An Open Letter to EMS “Bros”

Dear Males of EMS:

I would like to remind all of you that the year we are in as of the date this is being written is 2017. A lot has changed in the last 30 years or so. Hell, a lot has changed in the last decade. Maybe you’re one of the guys who decided they wanted to join up and be a paramedic or EMT after watching “Mother, Jugs, and Speed” once too many. There may have been a day when one could be counted as socially hip if they routinely referred to their female partners and coworkers as “sweetie,” “little lady” or other pet names that one might think sound so cute and sweet. Maybe even today you think it’s perfectly alright talk down to the women of EMS and explain the ways of the emergency service world because these ladies couldn’t possibly understand this man world. And when someone calls you out on this crap, you try to say “Oh, I was just kidding!” Well, here’s what I want to say to you:

Shut the fuck up and respect these women.

Were you raised in a barn? Did you somehow not evolve from Neanderthals who used to find a wife by hitting her with a club and dragging her to the cave to have his way with her? I know your mother raised you better than that. I have to wonder, how would she feel to know that her son was such a moron and thought so badly about women that he thinks he has to be the big, bad, man who tells the little lady who wants to play medic how it is?

Or, maybe the problem is the lack of endowment between your legs.

I have had the pleasure of working with women who have run circles around me. I have worked with women who are much more knowledgeable about medicine and patient care than you will ever be. I have seen women get the hardest tubes, the toughest IVs and lift that bariatric patient that you had to call for a second rig for.

And sorry to disappoint you but most women in EMS are not badge bunnies who want to have sex with you (doubtful they would have sex with you anyway).

Treat women with respect. Period. If you can’t do that, get out of EMS because you are a large reason why EMS is looked up as the redheaded stepchild of emergency services and healthcare. You are what makes us look like a bunch of cavemen with the IQ of Forrest Gump.

Would you want your sister or your daughter treated the way you treat your female co-workers? If not, then don’t do it yourself.

Grow up. The station is not your frat house.

With Love,
Medic 51, NRP (Ret.)


Intubation Is Overrated

One shift I was called out to a code and when I arrived I decided to work it. This was back in the days of the “scoop and run” method of resuscitation so we were trying not to spend much time on scene. When it came time to try and drop a tube, the patient’s anatomy and other factors were working against me. After three attempts, I dropped in a CombiTube and began to ventilate. As I checked placement, I thought, “Huh. This is moving some good air. Let’s roll with it.” I had a firefighter riding with me so I was able to take a moment to do a proper radio report en route, which included the fact that I was unable to intubate the patient and had dropped a Combi. When we arrived, the doctor was ready to pull out the CombiTube and drop an ET tube but noted that air movement was more than adequate so it was left in while they continued to work on the patient.

From then on, I made it a practice to use a CombiTube over an ET tube. Among the reasons for this was that the CombiTube was much quicker and almost always successful without having to manipulate the patient’s neck and jaw in unnatural ways. If I was in a controlled environment, I could drop tubes all day every day but in an ambulance with little room to work, this is usually a different story (and if we are honest with ourselves, this is more often the case than not). Intubation is an art, one that is very easy to mess up for a variety of reasons.

One of the dogmas of EMS is that intubation is an essential skill and without it, there is not much use in being a paramedic. Such dogmatic devotion to skills is largely what has held EMS back as a profession almost from its inception. The reality is, as a group, paramedics stink at intubation. Let’s keep in mind that intubation was never intended to be practiced in the back of a cramped moving vehicle and that the method by which a patient is intubated does not lend itself well to an ambulance. Even medics who are good at intubation often run into difficulty dropping tubes in such conditions.

It’s time to let it go.

There has been a big blow up about intubation possibly being removed from the National Scope of Practice model. I really hate to tell those who are crying foul over this that research does not support their position. As mentioned above, EMS as a group stinks at intubation. Multiple studies have also shown that other methods of airway management (even something as simple as an OPA) can provide the ventilation necessary for out of hospital management of cardiac arrest. In the AHA algorithms, airway management is way down the list in favor of quality CPR and defibrilation.

