Insomnia

I haven't been able to sleep the past few nights.

Because every time I close my eyes I see someone I love in the place of someone I recently pulled out of a twisted, battered and broken hunk of metal.

Because I am so angry at someone I don't even know for putting the precious gift that is the life and trust of a child in jeopardy.

Because no one should have to hear the echos of a child calling for their mother, and the echos going unanswered every night.

Because it's not my job to collect ghosts in my heart.

But this was one of those calls where I just can't help it.

How Do You Do It?

As a volunteer, it's a question that I get asked frequently by many who don't understand EMS or the fire service: "How do you do it? How do you manage to commit to that level of volunteering? How do you keep doing it and not burn out?"

And, often, I look at them, and I'm not sure how to respond.

Because, truthfully, I'm not sure how I do it.

I'm not sure how I manage to say that 12 hours on an ambulance every week is more important than my work, my relationship, my friendships.

I'm not sure how I manage to get out of bed in the middle of the night as a duty officer and leave the comforts of my warm bed - the Firefighter, and Annie curled peacefully in sleep - as I venture out into the unknown.

I'm not sure how I manage to take on the burden of other people's panic and pain, yet not make it my own.

I'm not sure how I manage to walk off a scene where the unspeakable and unimaginable has occurred, and then reintegrate into civilian life less than hours later looking and sounding little worse for the wear.

And if I do manage to do it - I'm not sure I do it particularly well or with grace.

Volunteering in EMS and the fire service is not easy. It is not for the faint of heart. It's not for those that yearn for a life of comfort and ease.

All I know is that when my shift comes round, my pager goes off, and the chaos of the world beckons is that I *do* it. There's no thought as to how, just that it needs to be done.

And maybe it's that compulsion - the calling that needs to be explained. The why - not the how.

So for those of you who are reading this and understand the calling - what's your reason? Why do you do it? Because, really, I don't think any of us could explain the how without explaining the why. I know I can't.

Intentions

Many of you have probably noticed that it's been awhile since I have done an honest-to-goodness EMS related post. Maybe you've also noticed that this was originally supposed to be an EMS blog, with bits and pieces of my life outside of EMS tossed in for a change of pace. Sadly to say, I've clearly gotten away from my original intentions for this blog.

Intentions. They're something that I have been thinking about quite a bit recently.

When I first became involved in EMS, I had such good intentions; save the world, make a difference, help someone--even if it is only one person. Those intentions were strong and true, and I still stand by them as my reasons for getting involved in EMS. Those are enduring desires for me, whether they are related to EMS or my future career in education. But somewhere along the way, the reality of executing my intentions changed.

It has been well over two months since I have engaged in patient care; all I do now is drive and play a game of politics which I despise. While part of this has been due to extenuating circumstances, particularly staffing changes that have stretched my squad's resources thinner than you could possibly imagine, it is easy to become disillusioned with my role in EMS. What drove me to love EMS in the first place is rapidly becoming my undoing. There is nothing that I enjoy more than for 30 minutes being able to engage with another human being, and creating a relationship--however brief it may be--that serves to offer compassion and professional skill to make their immediate situation better. Unfortunately, when you are the only certified driver on a two-person crew, engaging in patient care is no longer an option. Instead, you are trusted with the safety of your tech and patient in bringing them to the desired destination. And not that driving and safely bringing both patient and volunteer to where they need to go in one piece isn't a noble goal, but it's not what I love about EMS.

Growing up, I was always told, "Do what you love. If you don't, then you'll never find true happiness." And I think that I've reached that point in EMS where I need to make a decision: I am no longer doing what I love, and as a result, I am no longer happy with my work. The skills that I was so eager to learn during my days in EMT class, and in my early days of in-service training, are skills that I no longer have the opportunity to use. And when you don't use them, you lose them. If I am to stay in EMS, I need to find a place where my entire skill set will be appreciated and valued and utilized to its fullest potential.

There will be some changes coming shortly in my life. You will probably read about many of the big ones on this blog. In August, I start student teaching, in December I graduate and enter the real world filled with idealism, enthusiasm, a strong dose of "where there's a will, there's a way," and a whole lot of good intentions. 

Changes

Hi. Hello there. Have we met before?

Oh...yes, I'm CW. It's so nice to see you again.

Oops. Apologies for my extended absence from the blog. Things have been...crazy.

You see, there's a lot of changes that have happened in the past 3 months, and a lot of changes that will hopefully be happening soon. I'm in this odd state of finishing up both undergrad and grad school all at once, I have my Teaching Associateship rapidly approaching, I'm moving somewhere in a 3 month time frame as well, and essentially starting life in the real-world(ish). Hell, I even bought a car; that practically screams "Welcome to the real world, grown-up!" I think my mind just imploded on itself in the face of all these adult prospects.

