On the Way to Paramedic in Northern VA
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Tuesday, February 21 2006
Of Hats

It is a difficult thing, being released as a medic on the transport gig, but Basic Life Support (BLS) on the rescue side.

Those not in the EMS field might think, "Hey - a medic is a medic is a medic. Why can't you do medic stuff running 911 calls?" The short answer to all that is that each jurisdiction has its own medical director - a doc - and it is under the doc's license that advanced life support (ALS, or medic stuff) is practiced. Naturally, the doc is placing his license on the line with each medic operating under him. Docs therefore like very much to know the medic's capabilities before releasing said medic to the World.

On the rescue side, there is no one available to DTs to precept him as an ALS provider - so that's not a Happenin' Thing. One must continually glance upwards at the Hat currently in use. Is it the heroic white Stetson of ALS? IVs and ECGs all around! Raise your hand if you're having chest pain, the attendent will be handing out nitro and morphine shortly.

Ah, but do we see the brim of the diminutive brown fedora of BLS? Yes? Uh, have some O2.

Indeed. One of DTs' partners in the past was a fully-certified ER nurse, "slumming" on the ambulance, who had not yet gathered in an EMT-Basic certification. So saith the Seinfeld EMS Nazi: "No patient contact for you!"

The urge to provide care in excess of my current Hat status can be strong. An elderly patient fainted when he stood up? Medic sense is tingling... could be a heart problem, but must... restrain... hand... from... monitor. Can't... hook patient up... as a BLS provider.

We were called out to a Recreation Place recently for a fellow who felt chest pain on exertion. He was sitting in the manager's office when we arrived, no pain, no tightness or shortness of breath, slightly diaphoretic (sweaty), alert and oriented, no history of cardiac problems, hypertension, etc.

The medic arrives and places the patient (as medics may do) on the heart monitor - 3 lead. Everything looks fine. Hmmm, says the medic. Let's do a 12-lead (which gives a more detailed picture of the heart's electrical function).

"Aha," says DTs, pointing, "ST elevation in AVF. Inferior wall injury. Yay 12-lead."

The medic is amused, outwardly, but inwardly... DTs' psychic abilities detect a "why the heck did you guys make us drive all the way over here when you could have handled this?" Or perhaps it is not his Psychic Abilities, but his Overactive and Defensive Imagination.

Sometimes it feels like being Clark Kent, with nowhere to change clothes...

The amusing thing, thought DTs, is that this patient would probably end up with a coronary stent - a procedure not performed at the hospital to which the medic was taking him. It would be entirely possible that in his transport gig it would be DTs who took him to the cath lab.

"Say," he imagines the patient saying. "Nice Stetson. Aren't you that guy with the fedora?"


Tuesday, February 14 2006
Ozymandias

Well, word has finally arrived concerning DTs' efforts in the 911-job-hunting arena, Part Deux. Specifically, with the City of Alexandria.

All is Despair.

While the process is public knowledge, the Powers of Alexandria do not go out of their way to explain things to the prospective candidates; DTs is therefore breaching no confidentialities here.

To review the process with a baseball analogy:

At Bat: Everyone who registers is notified of and is invited to take the written test; one needs only show a photo ID at the gate. The test is known as the HOBET, or Health Occupations Basic Entrance Test. It takes three hours or so, and the questions are broken into categorical sections. Each test section is timed. The sections are Essential Math Skills (whole numbers, decimal operations, fraction operations, percentage operations, number system conversions, and algebraic equations); Reading Comprehension, Reading Rate, Critical Thinking, and Test taking Skills. Other categories include a Stress Level Profile, a Social Interaction Profile, and a Learning Style evaluation section.

First Base: The test results return. DTs scores a 98th percentile again, which is slightly disappointing as I studied up on the fractional math stuff, having done little with it since High School. Still, a pass is a pass.

Second Base: The actual numbers are murky, but of 139 (or so) taking the test, 60 (or so) actually passed. These are invited to participate in a practice physical (detailed in this blog elsewhere.) DTs passes the practice with ease, but vows to continue his beefcake regimen anyway.

The actual EPAT is administered in two steps: Step 1 in under 2:45 and the totality of the test (Steps 1 and 2) in under 5 minutes. His Beefiness accomplishes Step 1 in 2:24, a full 21 seconds ahead of schedule, but cautioned by Aesop's tale of the Tortoise and the Hare DTs does not lounge - no! He completes the physical test with a 3:18 total time.

