beings. There are all sorts of ways to do this, and they’re all intertwined. Exercise and physical strength benefits you both in your capability to do the job (lifting, driving, carrying bags, etc.), but also allows you to burn through the catecholamines that build up over the course of the shift. We have to remember that all of those neurotransmitters and sympathetic hormones affect not only our physical health, but our psychological health as well. This includes better sleep cycles, more stable interpersonal relationships, and helps keep us from compassion fatigue.

This all ties into how we treat ourselves as spiritual or emotional beings. The concept of the “beauty to death ratio” is a great way to look at this. We need to make sure that we build beauty into our lives, so that we don’t become blinded to the fact that our reality isn’t actually real life for most people. Real life, apart from EMS, is full of beauty, happiness, love, and good people. Addressing these three aspects of ourselves will help keep you from becoming jaded or burnt out.

2: Look out for your partner.

As much as our society tries to tell us that we’re not our brothers’ or sisters’ keepers, in this job, I think we have to be. This doesn’t mean imposing our worldviews or moral values on people, but it does mean looking out for people. It means saying, “You’re important, your life matters, and therefore your safety and health matter to me.” I’ve been in the situation two or three times where I’ve had to put a unit out of service, or call a supervisor even when I’m off duty, if I hear about a friend or partner who is potentially depressed or suicidal. While those have made for some very difficult short-term relationships, the long-term benefits of gratitude that have been expressed when someone knows that they are cared about unconditionally is absolutely worth the uncomfortable moment. When you spend as much time as we do with our partners, we can learn a lot about them. Keep an eye on them after a potentially hard call. See if their mood is changing, or if they are more easily irritable. Don’t be afraid to ask them point blank, “Hey… are you doing alright? I’m worried.”

3: Reputation is earned every day.

It’s amazing how subtle and profound this one can be. Reputation is formed from the moment you show up to your very first shift as a student. It means being on time, ready to work, with a good attitude. It means not dodging the annoying work around the station, but being a team player. It means addressing superiors by their rank or title. It means addressing patients by proper names or “Sir/Ma’am”, until given permission to do otherwise, regardless of who the patient is. It means checking your equipment every day, showing up in a clean uniform, tucking your shirt in and having clean shoes. It includes taking pride in your appearance, and the appearance of your truck (if its dirty, wash it, its not that hard!). It means not complaining, not getting angry, or at least knowing when to have those moments. And it certainly revolves around your clinical care.

The most important thing to remember about reputation is that the community that we work in is small. Your reputation follows you wherever you go. Reputation has to be earned, just like respect. In the public safety community, your reputation does not start 100/100, and then work your way down. People look at you skeptically until you prove yourself, so be willing to put out the best effort possible in every situation. And, in the blink of an eye, reputation can be lost. Everybody is watching, making judgements, and filing away how you handle yourself, practice your medicine, and how you treat people. Be willing to work hard and fight passionately to maintain yours!

4: Slow is steady, steady is smooth, and smooth is fast.

Public safety, like the military, is built on lessons learned, and those lessons are usually learned how from failure and not successes. I’m fond of studying military and medical axioms, because in a profession with a strong oral tradition, we can learn much from witty little sayings our seniors dole out like candy that actually hold decades or centuries of experience. One of my favorite is in regards to clinical care. I first heard this years ago well reading about the United States Navy SEALs. The idea is this: slow is steady, steady is smooth, and smooth is fast.