But there have been a few constants in my life that I've become supremely grateful for these past few months:

1. Coffee. In copious quantities.
2. The rescue squad, and my utterly dysfunctional, yet completely adored crew mates.
3. My mentor-slash-adopted grandfather, the ever present voice of reason and encouragement.
4. The solitude of the children's books room in the education library.
5. Coffee. In even more astounding quantities.

Yet, in spite of all these lovely, and much needed, constants, I have come to the conclusion that I, in fact, fear change. Which is a shocking revelation because I have spent much of my life trying to convince myself that change and fluidity are good, and that I am an adaptable person by nature.

This is, apparently, false.

Never have I been more frightened of what the future may hold in my entire life.

This, alone, is a frightening realization in its own right, given some of my past life experiences; for this to be the single most frightening prospect I have ever faced is, in many ways, ludicrous--irrational. I've faced down tougher stuff. I should be stronger than this. I should be more courageous than this. I should be fearless.

But I'm not.

There's a part of me that's crying out, "This is all happening too soon! You're only 21! You're too young to be taken seriously by the real world, much less have half a chance of making it out there." That part of me desperately wants to believe such things to be true. That part of me is clinging wantonly to the familiar, kicking and screaming in protest in the face of change, and that is the part of me I find most disappointing.

So from here on out, there will be some changes. I refuse to disappoint myself; to fall short of my own expectations. I refuse to let the prospect of change confuse and paralyze me with fright.

"The only way to make sense out of change is to plunge into it, move with it, and join the dance."--Alan Watts

Holiday Cheer in EMS

This is what happens when you let us out in public. Happy holidays folks!

--CW

CPAP: Making Sick Patients Better

If there were a single intervention whose effectiveness I had to say impressed me nearly every time, it would have to be the power of CPAP (Continuous Positive Airway Pressure).

I've mentioned this before, but there are few things more intimidating than being a fairly new EMT and walking into a situation where your patient is clearly sick and you're faced with a 45 minute ride to the hospital. I can hear the patient's respirations from two rooms away--the loud, wet gasps that tell you "Oh crap...", and my mind jumps to envisioning exactly what sight will greet me a mere 30 feet away.

She's tripod-ing, perched on the edge of the bed, and her eyes are wide open and pleading--trying to communicate a desperation that words are failing right now. She is frightened and she knows that there is something very wrong with her right now. Her years are catching up to her, and she wonders if this is it. You can see the edema in her lower legs from 15 feet away, her swollen ankles peeking out from the modest nightgown she dons.

Your observations begin to mold into a concrete set of suspicions about what you're facing, and you start racking your brain for everything that your remember about congestive heart failure. Does she have a history? Cardiac? Respiratory? Otherwise? Medications--what's she been prescribed? Those neatly lined up pill bottles on the bedside table tell a much larger story, I'm sure. When did all of this start?

Her husband is rambling nervously at my side, and I tune into "COPD", "she takes pressure pills", and "she takes  water pills". At this point, I'm at her side, and introducing myself and taking her hand. The death grip that follows is no surprise. I feel for a pulse and it's racing beneath my fingers. It takes a split second for me to make the "load and go" decision.

We apply hi flow oxygen, shift her to a rolling chair borrowed from the kitchen, and wheel her to the entryway where our stretcher sits at the opening to a narrow maze of halls in this one story home. The transfer is efficient and professional, and I am anxious to get her into the back of my truck where I have something that might relieve both the patient's and my own anxiety.

A month ago, I had spent two hours of CE preparing exactly for this situation. A month ago, our OMD had devoted two hours to educating his EMTs about an intervention that works, and works perfectly in certain circumstances: continuous positive airway pressure, or CPAP.

Positive Airway Pressure is a form of ventilation that EMTs are introduced to early on in their educations. When you are taught the "A" of ABCs, you learn the necessity of ventilating with a bag-valve mask (BVM) in certain situations where either the airway is compromised and the individual is unable to breathe adequately on their own. Ventilations with a BVM are a means for providing Positive Airway Pressure. However, the majority of my patients that have been on the receiving end of a BVM are usually no where near able to communicate with me; rather, they hover right around "unresponsive". Yet there is a whole other class of patients that are alert and able to communicate, yet could also benefit from Positive Airway Pressure with a continuous flow. Thus, CPAP was born as an intervention for a variety of conditions ranging from sleep apnea to congestive heart failure to chronic obstructive pulmonary disease (COPD).

As we transitioned the patient from house to ambulance, I quickly and mentally reviewed my indications and contraindications for CPAP. My patient hit nearly every indication for CPAP and no contraindications appeared to be present; thus began my first experiment with rigging up the CPAP and applying it to my patient.

