EMS

No time for goodbye

I bid farewell to two fire service colleagues yesterday - one retiring, the other promoting & transferring. Both goodbyes were interrupted by emergency calls. Just a quick, tight handshake and that pull-in half hug that guys do, then I ran for the ambulance. Years together in the firehouse, over in a few seconds.

That’s all endings, isn’t it? Coming, coming, almost here, gone.

Perhaps the best we can do with each other is to forget that we will all part company someday. Together, these colleagues and I have seen many people’s last moments as human beings on earth, the culmination of decades of life, slipping away on a street or in an ill-lit basement. Almost gone, almost gone… gone. All their private moments, all the thoughts they never shared, lost. Gone in less time than it takes to shake someone’s hand. Not enough time for unspoken truths.

In those moments, I was on fire. We were working, so we were all one. Nothing could be allowed to go wrong, not even the fumbling of the greenest rookie in the room. It felt like my mind flowed out to encompass the scene, seeing through everyone’s eyes. Strobing windshield spiderwebs, orange traffic cones. Musty cigarette pillows, overturned med bottles, urine and cold skin. In those grotesque moments I could forget about the last handshake, the pressure of the next call pulling us apart.

I was happy, in spite of what I was witnessing. I thought it was because I was doing something that mattered - trying to save a life. But maybe I was also happy because when we worked together, I forgot all our own endings. I forgot that one way or another, we will part ways.

Surely that demands that we stand with each other, speak nothing but truth to each other, live to preserve each other. Surely we must

but I have another call. I have to go. It’s been great. Be safe.

See you.

Paramedic everyday carry - 3: Pens

I could nerd out about pens for a while. In fact, I might do so right now.

Some EMS providers don’t care about the pen they carry. They grab the closest thing at hand, probably a clear blue bic with a flimsy plastic cap that promptly gets lost. Who cares, right? There’s a hundred more pens just like it, back at the firehouse. If they forget one, they just ask to borrow yours.

We call these people “monsters.”

When you really pay attention to the tools you use, even the most mundane ones, you start to see how every preference is shaped by your environment and how you chose to interact with it. I want a pen that:

  • Clicks on. I want to jot notes without needing two hands to remove a cap, which I would lose anyway. If I’m getting my gloves dirty/bloody, I tend to try to keep one clean as long as I can, and that’s the pen hand. (I also change gloves frequently on gross calls. Medics: change your gloves. Seriously. Don’t be out there doing your best Hawkeye Pierce impression on a trauma call. And if you don’t know who Hawkweye Pierce is, it’s not because I’m old, it’s because you don’t know your history. Change your gloves. That is all.)

  • Can write almost anywhere: the back of my glove, or on ECG paper, or fabric tape. I don’t do the notes-on-glove thing very often, because of the way we divide roles on a call. The lead medic runs patient care, while the driver gathers history and enters it into a tablet. That will eventually become the report we transmit to the hospital, as well as our permanent record of care. My driver, it she’s any good at her job, should be capturing info as we gather it. So, the rookie doing a blood sugar test knows to call out the result and make sure the driver acknowledges it. The driver also summarizes info for the lead medic, in case I didn’t hear a particularly salient piece of medical history (“patient is a diabetic” or “patient is taking blood thinners” or “the last time I ran this patient, they coded and we resuscitated them”). But every now and then, something comes up while the driver is busy, and I have to scribble a bit of info on my gloves. Then I have to keep that shriveled up glove somewhere handy as a reference, because I change my gloves on calls, as you should. In those situations, I want a pen that can write anywhere.

  • Has a thin tip, but not so delicate that it isn’t easily legible. Personal preference.

  • Is cheap enough to be bought by the pack and tossed out at any sign of contamination. Or can be easily replaced when, on a day when I had more faith in my fellow medics than they deserve, I loaned it to someone, who then kept it and sent a shitty bic pen through departmental mail to taunt me. I’m looking at you, Paul.

Anyway, I use Uni-Ball Jetstream Retractable Ball Point Pens with a 0.7mm tip. Bought in a 3-pack, each one runs under $4, and usually lasts me a couple months. You can also buy them in a 12 pack, which is a much better deal. It writes smoothly, doesn’t bleed, and, well… that’s it. It’s just a pen, after all.