Breaking it down, “slow is steady” means to consciously slow your breathing, slow your speech, and be decisive about your actions. I usually start this on the way to a call if I know that there is going to be the potential of a lot of stress. I’ll give an example: I responded to a call of a two year old who drowned in a toilet. We had updates enroute from dispatch, and then police on scene, stating that they were starting CPR, and that the airway was compromised. I remember sitting in my seat, slowing my breathing, and telling myself, “I am cold. I am steady. I am not going to panic. I am in control, and I will feel nothing.” I said this to myself over and over, until I physically started to feel colder. That was the clinically best run pediatric call I’ve ever had. I never raised my voice, never got out of control, and brought a sense of calm to the scene that my new parter and new firefighter stated later that they fed off of. It’s a cheesy thing to do, but that kind of zen state enroute to a call is something I’ve always done, and works for me. “Steady is smooth” means that as you slow down what you can control such as breathing or your mental space, your physical actions become easier to control. There’s excellent evidence that once one’s heart rate increases past 120 beats per minute, it becomes more difficult to have situational awareness and fine motor control. This is incredibly important in a job with as much cognitive strain and absolute need for fine motor control as we do as advanced prehospital providers. Whether it’s intubating someone, working out drug dosages, starting IVs on your patient… All these will benefit from a smooth approach, not stabbing someone blindly with a needle or bullying a tube into a hole that you’re not sure is their trachea.

By being slow and steady, you actually do things much more quickly and efficiently than if you rushed through the process. Not only will you be more accurate and successful in your first attempt at a procedure, recalling a protocol, or communicating on the radio, but with that effectiveness, you won’t have to repeat anything. Your scene times will be faster, and you’ll be able to accomplish more in the back of the ambulance. People always thought it was crazy that in a 6 block transport with a major trauma patient, I could still have oxygen, monitor, oxygen saturation, capnography, blood glucose, two large bore IV’s (barely running, but able to be used at the trauma center – permissive hypotension people!), a complete physical exam, and two sets of vitals done.

It may seem like a cheese-ball of a saying, but it has been tested in the harshest of environments and stood the test of time, and is worth ingraining into your soul.

5: Everyone can hurt you, but its not about “us vs. them”

One of the first things that I was taught – maybe the very first conversation I had with my preceptors on day one of my field internship – was them telling me to always remember that everyone can hurt you. This Sobering message that actually kept me from significant physical harm or even kept me alive in some very sticky situations.

It is true though, that everyone has the potential to hurt you. The first time as a paramedic on my own but I don’t with a firearm on scene, it was an elderly patient in her early 90s who was altered and septic, and kept reaching for something over her head. I assumed that she was about to start seizing her that this was some kind of repetitive motion due to her altered mental status. My partner, who is much more seasoned and situationally aware, looks to see where her hands kept going, and found a small 25 caliber handgun, with four rounds in the magazine and one in the chamber. I will never forget Andrew pulling the magazine out and pulling the slide back on the weapon, and watching that round of ammunition fly into the air. My heart stopped. it never occurred to me that an altered elderly patient might actually be trying to defend yourself from people she had no concept of, and had she found her firearm, it wouldn’t have mattered the reason why she pulled the trigger. One of us would’ve been just as hurt or dead.

This experience stuck with me. I learned to wake up the apparently drunk patient after patting them down gently to check for obvious weapons, and then putting their hand and a wrist lock so that I could control them should they become violent. One night in about two in the morning, this kept me from getting stabbed with the switchblade. I could share more experiences, but I think this demonstrates my point.

Working in an urban environment where there was a lot of gang violence, I was always checking people for weapons. Many times people were under the influence of alcohol or chemicals. The repeated exposure to this kind of violence, both directed at other people and directed at myself, definitely hardened my interior. I came to a dangerous place where I realized I had a very much “us against them “mentality. and I actually do think that, to a degree, there is an us/them component to the world. No one understands what we do, and no one looks out for us like our brothers and sisters on the ambulance, our firefighters , or police officers. we always try and watch each other’s backs.

The danger those assuming that everyone is out to hurt you. The perspective I gained with some wisdom, demonstrated to me that I had been completely wrong. Most people, regardless of socioeconomic standing, just wanted to live and work in love and raise families in peace. A small percentage of the population created the rest of the problems. I think we all know the districts in our area of operations that most of the violence and chemically altered patients come from. It becomes easy to stereotype and generalize anyone from that area as being a troublemaker. But they aren’t, not the least.

So well it’s easy to feel like it is us against them, remember that everyone deserves to be treated with respect. You can defuse most of the fights by treating people well. You can still look after your coworkers without falling victim to the cognitive biases that accumulate over time if you’re willing to recognize the fact that they exist.