There is no better sense of satisfaction and relief when you start out with a patient who is clearly very sick and 45 minutes out from the hospital, and 10 minutes down the road there is notable improvement in your patient's condition because not only are they tolerating your intervention, but they are also benefiting from your intervention.

What's even more satisfying is when you arrive at the hospital with a patient who is in congestive heart failure, yet due to the lack of several notable signs and symptoms the doctor has trouble telling exactly why you brought in this patient.

The great thing about CPAP is that if your patient can tolerate it, and the indications are present, CPAP can, and often will, make your patient better. More often than not, providers at the basic level are already intend to, and often do, apply hi flow oxygen to a patient who is having difficulty breathing. It is one of the most fundamental protocols that you learn as an EMT-B. In many ways, CPAP is a jacked up version of hi flow oxygen whose mechanism of operation makes it much more effective in certain situations. If OMDs around the country are already willing to let their EMTs utilize high flow oxygen, then why not expand their access to yet another tool that can make an even greater difference for patients whose symptoms are drilled into our heads, but for which there are very few things that--nationally--we, as basic level providers, are able to do to alleviate such symptoms. CPAP is a tool that can make a difference, and isn't it our goal as providers to bring our patients to the hospital in better condition than they were when we received them?

I may be over simplifying the science behind why CPAP, or I may not fully understand why it is often a skill reserved for individuals at the Advanced Life Support level due to the whole "newbie" thing, but I can tell you this. It's as frustrating as hell knowing that local protocol was the only thing preventing a BLS truck from administering an effective intervention  at the pre-hospital level when my grandmother went into congestive heart failure. Even though she lives less than a mile away from a staffed rescue squad in a suburban New England town, she landed in the ICU for four days because of a lack of timely and effective interventions--interventions that she failed to receive until she arrived at the hospital. And last time I checked, that's not what EMS is all about.

There are some services that keep their EMTs on leashes with a scope of practice so narrow you could fit it on the head of pin; Small-City Service in the town where I go to school in Virginia is one of them. As a BLS provider at Small-City Service, you are rarely viewed as more than a medic chauffeur or BS (and yes I do mean BS, not BLS) transport unit. And then there are services like mine, Small-Town Service, VA where we have an OMD that understands the value in giving his providers the tools they need to do their job well and to treat their patients accordingly.


And isn't THAT what EMS is all about?

Question for the Day

What's your favorite way to avoid burnout?

I was reading an interesting post over at AmboDriver the other day, and it was a serendipitous moment as this is something I've been struggling with a bit recently. So in the name of my ever curious nature, I ask all of you: what do you do to let loose?

I'm looking for some good ideas, so fire away!

--CW

Everybody, Somebody, Anybody and Nobody

"This is a little story about four people named Everybody, Somebody, Anybody and Nobody. There was an important job to be done and Everybody was sure that Somebody would do it. Anybody could have done it, but Nobody did it. Somebody got angry about that because it was Everybody's job. Everybody though that Anybody could do it, but Nobody realized that Everybody wouldn't do it. It ended up that Everybody blamed Somebody when Nobody did what Anybody could have done."--Anonymous

There's been a huge shift in mentality in this country in the past few decades. Vague, I know, but it's true in an ungodly amount of contexts; attitudes about sex, marriage, adulthood, responsibility, accountability, parenting, education, politics, and civic involvement have all changed drastically since my parent's generation. While the shift in many of the attitudes I have just listed deeply concern me and make me frightened for the world that my generation will inherit and be responsible for living in and attempting to fix, I'd like to spend a bit of time discussing the last one that I mentioned, civic involvement, including attitudes towards community, volunteering and citizenship.

This change in attitudes about civic responsibility is something that I've been thinking about for awhile--for a lot of reasons. It is something I've been discussing a lot with my fellow volunteer EMTs in the context of the rescue squad, and this idea has also been consistently resurfacing in discussions with my social studies education cohort as we've been talking a lot about the responsibilities that social studies teachers have to their students, including fostering a notion of civic responsibility and citizenship.

There is a radically different approach taken to volunteering within and for one's community in today's world of instant gratification and looking out for the top dog than there was even ten to fifteen years ago. Growing up, I was regaled with stories of the tight-knit community that my mom grew up in the mid-20th century Midwest. It was a place where friends and neighbors served one another in a capacity unfathomable to many small towns today. I was raised on my maternal grandfather's reminiscences about the civic capacities he served in, and the pride that he derived from not only serving his local community, but also his country as a military man. I was raised by parents who understood what it meant to serve as they volunteered much of their time in the schools, as coaches and as church leaders. Growing up, I never lacked role models of citizenship and commitment to the community, and I think that foundation of support is what continues to drive me today in my dedication to public and civic service. I am lucky in that regard.