I once bought myself a nicer pen, with a metal housing that looked very slick, and I really liked it… until it got lost. It only set me back about $12, but when it came time to replace it after less than a year of use, I balked. This is why, as they say, we can’t have nice things.

I also highly recommend carrying a Sharpie marker of some type. I use a Sharpie Twin Tip, which has both a traditional fat marker on one end, and a thin nib on the other. Why do you need a sharpie? Because, in a mass-casualty event, when you apply a tourniquet, you’re supposed to write the time of application on the victim’s forehead.

Seriously. Have I ever done this? No. I’ve applied lots of tourniquets, in non-mass casualty events, and I just write the time of application directly on the tourniquet, where the manufacturer has helpfully provided a space for me to do so. (In case you’re interested, most of the tourniquets we use are the Combat Application Tourniquet type, in bright orange. They seem less fussy to apply than others I’ve tried, particularly with blood slicking things up, and they seem to do a good job at stopping arterial bleeds. I’m not an expert, just an enthusiastic user.) Not that I wouldn’t do the forehead thing if the necessity arose. As it happens, I write on our tourniquets with a sharpie.

I also use if for a million other tasks, like scribbling expiration dates on packages, because medication manufacturers delight in shrinking the text of their expiration dates to the point where you need an electron microscope to verify them. And other Sharpie things.

Don’t be a monster. Carry your own pen. And do I need to mention the gloves again? Good.

Next episode: eye & face protection

Paramedic everyday carry - 2: Flashlight

Note: I don’t receive any money or free stuff from manufacturers. My links include affiliate tags in case someone decides to buy a tool I recommend.

My main flashlight

I peer into lots of cars late at night, trying to determine if the person slumped inside is asleep or unconscious. I pick my way through strangers’ yards, in the rain, looking for an open window, because someone at this address has called 911 but no one is answering the door. I start IVs in unlit basement sublets. I use my flashlight several times every shift. It sits in a low-profile holster on my right hip.

To be honest, I think holsters look kind of dumb. I use one anyway. I could carry a flashlight in my pocket, but if I get blood on my gloves, there’s no way I’m going to fish around in my pants for it. The items in the holster are right at hand, and I can get at each of them by feel.

DSCF4780.jpg

The flashlight I carry is the Streamlight 66118 Stylus Pro LED (AAA battery version). I bought this flashlight almost seven years ago (I just checked my Amazon order history), and I can hardly believe it’s still going strong. Streamlight has an excellent reputation in the fire-rescue world for making solid products. For a light that costs less than $20, this has proven itself many times over.

What I love about this light:

  • It’s small and thin - just a little fatter than a medical penlight. It could be lighter, but the metal shell gives it a heft that I like. At 100 lumens, it’s very bright for its size. It takes normal AAA batteries, so I don’t have to plug it into a charger and leave it behind when its charge gets low. It’s cheap, so when I finally destroy it, I won’t sweat buying the replacement.

  • It doesn’t have a lot of ridiculous detailing on it. The makers of flashlights have a serious problem with greebling. Gear makers think people want every surface to be embellished with angular protrusions and pointless textures. That’s why I generally avoid any product with the word “tactical” in its name. - they tend to be cluttered with nonsense details to make them look cool. Hey, medics: don’t carry shit to make you look cool, carry shit that works. This flashlight has ridges at each end, which make it a little easier to handle with slick gloves, and a pen clip, and that’s about it.

  • Its metal case has put up with a ton of abuse. It also produces a surprisingly loud sound when I knock on the windows of cars or houses. I knock on glass a lot. You’d be amazed. People call 911 all the time because they see someone sleeping in a car, and they’re afraid to approach the vehicle to check on them. Bear in mind that when I knock on the window, I’m not wearing any more protective gear than the caller was. The only difference is that I’m paid to knock on the glass.

  • It has two functions: on and off. I don’t want my flashlight to turn on in low-power mode, or blink furiously in rescue-me-from-the-face-of-Everest mode. I want it to turn on, light up something, and turn off again. Simplicity is your friend in stressful circumstances. I want everything I use to work exactly as I expect. Also, it has a rubberized pushbutton on/off switch on the butt, which I like better than the Maglight-style twist on/off, or a side button, which tends to get switched on accidentally.

