Things I Should Never Do

When I teach Wilderness First Aid, I ask students to write down their worst fear around helping people in the backcountry, or any burning questions they feel anxious to have answered by the end of class. Since it's only a 16-hour course, there's a lot to pack in and I wouldn't want them to feel cheated after the fact. I keep the questions anonymous and I make everyone turn in something so that no one has to worry about ego (ego being the biggest obstacle to learning, as far as I can tell). After ten years of teaching, for the most part I see the same sorts of questions, such as "I'm worried about getting eaten" or "What do you do with a head injury?" and they're all questions the course touches on anyway. But last weekend I got one I'd never seen before.

The note read simply, "The things I should never do."

I instantly liked it, for being unique, and that it made me think, but I had absolutely no idea where to begin to answer it. It was more of a title, really, than a question, and it dangled there on the paper, incomplete. Add an ellipsis, and it could have been a writing prompt. "The things I should never do ..."

When hiking in the woods? To keep my marriage strong? In the name of first response? If I want to emerge from the wilderness? To avoid incarceration?

I knew the author was hoping for me to provide a list of forbidden actions, but as it stood, the list could have been mighty long. Even narrowing it down to its most obvious goal, that of not making a patient worse, leaves a lot to be said. As it turned out, these students had a lot of questions, and we ran short of time, and the "Never Question" became the only question I've not directly addressed during class.

It was only on the drive home that I thought of a succinct answer: Never project uncertainty, and never question your own judgement.

Scraping By

A coworker complained recently that another coworker was never willing to do more than the minimum required.

I grimaced inwardly because I regularly do just what is mandatory. To do more is to shirk my duties in some (or all) other aspects of my life. Frankly, the mandatory minimum is a fair amount, no matter where you are or what you do. Prehospital care provider, social worker, Chief Executive Officer; pretty much any position will suck you dry if you let it. Mandatory minimums prevent plenty of well-intentioned people from even getting involved with rescue. Sometimes I feel like we're lucky to have anyone on the squad, let alone those who dedicate so much more than the mandatory minimum (whatever the community would be like without them, I can't imagine, but I would not want to live here). My father always says: "We're all just trying to get by in a shitty world." I use this saying to assuage any guilt that otherwise might overcome me about not doing more than is required.

The last month I happen to have eaten and breathed rescue. There are the minimum four 12-hour shifts per month, plus an hour and a half-long monthly training and one hour-long business meeting. I completed an eight-hour ice rescue training nine days ago and recertified my Basic-status the week before that with the requisite written and practical exams. Then there's my Advanced EMT class, six hours weekly and 20 hours of clinical observation time. (My son cried to me last night, "Are you going to be studying forever?") I'm attending the Vermont EMS Pre-Conference all day tomorrow (with a test afterward) and Thursday (with clinical observation afterward). Then I'm teaching a weekend Wilderness First Aid and CPR course for SOLO Saturday and Sunday.

But I know it will all balance out by this summer, when I can go back (at least for a while) to my regular life of doing the mandatory minimum at rescue. I can hardly wait, because then I can (at least for a while) get back to meeting my minimum requirements with my family and other jobs.

Venipuncturin' Induction

I wouldn't say I've ever really been keen on needles, but I don't mind being around them, as long as they aren't directed at me. Given my record of fainting when giving blood or getting shots, I thought the hardest part of my EMT-I class would be letting others start IVs on me. As it turns out (and despite the large hematoma I received during that process), my biggest road block so far was sticking needles in other people. The IV arms (pictured above) were helpful for practicing, but I noticed that whatever I did, I did not cause them pain. It's impossible to fully prepare for the moment of truth: sticking an actual person.

Luckily for me, I had some excellent instructor-subjects, who not only let me practice venipuncture on them, but coached me through the process. I can't say enough about how helpful it was to have them remain calm in the face of my "fishing" (that's what it's called when you hunt for the vessel), all the while providing instructive feedback like, "No, it doesn't hurt. I think you're right on top of it. Feel through the skin for the needle and see if it's still heading for the vein. Don't give up. Maybe you're alongside it..." etc. Their well-feigned confidence in me was critical, as it provided me with enough gumption to follow through and finally get "flashback", the happy sight of blood rushing into the needle's chamber, announcing success.

Getting past the puncture itself, when the needle first pierces the skin, is the hardest part for both the patient (physically) and the provider (psychologically). Once you move past the patient's nerves it no longer hurts, so it's important not to hover at those initial layers. But newbies, unsure of what they're doing and hesitant to perform something so invasive, dread the depths and the possibility of not being successful. It's like standing over the water, preparing to dive. The longer you wait, the more painful the process is.

I'm happy to be past that hurdle; now I'm anxious to start sticking patients. And now I can be a more helpful pretend patient for my fellow classmates.

You Got a Bloody Right to Say

I'm none too excited to discover coagulated blood on the underside of a gurney while performing rig check - but at least I understand how this can happen. Patients - who tend to have other things to worry about during their trip to the hospital - would surely be appalled to know it's even possible. At best, it conveys a message that care providers are cutting corners. At worst we could be spreading infectious diseases, as these Health Service Journal and BBC articles worry with regards to UK ambulances.