Unfortunately, people like my parents and grandparents are fading in numbers. While they are people who understand that doing what is right can be satisfying in spite of the hard work and thanklessness that  community service often demands, they are largely outnumbered by people who expect (and often demand) such time consuming and passionate dedication for nothing in return. Today, we live in a culture that has socialized us to expect instant results, instant pleasure, and minimal effort when we do something. Just think about the smart phone revolution in the past few years. Never has been accessing information and entertainment been as rapid and effortless as it is in our technologically driven society.  However, volunteering in and for a community does not always offer such immediate rewards for such little input, and I feel like I can accurately say this drawing largely on  my experience as an EMT.

As an EMT, I am required to run a duty crew once a week for 12 hours. When it is my duty night, there are roughly 1000 individuals relying on me to fulfill my commitment to the community. Running for such a small-town service, if I fail to show up for my shift then we may not get a truck out of the building that night. There are few acceptable reasons for me to miss my shift, and if I do it's my responsibility to find coverage. For my actions, I am held accountable. Not every night in EMS is glamorous though, and there are nights where running duty conflicts with some other interest of mine or is an inconvenience at best. Some nights I show up and we don't turn a single wheel. Some nights I arrive at the station planning on (and needing to) complete several homework assignments or tasks, and we proceed to run all night. Every once in awhile I may run a call that taxes my patient assessment skills and ability to triage and treat; more likely than not I will spend a call addressing the feeling poorlies or "take me to the hospital because I said so." It is in this capacity that I serve my community, and I serve it proudly--regardless of the situation.

However, the town where I run is not the area in which I was born or raised. In fact, it is a community in which I am a transplant whom for some reason has become attached to the people and the way of life in this sleepy little town. I have chosen to make this little town my community-- and in tradition with the values upon which I was raised, my responsibility. There are many like me whom have stumbled across this community and have found a place to serve and call their own. Yet the dwindling numbers of native volunteers baffles me when I see so many transplants ready and willing to serve this area. When the rescue squad first came into existence, it's membership was comprised of a thriving group of individuals and families that were directly served and benefitted by the rescue squad. It was public service staffed by and for the community it called home.

But in recent years, membership has dwindled. In reality, there are about 25 individuals who run all of the calls at our service and about half of them commute into our little town once a week for their duty shift. New members are recruits that aren't residents of the town; they come from neighboring cities and towns, attracted by the pace of calls and type of patient care a rural, small town service offers. For a community that often prides itself on taking care of its own, there are very few residents that see volunteering for places like the fire department and the rescue squad as a worthwhile means of living out that pride. There are many that talk the talk, but few that walk the walk, so to speak. The responsibility is consistently passed down the line, thinking "How wonderful it is to serve (insert person X/place Y), but it's not my responsibility. Someone else will take care of it."

And that unaccountable attitude is more pervasive than I feel comfortable admitting. Not only do I see it in the town where I run EMS, but I see it in the classrooms I teach in as well. The other day I was discussing hot topic current events with a student in the government class I work with. When I asked them if there were any specific policy issues that they cared about, they replied, "Care? Why should I care? It's not like I can vote or do anything about it? I'm not even of age." When I pointed out that come the next election year, these would be issues that would concern them as they would be able to vote, they replied "It's not my responsibility to change anything. My vote doesn't even count in the grand scheme of things. I'll just let everyone figure out what to do about it all. There are people smarter than me out that can care." This is not the first conversation that I have had that echo such sentiments; even over a matter as simple as voting, there is that same widespread sense of passing along the responsibility to another. Yet the line eventually runs out and the duty cannot be passed on anymore; someone is eventually held responsible, and, thus, accountable.

And at that point, voluntary service becomes a duty. In fact, maybe that's the way it's supposed to be; that we all have a duty to serve our community in some capacity. Maybe it's this understanding of citizenship and service that has gotten lost over the past few decades. Maybe we've been passing the buck for too long that the notion of responsibility has gotten lost in the shuffle. Maybe, just maybe when we reach the end of the line people will be jolted back into realizing what it takes to make a community run.

I have long realized my duty to serve and I do so with a sense of pride and satisfaction that I have yet to find anywhere else, whether it be in the back of an ambulance or in front of a high school classroom. I only hope that Everybody realizes their duty as well, and Somebody steps up, before Nobody does what Anybody can (and should) do.

Deja Vu

I ran a call yesterday--a priority black cardiac arrest. There really wasn't much to do by the time we arrived on scene. The medic unit was already placed in service, and we ran a strip just to confirm asystole; not a surprise really, given that we had a 15 minute ETA to the scene and the estimated down time was close to 30 minutes or more by the time we arrived.