  • Did I mention that this is really, really bright? It’s actually too bright to be used to check pupillary response. In a pinch, I can use the very edge of the beam, but I never shine this directly in someone’s eyes. Really, medics: don’t do it, even for unconscious people. I have no idea how many lumens can cause retinal damage, but I’m not going to risk it.

  • Okay, I might as well admit that after writing the last bullet point, I went down a little google-hole about light exposure and retinal damage, and the answer isn’t as simple as lumens. It appears to be about the focus area of the exposure. It doesn’t sound like 100 lumens in a flashlight beam will cause lasting damage. Don’t do it anyway. If you wouldn’t want to look directly into the beam while conscious and alert, don’t blast it at someone who is having a Very Bad Day.

  • The only reason I have to emphasize this is I know you, medics. I see you. Don’t think I don’t know what you might do.

What I don’t carry: a medical penlight. That might surprise some people. Penlights are weak-sauce as flashlights, borderline useless. They have one function: to check pupils, which I do on nearly every call. But we tend to carry about a million of them, stuffed into every bag and crevice on the ambulance, so there’s always one within easy reach.

My second light

I also carry a headlamp in a small bag that I grab on high-acuity calls. I can’t count the number of times I’ve started IVs under terrible lighting conditions, whether in poorly-illuminated apartments or outside at night. In the past, I either handed my flashlight off to someone else, which took up a set of hands, or put it in my mouth, which was gross. I mean, I know where this flashlight has been.

I carry the Steamlight Bandit LED Rechargeable Headlamp, because I received it as a gift. Almost any headlamp will do. This one is about $20, and has held up very well. I like that I can detach it from its headband and clip it directly to my radio strap.

The advantage of a headlamp is obvious: you don’t have to entrust your light to the rookie, who promptly shines it the wrong direction. The downside: you have to be careful where you look, because you don’t want to blind one of your fellow rescuers. And if you have hair, which I don’t, then you might get blood or something on your hair when you reach up to turn it off or remove it. I recommend shaving your head. No more bed-head on those late night calls… anyway, that’s a discussion for another time.

Honorable Mention

I used to carry a Streamlight 88830 PolyTac Right Angle Flashlight clipped to my radio strap, and it was extremely bright and useful… until it came off and got lost. When I lose something that costs $50, I think twice about whether to replace it. In this case, I made like Elsa and Let It Go.

Next episode: pens

Paramedic everyday carry - 1: Introduction

There’s this amazing online phenomenon in which professionals in various fields show off their “EDC,” or everyday carry. Seeing which tools an expert carries with them at all times is a fascinating way to gain insight into what they do, and how their experience informs their abilities.

I first came across this genre in the form of a video in which grandmaster maker, comicon crasher, and mythbuster Adam Savage empties his pockets, explaining the purpose of each item, and I found it totally enthralling. (One of the most surprising insights was that he does not bother carrying any kind of multitool, because he generally works where more specialized tools are within easy reach, and travels so often that he can’t carry a knife.)

I’m a firefighter/paramedic with thirteen years on the job, and many more as a volunteer before that. I’m very particular about the tools I carry with me. I thought that the story behind those items might be useful for both fellow medics and anyone interested in the world of EMS.

I have some very basic expectations of each of the items I carry:

  • It must work according to my expectations. It doesn’t need to be fancy or high-performance, but I don’t want things to fail when I need them on an emergency incident.

  • It should be low-profile. My uniform pants, unlike some in the industry, don’t have extra pockets to stuff full of extra junk. I use a very small holster with a limited capacity, so I’m very particular about what goes in it. I also have a small bag, provided by my fire department, which I’ve customized with essential tools.

  • It has to be replaceable. With some exceptions, nothing can be very costly. If it gets trashed or contaminated beyond hope of cleaning, I want to throw it away and get a new one.

  • It must be in the same location every time, exactly where I expect it, so I can reach for it without thinking. The last thing I need under the stressful circumstances of an emergency incident is to be fumbling for something and wondering where I put it. Most people I know in fire-rescue are borderline obsessive about their gear in this way.

Next episode: the flashlight.

Oh and btw here’s the video of Adam Savage’s EDC that got me into this.

The day after

I work a strange schedule: 24 hours on, 48 hours off. In practical terms, I get up at 4 every third day, schlep to the firehouse to be on duty at 6AM, and work until 6AM the next morning. When I roll out of the station, I have exactly 48 hours to recover before starting the process over again.