I’m offended by much in this situation but mainly I’m offended at providers whose egos are so fragile that they feel the need to engage in fear mongering (“this is about saving lives!”!) and threatening to leave the field if they can’t intubation (if that’s how you feel, then please do see yourself to the exit). Paramedics have the audacity to make these claims while engaging in a medical field that has some of the lowest educational and entrance requirements of any branch of medicine. We have the audacity to demand the right(!) to drop tubes, administer medications, and perform procedures with no real education on what these treatments truly mean to a patient.

EMS needs to let go of the hero/victim mentality.

I stand as an advocate for EMS even though I chose to leave the field some time ago. I will fight, I will advocate, I will encourage those who practice paramedicine to be the best they can be. But, I do not stand with my brothers and sisters on this issue, not when we are simply not good at this skill and when there are much more efficient options for airway management which provide quality ventilation. If we truly want to have the means to give our patients the best care that we can possibly provide, we need to check our egos at the door and be willing to allow skills that do not benefit patients to be placed to the side.

Anything short of that, we are not in it for the patients. We are only in it for us.

Taking On Fire

All names and locations have been changed.

I was still an EMT and was working a 48 at a hospital-based service in the middle of nowhere. It was one of these places where you can’t even get a cell phone signal, where football on Friday night shuts the entire town down, and where God has to provide a pipeline for the sunshine. Most shifts were fairly uneventful at this place. I spent more time helping in the ER than I did running calls on most shifts. We didn’t see a whole lot of action but when the poo hit the fan, it hit hard.

My partner and I had just finished lunch and were flipping through the channels on the TV. The other crew had just left town on a transfer from our hospital to another facility so we were the only truck available in the county. The phone rang and I got up to answer. “Mercy EMS, where is your emergency?”

“This is Central, we need every truck you have to respond to the Bates Motel!”

I start writing down information. “Ok, we are the only truck in the county right now. What’s going on there?”

“Just go! Now!” I put my pen down. “Ma’am, tell me what’s going on.” “Just go!” The dispatcher hangs up.

I tell my partner what’s going on. “Do you want to go in blind?” He said, “Well, we might as well.” Before we could even get out the door, Central was calling us back and asked what was taking so long. “Listen, there is only one ambulance in the county, my partner and I are it. We are leaving right now if you will stop calling so we can leave!” She hangs up again and we go en route.

The Bates Motel was not far from our facility. It also was not far off from the depiction of the real Bates Motel. Nasty, shady looking, the works. We pull in and quickly realize that we are in the middle of a bad situation. And then we realize how bad it really is. Cops everywhere, guns are drawn, they are pointed toward a room, and three patients that we can see.

With no advanced warning, in spite of the dispatcher knowing was going on, we were right in the middle of a hot scene.We look at each other and partner says, “Scoop and run!”

We looked at each other and my partner says, “Scoop and run!”

A very quick field triage was as follows: One green, one yellow, one red, zero black.

We got them all into the truck and I haul ass out of there. “Medic 51 to Mercy ER.” The nurse answers, “Go ahead 51.” I key the mic back up, “We are coming in hot with three gunshot victims, we had to get out of there quickly due to shooter being on the scene, ETA 2 minutes.”

After we got back and I was able, I called Central back about that call. “Hey, just so you know, my partner and I did not appreciate being sent into a war zone without any advanced warning. You knew what was going on, you should have told us!” She cops an attitude, “It’s your job to help people and to go into those scenes!” Incensed, I retorted “No, it’s not! We don’t have guns, we don’t have vests! We are supposed to wait for the cops to clear the scenes and you know that! If you ever pull that kind of junk again, you better hope I don’t get hurt. That will be the worst day of your life!” She shoots back, “Well, a kid was shot!’ “And what good would we have been to her had we been shot?!”

The idiot had no response.

“Exactly. Next time, use your brain.”

The next day I left and received a phone call from my supervisor. “Don’t come in your next shift. You’re suspended for the way you talked to that dispatcher. And if the administrator wants to fire you, I will not have your back. You’re on your own.”

I sure enjoyed that unexpected week off. I slept soundly.

Let’s Not Make a Martyr Out of an Idiot

Earlier today I was saddened to hear the news of a Dallas Fire-EMS paramedic being shot in the line of duty while attending to a patient. But after watching the news conference where city officials gave an update on the condition of the medic and the patient (both are stable as of this moment), I’m still sad but I also found myself going, “what an idiot.”