But what threw me on that call more than anything else was a missed turn on the ride back to the building. Lost in conversation about the call, we missed the road for the most direct route back to the building, so we continued on down to find the nearest driveway to turn around in.

It was pure luck that I looked out my window as we pulled out away from the driveway to head back down the road, and I gasped at what I saw. An eerie feeling made its way down my spine. There was a black fence at the end of the driveway, with horizontal three slats, and the house number running down the corner post.

The last time I saw that fence and house number, there had been a body wrapped around the corner post, and a motorcycle in the ditch. And I had proceeded to work another code, with similar results: priority black.

Deja vu, no?

And as we rode back to the building, I couldn't help but notice only that they had repainted the house number, but left the crack in the fence.

Blog Series--Update

Hi friends...This is not a post of serious substance, just a quick update on the delay in my mini-series on BLS (or what I think should be BLS) skills.

Needless to say, it's that glorious time of year that all university students must face head on: midterm season. My midterm season is in it's full glory at the moment, so it probably wasn't my best idea to introduce a new series of post just as it was getting underway. However, fear not, I have not forgotten about my promised posts and musings (I know, you're so eager for them). I am still chipping away at finishing them, it's just taking longer than I hoped given my extremely limited (and ever decreasing) amount of free time.

On the bright side: I have a new favorite read in the EMS blog-o-sphere. I've added her to my list of the best of the internet, so you should take the time to check out Probie to Practitioner and see what she has to say.

Well that's all for now, folks!

TTFN,
CW

Scope of Practice, the Introduction

I've been having a lot of conversations recently regarding scope of practice, more specifically skills that are included in protocol. This has been a hot topic in VA recently, as it has been nation wide as well, due to the future changes that the national registry will supposedly be undergoing in the near future.

However, this discussion or protocol and scope of practice has always been a hot topic. Just check out one of the many blogs in the EMS blog-o-sphere (maybe AmboDriver or StreetWatch?) and you'll come across many posts that discuss the inclusion or exclusion of certain skills, drugs, etc. from protocol, and the merits of each.

But rather than focus on reforming the skills that EMTs around the country should undoubtedly have access to, I'd like to talk about several skills and pieces of equipment that I have found indispensable in my own experience while running at a rural rescue squad; in fact, I believe they are indispensable no matter where you run.

If you run with my service, you're looking at--unfailingly--at least a half hour transport to the nearest hospital, most likely closer to 45 minutes, maybe even an hour if you get sent on a mutual aid request. This exceedingly long transport time, potentially with a critical patient, is something that I don't think a lot of big city (or small city) providers fully understand the reality of. At my station, the majority of volunteer crews mark up at the basic level. Our medic level providers are few and far between, and as a result we rely heavily on a nearby county career-staffed station for medic-level services. QRVs are virtually unheard of, and if you have more than one crew in the building a shift, then you're the exception not the rule. While we do have access to a helicopter service for some of those calls that you know are going to be bad when you hear them go out, if you don't put them in the air immediately, there is a distinct possibility that ground transport may be just as efficient as flying them out. And you would be shocked to realize how long 30 minutes in the back of an ambulance with a patient who is seizing uncontrollably (and you have no medic-level rendezvous in your near future because they're on a call in their own first due) can feel.

So given that context, I want to talk about the merits of having the following three skills approved at the Basic level: 12-Leads, King LT Airways, and CPAP. In the following three posts, I will discuss some of my personal experience with these skills and pieces of equipment, as well as potential advantages and disadvantages. On the whole, I will be straightforward and say that I think these three skills are significantly more beneficial than they are problematic, but if you disagree, I would like to hear your ideas.

Coming soon: 12 Thoughts about 12-Leads.

Til next time,
CW

Some Calls You Never Forget

In EMS, there are just some addresses that you remember. Some of them may be associated with frequent fliers, some are associated with the most bizarre calls of your EMS career, and some are forever associated with those calls that leave ghosts behind.

In EMS, we all have those calls that we'll never forget. Over time, the may fade or blend into the memories of other calls, but they are never truly forgotten. In time, you are often able make peace with those ghosts left behind from tough calls, but in a small town EMS service there's a very good chance that you'll never be able to let them truly rest.

Small town EMS is an entity unlike any other. When you run those "oh sh*t" calls, they are to addresses that you may know; they are for family, friends, people you have grown up around, and maybe even members of your own department. That's not to say that you don't run those same calls in big city EMS, they just happen to be a bit more concentrated out here in the country.