Most days when I get off work, I go home, try to recoup a little sleep with a short nap, and have a day in which I write and run errands with low expectations for myself. I'm coming off a shift in which I've usually been privy to some horrible shit, and the primary goal of the day is to avoid and suppress it. I have a bunch of rituals designed to reinforce the firewall between the world of perpetual emergencies and the quiet of home, but it is work to maintain the defenses.

Over time, I've noticed something about the day I get off work. It's like the third rail of my days. I'm more likely to have an argument with my wife - so much so that I avoid discussions of meaningful topics. I'm overcome by strange and sweeping emotions. I have sudden, compelling ideas - maybe I should buy a strange wig at Goodwill and wear it to the Odesza show! - and tend to see myself as damaged, if not outright psychopathic for my ability to tolerate such constant doses of human suffering. 

Then I get a normal day, in which things feel pretty normal. Then I go to work. Those are the normal days.

 

An entire exercise regimen in futility

The turn of the year is often a time for reflection, correction of mistakes and hopeful chartering of new ways forward. I'd love to do all that, but first I have to talk about futility. 

I ran a call a few days ago for a young man in his 20s who had stopped breathing. His father was reportedly attempting CPR on him before our arrival. No matter how long you've been in EMS, a call like this one prompts feelings that range from restless anticipation to piercing anxiety. Every decision we make has luminous importance, world-altering weight. 

The picture on our arrival was a depressingly familiar one: a young person who had stopped breathing due to a probable narcotic overdose. Once relatively rare, this is now commonplace, a "bread and butter" call for us. We administered naloxone, a drug that counteracts the effects of opioids, and the patient almost immediately started breathing on his own and woke up. He denied taking drugs, even when reminded that this disclosure was protected by privacy laws - also a commonplace reaction. 

He had walked out of the Emergency Room, over the protests of the staff, before we even finished the paperwork on the call.

I may well see this young man again. I see many people fall down the rabbit hole of addiction, from the early calls when they collapse at work, to when mom or a boyfriend finds them unconscious in the bathroom, to when they are dead and we're trying to resuscitate them. I can try to keep them alive, but of course I can't do much more than that. It feels hopeless sometimes. At 6AM, driving home on the turn of the year, it felt abjectly futile. 

If you hope to achieve something in this world, then futility is the most important thing you must ignore. My written words will be pulp someday; trees will grow where the mightiest buildings now stand. You avert your eyes from the futility of your endeavors as we slide our gaze past the sun.

But right now, I'm seeing futility everywhere I look. At times, I perceive its shimmering edges - and something else behind it, distorted as if through a flawed lens. But mostly, it obstructs my view of the world and dares me to step forward and through it. 

Make no mistake, I love my job - love it. I recognize that there is an ebb and flow to the way we deal with the stresses of the job. I'd just like to believe that for one of those people, the day they almost died was the day things changed for them, when they started the hard climb upwards. I don't want the credit; I just want to look up and see them there. 

Thankless jobs

Within the world of fire/rescue, there are two particularly thankless jobs. First, 911 dispatchers, who are the first point of contact for the emergency system, and who must sort out the chaotic, frightening moments of an unfolding emergency*. The other thankless position is the one who arranges to have the correct staffing at every fire station, every day. Both these positions have this in common: when they do their jobs exceptionally well, no one pays any attention. When they screw up, letting their humanity show over the phone or radio, or short-staffing a station, everyone calls them out on the mistake. 

I would have thought that was the textbook definition of a thankless job: one in which good performance goes unrewarded, but bad performance is immediately condemned. This chart proposes more axes of thanklessness, including pay, public opinion, stress, and environment. 

For obvious reasons, I found it interesting that this and other lists classified fire/rescue as "thankless." It's true, I don't always get thanked for what I do, but I also enjoy having a career that's lauded and seen as worthwhile. More importantly, firefighting is listed as one of the careers with highest job satisfaction. That list, which discusses the "crummiest careers" and what makes them so rough, is worth a read. Not surprisingly, we don't reward the people who have to deal with our junk (literally and metaphorically) nearly as much as we should.

[* If you want to hear why I have so much respect for dispatchers, listen to this audio of a dispatcher handling emergency radio traffic after three police officers were shot while responding to a domestic disturbance. She is calm and controlled on an extremely tense and emotional incident.]