There is controversy about what was contained in the dispatch notes (the shooting was possibly coded as a self-inflicted wound) but this does not negate the fact that the crew still went into a shooting scene without police presence (a reporter asked if police were on the scene when EMS arrived and the answer was “no”). I’m not stupid. I know that no scene is absolutely safe but if you go into a situation that you know is dangerous and you have no protection whatsoever, you’re kind of asking for trouble. I really hate that the medic was shot and I hope and pray that he has a full recovery. But, he really needs to brush up on his fundamentals if he wants to have a longer career on the box.

Put down your pitchforks and torches, you will get nowhere with me. I won’t change my mind.

There have been the usual calls for arming EMS providers and for giving them body armor. Oh, please. Stop that stupid bullshit. EMS has no business looking any more like cops than they already do. Try going into a rough neighborhood where grandma is having a heart attack. Let me know how well it goes when you walk into her house wearing a tactical vest and a sidearm. Let me know about the suspicious looks you get or about the threats you receive (overt and otherwise). Tell me about the shooting calls you respond to where the patient won’t give you any kind of information about the incident because “you look like a fuckin’ cop.”

And let’s not kid ourselves. We all know people in EMS who are the last people on the planet that need anything to make them feel like they have any kind of authority. These are the kind of people that if they were to start looking more like the police, they would start acting more like the police than they already do (newsflash: No EMS provider has any kind of authority so stop thinking you have any right to order people around). I know one in particular who is a former military guy. While I am grateful that he served this country, he has the mental capacity of a grapefruit (he’s the stereotypical idiot grunt) and has no business carrying a weapon in public.

The answer is not to arm or military-up EMS and we damn sure should not be making some idiots who entered a scene where they knew there was a likely threat and had no protection into heroes. Such stupidity does not make them heroes, it makes them a liability because then they are no good to the patient or anyone else. In other words, all they did was create more problems for their colleagues and for the Dallas PD. That’s not bravery, that’s stupidity.

EMS just needs to start using its damn common sense and stop trying to be Billy Badass.

Invasion of the Pussy Cat Snatchers

llxcowmThe shift had been particularly busy. I had been on three out of town transports with a whole bunch of in-town 911 calls and transfers in between. My partner on this day was particularly salty because he had worked at his other job the day before and had zero sleep.

At some point in the early evening, he let his frustration be known. “This is bullshit! I need some sleep!” I was tired too, as in case he didn’t know it I had been running my ass off all day too. “While I understand that you have been up longer than I have, you’re not the only one on this box who wants some downtime.” He muttered something under his breath, and frankly, I don’t care what it was. I was just glad that we were on our way back to quarters and that there were some other units in front of us in the rotation.

A couple of hours later, dispatch tones out our unit. “Medic 51, respond to 76 Burch Street for a 35-year-old female complaining of vaginal bleeding.” We go en route and I’m pulling up the CAD on my Toughbook. “Hey, wait a minute. I know whose house we’re going to. She’s batshit crazy. I can almost guarantee you that this is a psych call.” My partner, still half asleep and fighting to keep the rig on the road, seemed to disagree. “Bullshit. We’re about to deliver a baby.” I shot him a dirty look as we went on-scene.

The house was the one I pictured. I ramshackle crack house in the middle of the ghetto. As I was about to get out of the truck after plotting how I was going to move around the three vehicles of assorted functional ability, the screen door came open, a woman came running out, and into the side door of my truck she bolts. I was obviously taken aback and shot my partner a surprised look.

I joined my patient in the back, finding her already lying on the stretcher. Not one indication of pregnancy or vaginal bleeding of any significance was noted, so I start questioning her. “Hi, Stephanie. Remember me?” She nods. “Yes, you took me to the E and R last time. The doctor said I had a cold.”

“Exactly, a waste of my time” was my thought. I then said, “Yes, that was me. So, what’s going on today?”

Stephanie holds her stomach and looks up at me. “Aliens came to my room tonight and they… did things to me.” Trying to keep myself from laughing, I ask her what the aliens did to her to make her need my help. She gets a very serious look on her face and says, “They stole my pussy cat.”

Silence. I could not speak. If I had opened my mouth, I would have started laughing my ass off.