I ran a call with a good friend of mine awhile back--ultimately, a fatality from an MVC (motor vehicle crash). The call was one of a series that we had that night (because where I run, when it rains it pours); this was our second response from the hospital, and as we were en route to the scene, we were advised that we were facing a potential code.

My friend and colleague happens to be small-town-born-and-raised, as many of my fellow providers are. Even as a transplant from the North, one of the first things you understand about this town is that it's a tight community, and when you hear a potential code go out over the radio you start fervently wishing that it's no one you know--that this time you'll get lucky and you won't be working a family friend or acquaintance. There was a look that flashed briefly over my friend's face, a look of desperation like I had never seen from her before.

Needless to say, she was not so lucky that night. Our transport for that call was to the hospital, but more specifically the morgue. The front of the truck was silent on the ride in, with few interruptions limited to the tones for the rest of the county dropping quietly in the background.

No words were needed that night, at least not immediately. The talking will, and does come, and the support of other providers can help you reconcile your actions as an EMS worker and make peace; yet the question remains, how do you grieve? Because it these kinds of situations you are not just a provider, you are a friend, a loved one, an individual who shares more common ties with the patient than just a singular call.

It's a question that I'm not sure a lot of small town providers have yet answered; in fact, I think that there are many answers to this question that are as unique as the relationships between patient and provider themselves. But I do know this: there are just some calls that you never forget. And that's okay.

Entre'act

Before I post my next musing, I feel like I should give a quick rundown of the rules that I will be following for discussing actual EMS calls on my blog. I'm borrowing liberally from Peter Canning of StreetWatch, one of EMS' most prolific authors and bloggers (and also, a personal role model of mine), so I will direct you to the following page:

• http://medicscribe.com/blogging/

I will try my best to convey the heart, or the essence of each story, but to protect my patients, fellow providers, the service I run for, and myself, there will be several alterations of superficial details.

I hope you enjoy the posts to come,

CW

The Involuntary Commitment Dilemma, cont.

So...have you been pondering? Come up with anything exciting? If you did, I hope you'll consent to sharing...

But until I hear back from you, I shall now commence a monologue on my own thoughts.

The first thing that I would do is finish assessing my patient and going through my own checklist for getting a refusal. The patient, comes first, and Officer Congeniality may need a subtle reminder of that. Secondly, don't engage with crazy; coming back with a snarky, "You do realize that what you're suggesting amounts to kidnapping, Oh Officer of the Most Sacred Law?" won't get you anywhere productive. If there's one thing that I've learned in my two years in EMS (sparkie though I may be), it would be that you want to be friends with as many people possible that show up to a scene. (Especially if you run in a rural area like I do, and there's only one or two golden guns in town that regularly show up to bail you out when you get the call for "domestic violence, scene not secure"). So this is where I would remind you to play nice.

And now that you've consciously reminded yourself to choke back that witty, sarcastic rejoinder that would have felt so fricken' good, I would suggest that you invoke the inherent usefulness of your partner in distracting the patient while you request a word with Officer Congeniality out of the ear shot of said patient. (If the reasoning behind this is unclear, refer to above point: play nice and make friends). There is nothing you want less than to embarrass an officer of the law who is wrong about...well, the law...in front of a patient. Calm and cool is the way to play this one, and hopefully you will get lucky and Officer Congeniality will see the error of his ways.

Should this not come to pass, you do have options. In our jurisdiction, medical command is always a viable option. Explain the situation, and most doctors will come back with a "Really?! Yes, you have permission to release the medically stable drunk man." On the off chance that your fail to get such a doctor with common sense, you may be told to transport regardless. In this case, put on your salesman hat and try for the transport one more time. If you fail yet again, go back to Medical Command and state your case. However, under no circumstances should you transport the patient without their consent. Even if the officer says that they will follow you to the hospital, that is going beyond your scope of practice and beyond his scope of the law. The officer, in order to properly invoke and ECO (emergency commitment order), MUST have legitimate proof that the individual is either a danger to himself or others without medical intervention.

So I've managed to muck things up for you and answer fewer questions than you thought I would, right? Well welcome to the world of refusals. Rarely is there an easy answer, and some of the most interesting ethical questions in EMS (I think) arise out of situations involving AMA and the art of the refusal, as well as the role of ECOs. So to pose a new question to you: has there been any questions or debates that have sprung up among you and your colleagues after a refusal or ECO?

Til next time, CW

Refusals and the Involuntary Commitment Dilemma

Refusal [ri-fyoo-zuhl]: one of the more complex decisions an EMS provider is faced with on a daily basis; a refusal of medical evaluation, treatment or transportation; a rejection of emergency medical services often made against medical advice.