Third Base: The culls are dejected, but Our Hero is not among them. Thirty or so candidates remain. A Panel Interview is scheduled. The panel consists of three EMS supervisors who ask a total of six questions. Questions include, "How would others describe you as a person of integrity?", "How would you deal with cultural differences in our patient population?", and others whose wording I don't recall, precisely.

To this point, one may note, nothing at all has been done of a real-life EMS nature. The HOBET does not ask any EMT questions; the physical is a composite of EMS skills, but in reality one would never have to perform them all in that certain time period. The questions are of the same nature, with the exception of this question, which has appeared before DTs twice: "You are toned out to a home where a patient has a knife and is threatening to harm himself - what do you do?" DTs is a firm believer that Folk with Knives can kill you, and that anyone who wants to do themselves in may very well Do You In to accomplish this. Exit, stage right, and call for PD is, I believe, the correct answer, and the one I gave.

Rounding for Home: DTs receives a letter in his recently-restored In box (an untimely computer crash has been repaired):

"Thank you applying for an ERT position with the Alexandria Fire Department. Unfortunately, the panel did not recommend you for interview with the Deputy Chief."

Tagged out! Tanj dammit!

It is enough to call one's self-esteem into question, but DTs is essentially a cheery fellow. I recall the wise words of Wallace Shawn, who played Vizzini in The Princess Bride:

Vizzini: "Ever hear of Plato? Aristotle? Socrates? Alexandria EMS?"

Westley: "Yes."

Vizzini: "Morons!"

Harsh, perhaps too harsh. A kinder interpretation is a completely fictional behind-the-scenes conversation:

EMS Supervisor 1: "He's perfect!"

EMS Supervisor 3: "His intellect is dazzling. He's astute, manly, and handsome. A Catch!"

EMS Supervisor 2: "Yes. But perhaps he's... too perfect."

EMS Supervisor 3: "You mean...?"

EMS Supervisor 2: "He would have all of our jobs, and do them more splendidly than ever we three did, together, were he hired. This Must Not Happen!"

EMS Supervisor 1: "Our course then is clear.... [Stamp!] There!"

Ah well. Alexandria was given the First Crack at DTs because they, unlike many systems in the area, do not require their medics to be firemen as well - DTs has no interest in the fire fighting side of things (actually, DTs just hates rolling hose), but there are Other Systems into which some thought must now be given...


Saturday, February 04 2006
Key of Fear

All systems support pretty much the same level of provider care for EMT-Basic (EMT-B): trauma care, splinting, bleeding control, that sort of thing, and for drugs the Basic is allowed oxygen, activated charcoal, oral glucose, and perhaps ipecac by order of the Poison Control Center. It doesn't sound like much, but really those interventions do take care of many of the patients we see.

In many systems, the EMT-Intermediate (EMT-I) can add "options" such as IV access and endotracheal intubation. Virginia is it seems a little different from the other EMS systems around the country. One of the differences is that here, an EMT-I is functionally equivalent to an EMT-Paramedic (EMT-P).

This means that here, in good ol' VA, the really heavy stuff is available to both EMT-I and EMT-P: epinephrine, lidocaine, morphine, demerol, ativan, mag sulfate, dopamine, dobutamine, nitro, vecuronium, all the drugs. But it gets even better.

Each "system" (county, city, or private service) has its own online medical director (OMD). Depending on one's OMD the options available to field medics may either expand, or contract. I've mentioned before that some OMD's simply want the patient brought to the ER with minimal interventions. Other OMDs are comfortable with their providers to the point where everything short of field surgery, it would seem, is permissible.

It is under such an understanding OMD that DTs is now, wearing his Transport uniform, a released Medic. Yay DTs! Yay, ice cream!

Yes, after several months of precepting, DTs has been "blessed" by the Powers and Dominions, and given a bright and shiny Key, even though he is still only an EMT-I (patience, patience, "P" be comin').

The Key, however, has come with a price. No longer is DTs a "third" on his transport rig. When the downward-spiralling patient is snatched from the outlying urgent care center for a time-critical ride to surgery at the Big Hospital, it is DTs and he alone who must keep the patient alive. No more "Do you think we should-" or "In my opinion we ought to-" stuff. No more may he pull off an EKG tracing and say, "This looks to me like X, what do you think?" - there is only the patient, and DTs.