Finally, I regained my composure while my partner just shook his head and got up front. I asked, “Stephanie, are you talking about the kind of pussy cat that goes ‘meow’ or are you talking about the one between your legs?” She says, “My pussy, my stuff. Let me show you.” She starts to unbutton her pants and I tried to tell her that it’s not necessary.

Too late. The pants are off and she is spread-eagle on the cot. “See! It’s gone!”

I assured her that her anatomy was there but she insisted on going to the hospital. After covering her and belting her in, I gave my radio report. “General, we’re coming in with a 35-year-old female whose chief complaint is missing genitalia secondary to a close encounter of the third kind. No sign of injury noted all body parts are intact. Vital signs within normal limits, we will be there in five. Any questions?” The nurse on the other end takes a moment to key the radio back up. “Nothing further. We can’t wait for you to get here. General clear.”

I couldn’t help but notice the laughter in the background.

After she’s dropped off and we return to base, my partner said, “Thank God it wasn’t a baby. It would have been like that scene in ‘Men In Black!'” He did not like being reminded that childbirth is an EMT skill, not a paramedic-only skill.

And thankfully, we slept the rest of the night, though I did dream about aliens who claimed to be here for our pussy cats.

RANT: Standard of Care

When I became an EMT, I quickly realized that EMS could be more than it currently is. So, I became an advocate for and supporter of increased increased education. I believe in evidence-based medicine in EMS. If EMTs and paramedics are ever to be recognized as real medical providers rather than getting the proverbial pat on the head by nurses and doctors, more education and acceptance of evidence must be embraced and utilized.

In other words, I’m an advocate for the advancement of EMS.

Even though I’m retired from being an active paramedic, I’m still part of a few EMS groups on social media. A discussion ensued about the Philadelphia Police Department’s “scoop and run” policy. If you’re not familiar, essentially anyone with penetrating trauma within the metro of Philly, PA gets a ride to the trauma center courtesy of a police officer. My understanding of the policy is that this is regardless of the availability or proximity of EMS.

Let me put this into perspective: A police officer who is likely not trained as an EMT, nor equipped to provide anything besides very basic first aid, throws a gunshot or stabbing victim into the back of his car and hauls ass to the hospital.

Now, you might be saying: “But Medic, if someone has penetrating trauma they don’t need a ‘medic, they need a surgeon and a blood transfusion.” You would be correct: Definitive treatment is definitely those things but that patient may have immediate life threats that can not be managed by a medically untrained police officer and instead would require a medic. The first thing that comes to mind is airway management. Can a cop suction an airway, place an appropriate airway (NPA, OPA, ET Tube, or whatever may be indicated), and ventilate a patient? No. All the cop has is a lead foot and prayer.

So I chimed in and indicated my concerns and disagreement with such a policy. Several disagreed with me and cited studies to back up their claims. As an advocate for education and evidence in EMS practice, I support studies but I do not support non-medically trained public safety officials transporting patients who are on the edge of death simply because it’s always been done that way.

I acknowledge what the studies say but I still do not support such policies from an ethical and moral standpoint. I was accused of not being a true patient advocate or of having my ego bruised. No. It’s because of the fact that I am a patient advocate that I believe police transport of injured persons is a crock of bullshit.

First and foremost: A patient’s family member is not going to give one single fuck about what a study says if their loved one dies as the result of aspiration or of otherwise having a compromised airway.

Also, ponder the following (all of this assumes we’re talking about a medically untrained police officer without proper equipment):

Can a police officer do a rapid trauma assessment and control serious external bleeding?
Can a police officer manage an airway?
Can a police officer provide bandaging and any needed splinting?
Can a police officer initiate IV access so that a patient can more quickly receive blood?
Can a police officer provide pain management of any sort?

Can a police officer do all of this by himself while he is driving?

And perhaps most importantly: Can the officer properly restrain the patient who will be lying in the backseat of his car in order to prevent worsening of the patient’s trauma and to otherwise keep the patient from being thrown around like a rag doll?

The answer to all of this is “no.”

Fuck the studies in this case. They don’t take into account that the patients are literally thrown into the back seat of a car, unrestrained, and sped off to a hospital by a police officer who likely has no medical training beyond the department-mandated Red Cross First Aid card and is weaving in and out of traffic and, as mentioned above, throwing the patient around the backseat with no restraint. They also don’t take into account that the patient is treated as a sack of potatoes rather than as a person.