The answer is to clean and disinfect well and often, but we all know the obstacles to this happening: particularly messy or difficult calls, middle of the night calls, frigid Vermont winter calls, calls coming at the end of your 24-hour shift. It isn't surprising we miss a spot now and then. Unless your squad consistently encourages a culture and habit of cleanliness, you aren't cleaning well enough. And not everyone knows how to clean. So here are some guidelines adapted from the NAEMT:



First, make sure you have good ventilation, and be methodical in your cleaning pattern so you reach each spot without overdoing any one place. Always wear gloves, and use eye protection when spraying down equipment. Clean and disinfect thoroughly after every call while at the hospital - not just picking up the garbage, changing the bedding and putting away the equipment, but actually spraying and wiping down surfaces. Use towels to mop up visible fluids. Use Cavicide or bleach solution (depending on your protocols) for gear and surfaces. Spray the entire stretcher including the undersides and wheels, let it sit for a few minutes, and hose it down well. Sweep the floor of the ambulance and then spray with a cleaner and let it sit for a few minutes before mopping out with clean water. Let all equipment, including the cot, dry completely before replacing. Don't forget to disinfect the dashboard and console, radios and telephones by spraying disinfectant on a towel rather than directly on these surfaces.

Many pre-hospital providers, including those who have been at it for many years, were never taught how to disinfect an ambulance, so don't assume just because "no one else is doing it" that it doesn't need to be done. Don't be intimidated - take the lead and make sure your ambulance is a safe environment for you and your patients.

For a thorough description of best practices, including the difference between disinfection and decontamination, see this EMS Responder article.

Ice Water Rescue

A friend of mine once fell through the ice while skating near the Burlington Boat House. I can imagine few things more terrifying, and although my friend managed to get out and walk away with moderate hypothermia, ever since I have been keen on learning about ice water rescue.

As luck would have it, I have my chance this month. Local firefighters invited EMTs from the area to join in their Ice Rescue Awareness and Ice Rescue Technician courses to better prepare us for these incidents. Although ambulance crew members are not typically expected to be proficient at ice rescue techniques (as long as we know how to treat the patient once they've been pulled from the water), the greater our skills and knowledge, the better we can perform in concert with firefighters or technical rescue teams.

You can find relevant courses, including Train-the-Trainer ones, at Lifesaving Resources, Inc. based in New Hampshire. And here's a link to a video of an ice rescue training held on Lake Champlain for the Burlington Coast Guard and Fire Department.

Roof Top Hopper

When I went to college in Burlington, some friends used to enjoy roof hopping along Church Street, Burlington's downtown pedestrian walk. Evidently, starting at the old Price Chopper, they were able to travel one entire city block - the one flanked by Cherry, Church, Pearl, and North Winooski Streets. Never one for taking risks, I'd get the willies just hearing them talk about it.

That was the first thing I thought of when I happened upon this news tidbit from VPR: "Man Rescued After Four Hours Stuck in Chimney in Burlington". According to the article, the man told police he didn't know how he got there. Was he drunk, or stoned? Did he just hit his head on the way down? How could he not know how he got there?

I can't help but wonder if the confused man might be a college student, carrying on the roof hopping tradition.

Avoiding the "Survival" Situation

When I tell people that I teach wilderness medicine, people often respond, "Oh, cool. So you're an herbalist?"

I'm not an herbalist. (If you're looking for an herbalist, try expert Charlie Kane.) I don't teach wilderness survival either. I know very little about foraging, or making tools from stone, or starting fires from flint and steel.

I do teach people what to do if they or someone else gets ill or injured in the backcountry: how to assess and treat patients, document their assessment and care, and how to get help; how to manage a group, consider the big picture, and hunker down for a rescue party; how to improvise a litter or shelter or traction splint or cervical collar. My students consider how to work in harsh environments and dangerous weather, how to pack the right first aid kit for their particular trips, and how to handle death in a remote environment.

Most importantly, we stress that avoiding the "survival" situation through leadership, planning, and injury prevention may be the most important thing to do when you head outside.

A Long Shot

Lately I've been wondering if I'd be likely to encounter a situation in my area of service when we'd be better off requesting helicopter medical evacuation, or Medevac as it's called. A paramedic helping in my I-course said it was unlikely; she said it takes 10 minutes for the Medevac team from Dartmouth Hitchcock - DHART - to do their mandatory safety check and get in the air once called. By the time they arrive in Addison County, load the patient, fly to Fletcher Allen Health Care (our Level 1 Trauma Center, the helipad for which is located on the old college rugby field where I played briefly, before realizing binge drinking was a post-game requirement), and have the patient transferred via UVM Rescue from the helipad to the hospital, we're looking at far longer than our typical ambulance transport time.

I had preferred to think there was some miracle option for getting really critical patients to definitive care in less than 40 minutes. But unless there's an extended extrication or the patient fits certain criteria requiring a paramedic, such as those outlined in the Vermont EMS Protocols (Part 3, non-Clinical Protocols, next to the last topic), we're better off simply driving our patients.