Today, many EMS workers practice in a world where there is little flexibility in regards to a patient's ability to refuse medical care. We practice in a world where practically any call that does not result in patient transport is considered "against medical advice", regardless of the actual circumstances; we work in an environment where judgment calls about your patient's true needs could easily mean the revocation of your livelihood if your assessment of the situation is wrong. We also happen to work in a world where the resources that we have at our disposal are often abused by those who do not in fact need them, and used sparingly by individuals who could actually benefit from our services in the manner which they were intended to be used.

Given these circumstances, it's a hardly a surprise that refusals are the grounds for some of the most profound decisions an EMS worker makes. How do you navigate the presses of the patient's needs, your organization's protocol and the availability of resources when dealing with a patient who is attempting to refuse medical care--all without jeopardizing the patient's well-being and your scope of practice?

In my first due, the most common refusal situation that we come upon--that oft puts the provider between the patient, concerned family, neighbor, etc. and a hard place--are individuals who are intoxicated either in their own homes or in public, but aside from being intoxicated appear to have no medical complaint. I don't know about your local protocol, but in my protocol if an intoxicated patient is attempting to refuse care, they technically are in violation of one of the conditions for an AMA refusal. However, I am not allowed to people-nap just because they are drunk and the law enforcement personnel on scene is trying to get out of taking responsibility for the individual, or a family member insists that they go to the hospital. If the patient can prove competency, meet my alertness and orientation guidelines, has stable vitals, no mechanism of injury, no chief complaint, and are refusing my care or transportation, then I am bound to release them after informing them of the potential consequences of refusing care.

Situations like the one I just described are the ones that generally come back to bite you in the butt; however, we do have a few measures in place to help you CYA. In our jurisdiction, if there is a possibility for concern, yet a refusal of care, the crew that responded to the call can ask the duty officer to make a welfare check a few hours later. Also, it should go without saying that in this situation medical command can be your best friend. Provided you supply medical command with accurate and detailed information, the decision is really then out of your hands. Finally, documentation, documentation, documentation is a priority. As with any refusal, documentation that is thorough and accurate is essential. Laziness and refusals are never a good combination, and a refusal should never be seen as the easy way out.

But now comes the twist...you've been dispatched for an "unknown problem, man lying on bench" and you arrive on scene to a patient who has copious amounts of ETOH on board, and a policeman with a low tolerance level. It's 11:30 on a Friday night, and this officer's headache is only just beginning. You approach your patient, do some assessment and then offer to transport the patient if he would like to go, to the hospital. You make the offer because it's the patient's choice of whether or not it's an emergency, not yours, but ultimately he doesn't want to sober up. There doesn't appear to be anything medically wrong except for the fact that he's drunk--and he freely admits to it, bordering along the line of hubris. But drunk, at least to this officer, qualifies as a medical problem--the EMTs jurisdiction, not his (at least for tonight). So as you start going through your AMA checklist, Officer Congeniality butts in with the bomb: the threat of an involuntary commitment. So, I pose this: what's your next move?

I hope the first thing that you said was know your laws; if there is a law that impacts your scope of practice, know it. If there's a law about transporting a patient while restrained, know it. If there's a law about committing patients involuntarily to medical care, know it. One of the first things that they teach you in EMT class is that you play many different roles in dealing with your patient--one of them being the role of advocate. If you don't know your states', county's, city's, etc. laws, then you cannot appropriately advocate for your patient. For example: in the state of Virginia, a patient cannot be committed to the care of medical providers unless the two following conditions are met in conjunction with a demonstration of mental illness or compromised mental health: 1) the patient is a risk to themselves, or 2) the patient is a risk to others.

So assuming you know your laws, how do you proceed next? I'll pose my thoughts in an upcoming post. Ponder as you will until next time :)

A Bit of Background, Part 2

I essentially stumbled my way into EMS. The winter of my senior year of high school, I was bumbling through a job interview for the summer camp I had worked at the two previous years. I use the term "bumbling" because the camp director is quite possibly one of the most intimidating 6'7" giants I know, and I don't think my answers were ever more eloquent than "yes, sir" or "no, sir". So of course, when he asked me if I would like to take on the additional responsibility of becoming a trip leader for the camp sponsored hiking trips I was left with two options: "yes, sir" or "no, sir". Given that I happen to love hiking and the great outdoors, I went with the former. The director then proceeded to inform me that I was to come up to camp two weeks earlier than the majority of the other counselors and partake in a mandatory training class for this new part of my job; I was to become a Wilderness First Responder.