It’s unbelievable that in 2017 we still have a major city giving 1960s-level of patient care.

EMS has come a long way since its inception. We have a much higher standard of care for trauma patients that has little emphasis on “scoop and run” and an emphasis on actually beginning treatment of the patient. Police officers simply are not trained or equipped to provide this standard of care.

I’ve not been able to find out if any lawsuits have resulted from this “scoop and run” policy but I would be willing to bet that if someone died as a result of lack of proper care or as the result of being improperly transported, a jury would not be too kind to the City of Philadelphia or to that unfortunate police officer who is on the receiving end of that lawsuit.

Police officers do many wonderful and amazing things and I am grateful for what they do. However, in my experience, most cops would agree that playing EMT is not something they want to do or should do.

Let the cops be cops and leave the medical treatment to those with the education to do it properly.


My First Ghost

All names and places have been changed.

The ink on the card that the NREMT had send which read “Paramedic” was barely dry when I acquired the first of what I call “ghosts.” Ghosts are what I call the patients that I have who will always stay with me and that I think of almost every single day. For many reasons this was a day that I would never forget… but it’s one that I wish I could.

It started out easy enough. This was one of my first shifts out of orientation at my service and I had just clocked in. I was met by my partner for the day – Kirsten – with her usual bear hug. “Dude! Congratulations. I can’t believe I get to work with you as your partner now.” I smiled, “Yeah, let’s hope it’s a good day.” While I was checking off the truck we made small talk about where to grab breakfast in a few minutes. Soon I was joined by an EMT student from the community college who was assigned to my truck for her clinical rotation. As Kristen and I are showing her the equipment, the tones drop.

“103, respond to Elm Ridge Apartments, apartment 47. 8 month old female, un-witnessed cardiac arrest. Fire department is en route.”

I look at Kristen and utter the first word that came to my mind: “Shit!”

We respond and hear the crew chief go en route in the sprint. We arrive and as I’m walking up the stairs a firefighter comes running down holding a blanket wrapped… something. “Bring her to the truck.” I open the side door and he places the lifeless little one on the cot. I begin setting up for an IO while Kristen puts the monitor leads on her. To say that I have tunnel vision during this time would be an understatement. I tell the student to begin compressions and I am about to drill the infant’s leg. I start going over the PALS protocols in my mind.

(Thinking): “Ok, let met get this IO going and push some Epi… Fuck, what’s the dose? Gotta get a tube in… Why isn’t she compressing?!”

The crew chief has joined us by this point and can tell that I have total tunnel vision. He looks at me and taps me on my shoulder. “Stop. Take a good look and look at what’s going on.” I regain some of my composure and take a look.

Quickly, I realize the gravity of the situation. She’s cold. She has rigor. She’s dead.

Fighting back tears, I key up the radio and call for the coroner. PD has arrived by this point and have begun talking to the parents. I jump out to deliver the bad news. This is news that no one should ever have to hear, and damn sure should not have to deliver. I ask them their names and their daughter’s name and begin talking to them as gently as I possibly can. “Kimberly has been without a heartbeat and any breathing for quite some time. I’m so very sorry but there is nothing we can do for her. She’s gone.”

Needless to say, they become quite upset and I comfort them as best as I can, all the while trying to fight my own grief and hold back my own tears. These people have just lost their treasure, their gift from God, their little girl. And here I am, an uninvited and – at this point – seemingly unwelcome spectator to the initial stages of their grief. I feel utterly powerless. I am unable to even attempt to do what I have trained for over a year to do because there is simply no point. It was too late.

I was too late.

Eventually we transport Kimberly to the morgue. Mercifully, the rest of the shift was mostly uneventful, a true gift from God if you ask me. Later that night after I talked to my wife, I went to a secluded spot at the station and sobbed. The weight of this call was squarely on my shoulders and I needed to let it go.

To this day, there’s rarely a day that I don’t think of Kimberly. For months I would regularly see her lifeless face whenever I closed my eyes. This eventually passed, but the memory of this event has left me a little more broken than I was previously.

Kimberly: My first ghost.