To learn more about what happens during airmedical transport, you can apply to experience DHART's ride-along program, which is (not surprisingly) overwhelmingly popular.

You can read more about helicopter use specifically with regards to search and rescue operations at the Wilderness Medical Society site, where you'll also find a helpful list of articles on other topics in wilderness medicine.

A Different Sort of Emergency Preparedness

I love my EMS pants.

There. I've said it.

Once a long time ago I had EMS pants and they were horrible. The elastic was itchy and made my skin burn. The thigh area was bulky from multiple gear pockets and tabs, which is great except it was in contrast to tight, straight pant legs with no zippered boot opening. The waist band was narrow and unaccommodating of post-dinner waist lines. And somehow my pen kept sliding out of its holster, adding insult to discomfort. Truth be told, the trousers looked and felt geeky and uncomfortable rather than professional.

I know there are people reading this thinking "what a girl". That's fine. But I'm practical, and if you aren't comfortable, you aren't working well. Besides, there's no reason EMS pants can't look and feel good. I know this because I've discovered 5.11 Tactical Series Women's EMS pants. The legs are perfectly boot leggy, the pockets many and large (but somehow not overbearing), and the waistband is wide yet low like man-pants.

Discover them yourself; eat dinner without fear, and find your pen again.

Staying Power

Health and EMS ought to go hand in hand, and it stands to reason that emergency personnel should serve as role models and advocates for healthy lifestyles. It's a shame, then, that it's so darned difficult to stay healthy as an EMT.

Right off the bat, you have a lot less time for exercise or stress-relief. A few times while on duty, I attempted to walk the three blocks to and from the station to do weekend chores, and was told I couldn't because the ambulance might have to pick me up if we got a call. I understand, but it was my only chance to really stretch my legs during a double shift. Add to that the unpredictability of calls and the frequent accompanying need to scarf down food or grab something quick at a convenience store, and you have a recipe for obesity. (As an aside, the owner of the closest Burger King reportedly requested that we stop getting food there while on duty because ambulances parked in the parking lot all the time look bad for business.) Helping with hurricane relief last summer, our diet consisted strictly of fast food and MREs (see picture below of a typical meal time). Don't get me wrong; I was happy to have food to eat, period. I know MREs are the food of choice because they have staying power, and you never know when your next meal will be. (You never know where the next bathroom will be either, but never mind). My point is just that we shouldn't be surprised at statistics like the following put out by the NREMT Research Department: 75% of EMS professionals are overweight.

How can we encourage and support healthy lifestyles among EMS workers? To those who know the constraints of working in the field, the question may seem frivolous to ponder and easy to answer. We can't, and we have bigger fish to fry.

To others who won't accept this excuse - including the National Association of Emergency Medical Technicians - the answer is obvious. Any way possible.

You can read some excellent articles on health and fitness for EMTs here at EMS Responder.com, and here at EMS1.com.

Provider Dividers

I first became a Nationally Registered EMT-B in 1999, and this week for the first time ever I received the NREMT newsletter, The Registry. I'm not sure if I wasn't on their list before, or if they make EMTs wait a decade before sending it along, or if they just now decided to start up a newsletter, but no matter. I'm getting it now.

With its subway-rag size, The Spring 2009 Registry certainly caught my mail-opening eye. But what really grabbed my attention was the front page article explaining the ongoing national shift to four levels of emergency medical provider. With plans for the change to be complete by 2014, and with the Vermont EMS office being so quick on the ball with everything (really - they're good), it's not surprising I had heard several months ago that something like this was in the works. But until now I had not realized the move would be nation-wide.

The idea is that interstate consistency will "address the major problem of fragmentation in EMS". In other words, we're getting our act together. It doesn't take a paramedic to see it will be helpful in myriad ways for provider levels across the US to mirror one another. So cheers to the move that just might be our ticket to more respect in the healthcare industry.

Essential Kernal Sanders

Senator Bernie Sanders, I-Vermont, supports first responders in numerous ways.

I hadn't really thought much about this until he took time to address the crowd at the Vermont State EMS conference in April, clearly stating his will to help the EMS community. Since then, it seems every time I turn around I bump into an announcement of something or other he's proposing or completing for us. For example, Sanders was an original co-sponsor of the resolution to designate September 25th National First Responder Appreciation Day. Gestures such as this increase recognition of and appreciation for what EMS providers do, translating into further community and government support down the road. Sanders also introduced a bill that would both allow communities to offer pension and insurance benefits to local fire and rescue volunteers, and require federal reimbursement of those benefits. The bill would also offer a standard income tax deduction for active, participating first responders. With fire departments and rescue squads having more and more difficulty keeping things running and finding enough personnel, legislation and forward thinking such as this are critical to the future of EMS.

In fact, EMS might be facing it's toughest time yet in its 35 year history. The expectations of what EMTs can do, the amount of (costly) training EMTs must have, and the pricey technological equipment we carry on the rigs have all increased exponentially. The EMS industry is an expensive animal that has yet to be recession-tested in its current form. We need all the legislative Bernies we can get.

The NAEMT offers an excellent guide to "grassroots lobbying", and if you're so inclined, you can have a hand in shaping legislation important to EMTs.