The reasoning behind this training made perfect sense; given that I would be venturing into a formidable mountain range with eight campers (who were for the most part under age 16), it would make sense for me to have a reasonable knowledge base of emergency medical skills and situations in a wilderness setting on the off chance that something actually went horribly wrong. SOLO Wilderness and Emergency Medicine School was the group that provided our training, and if you are ever looking for an extremely professional, knowledgeable and well run wilderness medical training class, I would highly recommend SOLO above all else (http://www.soloschools.com/). The WFR class is an 80 hour long class and provides an amazing foundational skill set for anybody who is an outdoors enthusiast or interested in pursuing an outdoors-recreational line of work.

Needless to say, I fell in love with my WFR class. I loved the content, I loved the practicals and I loved the sense of knowing that I could be useful in a crisis situation. The class didn't just teach you how to do medical things in the woods. It taught creativity; how to use what resources were available to you; how to manage under stress; how to interface book knowledge with practical application; how to work as a team; and how to be a leader. And luckily for me, all of these lessons came at a incredibly formative moment.

That fall I shipped out to university. University is this amazing opportunity for self-discovery, self-definition and finding direction. In all honesty, those were three areas in which I found myself greatly lacking upon arrival at the school of my choice. Sure, I knew what I kind of wanted to do with my life, but other than that I was S.O.L., to put it quaintly. Cut to gracious stumbling act, part two.

When I arrived at university, I found this amazing wilderness oriented rescue group that was a perfect fit for my interests. My savior complex was satisfied (*grin*), as was my love for the great outdoors, and I finally had a practical application once more for the knowledge I had accumulated during my WFR class. Less than a month into my membership of this group, I was presented with a new option for pursuing what was quickly becoming an evolving passion: EMT class.

Getting my EMT was the best thing that I have ever done. It opened up a whole new world to me that I quickly fell in love with. It was a brand new body of knowledge for me to explore and master, and once again social media played a really big role in my new found passion. In fact, social media only fueled my "sparkie-ness". I was (am?) insatiable, and attempted to get my hands on every POV and piece of information that I could that dealt in some way or another with EMS.

And now we come to today, where I am making my own attempt--minor though it may be--to make a contribution to this world that I have come to love so much, and that has welcomed me with open arms. This blog may be graceless at times, and my ideas or questions might be rough at best, but like the start of my career in EMS, I am not afraid to stumble.

The Life I've Chosen

About two years ago, I had that moment that most people can go a lifetime without feeling. It was that "So this is where my life has been heading all along..." moment--a moment of elated epiphany--that of course was followed by an overwhelming sense of "Oh sh*t. This is where my life is going. Now what am I going to do about it?"

How did I get to that moment, and what exactly was my realization, you ask? Well, let me introduce myself first and then we'll get to that.

My name is CW. I'm country girl at heart (read: reformed Yank), living in the great state of Virginia. I'm a university student working towards a bachelors degree in history and a masters degree in Secondary Education, and with all that oh-so-rare-and-spare free time that I have, I'm a volunteer EMT in a rural community just outside of where I go to school.

From the time I was old enough to have an opinion, I've shared it. From the time I was old enough to know what a goal was, I've had one. While the goal was always changing when I was younger (because god forbid a 7 year old actually have a set opinion on what she wants to do with her life), in recent years I've settled on wanting to shape America's future. I want to help people. I want to change a life.

Now you're probably thinking, "THIS is the goal that she settles on?! How on earth are wanting to save the world, and that pivotal epiphany she talked about one and the same?" Well, truthfully, it kind of just happened. And by kind of just happened, I mean one day I realized that everything I had ever truly been passionate about was related to affecting change and helping people. Go figure, that I found an outlet for that in becoming an educator and an EMS worker.

Education and EMS are a life I have chosen, and that I love. But in choosing two such fields, I have inevitably found myself being plagued with this impending sense of responsibility to humanity (read: this is my "Oh sh*t" moment). How do I ensure that my contribution to education and EMS are not solely for selfish purposes? How do I make what I do matter? How can I channel that enthusiasm that "sparkies" are so fondly known for into something productive and generative? And this blog became part of the answer to those questions.

When something takes over my interest I like to ask questions, I like to share my passion with others and I like to learn as much as possible about a given subject. Luckily for me, social media has taken a strong root in both EMS and education. I have found some great individuals and resources in both fields that have inspired my foray into EMS and education, and I have come to a point where would like to add my own knowledge, experience and questions to what is out there. I claim no expertise, no finality or even a semblance of brilliance in regards to my contributions; however, I hope that someone out there might find a morsel of meandering thought that is of value to them.

This blog is primarily about EMS and American education, but you can expect to learn a bit about me outside of those two realms of my life. As I said, this is the life I've chosen--in more ways than the two fields I see myself dedicating my life to. I've chosen the southern way (but darn if I give up fresh NE seafood and my Boston Red Sox), country livin', and the music to which I geek out. These will be making an appearance among my musings, and I hope you enjoy.