But never forget: it is an incredibly dangerous job. And yes, some people will want to hurt you. Talk to your police officers in your area. Learn how to search people well. Learn how to look at people’s hands and eyes and body language. Do right along’s with local lawn force meant and have them teach you. That kind of knowledge can literally save your life.

 

So that’s the first installment. I think I’ll be posting these in five point posts, and mix those up with some stories from my career. I hope this helps my friends at any point in their career! Thanks again to Jess for the inspiration to write this post, for my other friend Jess (@jkwillettmd) for convincing me to start this blog, and my friend Ginger for proofreading. Life is a team sport! Be safe out there, my people!

 

 

On Twitter and Hope

Wow. I haven’t written a post like this in a long time. I think I’d been feeling scared of my own physical pain, and using that as a shield to protect me from some of the emotional stuff that has been circling in my own heart at times. And then, through a random set of circumstances this evening, all the fear and urgency of helping one of our own came rushing back.

Through the #FOAMed community on Twitter, I’ve met critical care providers on all levels and of all nationalities, and been able to discuss and learn from them. I’ve read books recommended, listened to podcasts, and added things to my bucket list. Today, when one of the doctors posted this, it through me for a loop

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The young woman who posted this is a beautiful human, living out in Dublin, Ireland. A physician from back east retweeted it, bringing to bear an amazing international response of caring people who were able to track down people who knew different parts of her life, calling, leaving messages, getting her address, and hopefully getting this woman the urgent help she needs.

It has me thinking of my own story, yet again.

It has me remembering being a young, naive EMT, just starting out and being so impressed by the paramedics that I did my first ride-along with. It brings back the first arrest that I remember, a horrific traumatic arrest the day after Christmas, 1996. It brings back the good memories of partners and dancing in the rig, responding to calls and having the best time of my life. It also brings back all of the trauma, heartache, sleepless nights (or days as the case was) because of the nightmares, and the unbelievable heartbreak of getting pages or phone calls that friends had taken their own lives. It reminds me that I was almost one of them, that I had chosen how, had a plan, and through only the grace of God, was I unable to find the right time to follow through with that. This led to a year away from work, then returning to the job I love, only to be faced again with the challenge of being injured and dealing with the chronic pain and multiple surgeries since.

All of this reminds me of the simple fact that we have a place and a role in this universe. We have the opportunity to love those in our world and sphere of influence. We have the chance to look out for our loved ones, our coworkers, and our friends. Often times, those categories overlap. That is fortunate, because that means we are more invested in each other’s lives than most people. When you work as closely as one does in medicine or public safety, there really aren’t many things that we don’t know.

More than that, we know each other. When you see someone showing signs that they might be struggling, we should make the effort to ask. It’s hard to do, without a doubt. It’s uncomfortable to enter into a conversation that really might well offend someone, as many in our professions are so good at putting up walls, compartmentalization, are those that try to be strong. I’ve been on the receiving end of these conversations. I’ve been on the initiating side of them. I’m thankful some of the senior medics looked out for me, and I’ve been thanked (although it took some time) by those I asked about or got a supervisor involved.

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There are so many resources out there that can help. Here are a few:

US and International Resources:

To Write Love On Her Arms – Resources

The Code Green Campaign – Resources

It can also be really hard to ask for help. If you find yourself in this darkness, understand that pain needs to be felt. This is a safety mechanism in our bodies and minds. There is no shame in going to the doctor if you tear your shoulder up, and there is equally no shame in asking for help sorting out the thoughts, feelings, and memories that we all carry. In fact, I would venture to share that almost anyone you share with will think it the greatest honor you can bestow on them. If you are willing to trust them with your life – quite literally – on the job, trust them with your life in this area, as well.

We are wired to help. We want to be there for you.

** As of this writing, I have no idea what the outcome of the situation in Ireland is. If you would, pray or send good thoughts to this young woman. Thanks…