Annie

I've decided that since I can pretty much guarantee that this dog will be a feature in many of my future blog posts, she deserves her own introductory post.

So world, meet Annie!

This dog took my life and changed everything about it - and made a million parts of it even better than I ever could have imagined.

Annie is a rescue hound. For the first five years of her life, she was kenneled, mistreated, under socialized (with humans), and bred as often as she could be. She is one of the lucky ones - breaking that cycle of mistreatment that so many hounds are subjected to. The first day she was brought into a foster home was the first time she had been treated kindly. She was a girl with her tail tucked between her legs, not knowing what to expect of humans - yet resilient, in that she was willing to learn and try. To give people a chance to prove that there are kind people out there. It was slow work. But for every success, every time a human was gentle and kind, she was so grateful and was happy to try and make that act of kindness happen again.

She has come a long way from those first few days with her foster mom, and her first few weeks with me and the firefighter (read: significant other).

I have never laughed so hard, so often - loved so much and so openly - and been so humbled by the trust of another.

Annie is a special dog. She's got personality, energy, silliness, and a whole lot of love. So I'm sure there will be many a post to come about the things she teaches me (and quite a few funny stories accompanying those lessons along the way).

So know her, love her and watch us grow. It's been a fun adventure so far (see: her first bath below).

(Screw you, mom. If I have to get tied up and wet, so do you.)

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?

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.

Role Models

I've come to the conclusion that when the going gets tough, the tough find role models that can provide that extra bit of incentive and support to achieve one's goals--and then they get going. Recently, I've been feeling kind of overwhelmed by life, particularly by the demands that my academic pursuits have been making on my time.

For those of you who have been around since the beginning, the fact that I am simultaneously pursuing both an undergraduate and graduate degree comes as no surprise. For those of you that know me personally, the fact that I am on an accelerated track for both degrees is also not new information. For anyone with a bit of common sense, the fact that I am struggling and under some pretty intense stress should not blow you out of the water.

As a result of this academic (and many-other-factors induced overload), I've been floundering a bit. For most of my life, I have been largely intrinsically motivated. I choose to do and pursue things that I am passionate about because accomplishing those acts makes ME happy. There was a substantial period in my life where I struggled with the lose-lose reality of pursuing not-quite-passions because I believed that they would make other people happy, and thereby make me happy; it turns out my theory was horribly wrong in that regard.

And I'll be honest: history and teaching do make me happy. In fact, they are two of the things in my life that I am most passionate about (if there is confusion on this point, I refer you to why I started the blog in the first place...); however, lately I've realized that my personal fulfillment in the pursuit of an undergraduate and graduate degree is hardly cutting it anymore. I feel as if sometimes my workload is isolating me from the relationships that will make my eventual achievement of these goals enjoyable. Sometimes I feel like Hermione Granger.

No...I'm not kidding. If you want a better understanding of why I identify with a fictional character, read this; maybe then you'll understand. To me, Hermione Granger is an inspiration of sorts; the girl who didn't let anything get in the way of her voracious academic pursuits; the girl who wasn't afraid to fight for her dreams and what she believed in; the girl who valued her friendships above all else; the girl that I grew up idolizing. Yes, Hermione Granger has been and always will be a role model to me as a still-trying-to-find-my-way, at times graceless, yet well intention-ed young adult. With some of the stuff that I have been dealing with in the past few months, having a role model like Hermione has provided me with a model of how to keep on in the face of adversity and challenge.

That's not to say that all of my role models exist in the fictional realm. I am so unbelievably blessed to have an extraordinarily high number of impressive and commendable individuals in my life after whom I can model my own actions and choices, as well as rely on for support. And since my life has kicked into high gear recently, that support has been indispensable. So I would like to say a thank you to a few people whom have remained steadfast in their support, compassion, love and inspiration in recent months. Your companionship and dignity with which you live your lives continues to amaze me, and makes everything that I am working towards that much richer.

To my mom: I love you and you are truly one of the strongest women and supporters that I know. I don't know where I would be without you in my life.

To my adopted grandfather and mentor: your kindness helped a very lost little girl find her voice and her way, and I look up to you in more ways than you will ever know. Thank you for taking this fellow Yank under your wing, and teaching by example that a little bit of compassion, humility, laughter and common sense can take you far in this world.

To my beautiful cousins and sister: each of you have inspired me in unique and varied ways to try and be the best person that I can be. Each of you are veritable fonts of strength, grace, compassion and fun, and I am constantly amazed and humbled by the women you have turned out to be.

To the three musketeers: it always comes back to you. You are the rocks at the center of everything I do, and I know that we can face anything together and come out stronger for it.

To the family that I have chosen: friendship does not even begin to cover what I have with each and every one of you. Celebrating life's little moments and pleasures with you, whether it is a rich cup of coffee, or one another's triumphs and achievements, has left an indelible print on my heart.

It is with and because of each of you that the stress becomes manageable and the rewards become richer and the memories become stronger. You are the true role models that are helping me get through the overwhelming stress that enable me to keep my head in the game, channel my inner Hermione Granger, and face each challenge head on with no fear and the sweet taste of satisfaction. Thank you, and I love all of you.