Gone is the comfort of a second opinion, from wiser and more experienced providers, replaced by the imprint from a Vibram-soled boot on DTs' tender backside, the last remnant of having been kicked out of the nest.

To be sure, the precepting was not a timed event. "Well, it's been a couple of months - toss DTs into the fray." No, many tests and interviews and scenarios and real-time trials were overcome before the Key was relinquished to DTs' latex-free hand. In the opinions of Those Above, then, he is ready.

But it is a heady and frightening experience, I do not mind saying. Probably all newly-minted medics do this, but I find myself looking at the thing every now and again.

It is a small key, not like a Key to the City, but infinitely more useful - and daunting.

"You'll be picking up terribly ill patients, DTs", says he to himself. "You'll watch loved ones planting kisses on the recumbent form of your patient. From the family's perspective, the rig doors close and off they go, with you and you alone in back to keep 'em alive. You better know what you're doing here, man."

Indeed.

The strongest impulse I felt on receiving it was, "Here - take this back, just for a little while. There's a couple of things I'd really like to brush up on, re-study, you know, a refresher course or two might not hurt. Maybe next week is good. Yeah, next week definitely better, I'll know more by then..."

The Powers and Dominions must have read it in my face. "Good," said They. "Keep that attitude, and get out. Oh, and don't lose it."

Not sure if they meant the Key, the Fear, or my composure. Guess I'll just have to hang on to all three.


Wednesday, February 01 2006
EPAT

In a perfect world, the dispatches for our calls would sound something like this:

"Medic 2, on Five Adam, for a difficulty breathing, 123 Fubar Street."

"Medic 2, be advised, your patient weighs four hundred twenty pounds and is in the back bedroom on the fourth story of the townhouse. The hallway to the back bedroom is narrow, much furniture will be in the way. Your patient will be unable to stand or walk. There is no elevator. The stairs are narrow and unlit."

In the real world, of course, the first sentence is about what we get. It is after all Dispatch, not the Psychic Friends Hot Line. But all the other stuff could be true, too. To the extent we can, therefore, we anticipate.

Since we don't receive such detailed information ("Sven! Ahnold! Put down the fire truck and go with the ambulance for a lift assist!") we the crew must be able, within reason, to handle the physical end of things

Fire guys have their physical tests, and so do EMS folk - the EPAT, or Emergency (rescue technician) Physical Abilities Test. Generally administered in the dawning time of a system's hiring process (each locale - city, state, county - is called a "system") the EPAT strives to find if, in general, a candidate is minimally qualified to do the kind of stuff EMS does all the time.

The particulars of such tests vary between locales, but one local system conducts the EPAT test thus:

The candidate will

  • go twice up and down a flight of steps (3 landings) with 25 lbs of equipment in each hand, no skipping steps;
  • perform CPR on a mannequin for one minute at a timed rate;
  • "rescue" a 165 lb mannequin in fire fighter gear by lifting it and dragging it backwards 30 feet;
  • hoist a 100 lb bag and carry it thirty feet, up a stairs, back down, and another thirty feet.

 

The candidate is given 165 seconds to complete the aforementioned, after which he must

  • lift one end of a Reeves stretcher, with a 165 lb patient, above his head and lock his elbows;
  • lower same in a controlled manner;
  • push a weighted (400 lb) cart sixty feet and pull it back (60 feet) in a controlled manner.

 

The total time allotted for ALL tasks is five minutes - but if one misses the 165 second mark on the first set, the test is over - "Thank you, come again."

"DTs, my mind is calmed," I hear you say, "To know that my girthy Aunt Bertha will be carried safely by no Caspar Milquetoasts. But why mention this test?"

I mention the test because, on Saturday, I have the wonderful opportunity to take it. Last week DTs took the "practice" - same test, same timing requirements - and passed. His feeble suggestion at the time that "this should, you know, count" was brushed aside, though, and so it is all to do again.

Truthfully, DTs took the test last year, and passed as well, so one would expect a breezy attitude. It is to laugh - Test Anxiety is ever the hobgoblin. And so he daily retreats to the dim and sweaty corner of his abode wherein resides the Gym Stuff, slurping noisily at chocolate Mus-L-B-Big shakes.

Away with him, then - back to the cables and pulleys to prepare.



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