Dear Stupendous Students 2,

Typos, much? Oh, well it still works! This
little Information Gatherer is whipped out
by the driver on almost every call. 

Hi! Welcome to my official guide to Being a Stupendous Student, Part 2. In the first installment you followed my 10 step program for getting off on the right foot. Part 2 is going to get you on both feet, and keep you there! Being a paramedic student is one of the most stressful, awkward, and invigorating stints of your career in Paramedicine! I want to help relieve some of the tension and uneasiness, and nurture more of the fun and learning with my tried and true tips for the ideal learning environment for Paramedic Students. And I’m not above admitting: The more my students learn, the more I learn. The learning environment is a teaching platform for the learner and teacher as well, and I teach while I learn and learn while I teach.  That wasn’t confusing! Learn it. Then teach it :)

The first thing I see students get tripped up on is going on a simple call. I don’t think it’s because they don’t know how to go on a call, or because they lack the training necessary to successfully accomplish a patient encounter.  I think it’s because they don’t know what’s expected of them, they’re nervous/intimidated, and possibly haven’t had much experience in the 911 response environment. At New Bedford EMS ambulances are staffed with 2 Paramedics who rotate calls and follow a predictable routine for information gathering and patient assessment. With the exception of a severely critical patient or utter chaos, the driver will always start gathering and recording information, checking meds, and interviewing family members/bystanders. The passenger, who will be the tech and document for this event, will begin hands on patient assessment including managing resources, initiating treatments, and developing a working diagnosis. 

Let’s break a relatively simple medical call down into its various parts, and focus only on the pieces the student can manage.  You’re dispatched for a 54 year old male with back pain. Inside the residence you observe a middle aged man sitting upright in a chair, speaking with firefighters and police in no apparent distress, with no obvious trauma noted. At this point some preceptors like to swivel to the intern and sneer, “so whaddya gonna do, Paramedic?” I’m not a fan of this style, and I don’t agree that with an audience of other emergency personnel, family members, or random bystanders, this is the time or place for such a challenge. I prefer to see a student approach the patient respectfully, introduce themselves, and start the survey with open-ended questions while obtaining a baseline set of vitals! *GASP* Real interventional stuff, here! Shouldn’t she be telling me to start an I.V.? I am a PARAMEDIC student, aren’t I? Yes, but we’ll get to that. First I want to see you develop a rapport with the patient, begin a verbal survey of the complaint, and check a blood pressure with a stethoscope! Don’t palp your first pressure. It’s just not acceptable. 

The male is c/o dull lower back pain radiating to L flank, sudden onset at rest about 30 minutes ago. He reports a recent history of dysuria, malodorous urine, and progressing fatigue over the last 4 days, denies recent trauma and all other c/o distress at this time. He confirms past medical history of kidney stones, but states that pain was abdominal and much more intense. He is alert and oriented x4, eupneic with clear, equal bilateral lung sounds, skin is hot to the touch, dry, and intact with a bounding pulse rate of 120, and normotensive. Ok, so we’ve developed a good rapport with our patient who consents to transport to definitive care, and we’re working with tentative diagnoses of UTI vs. kidney infection vs. kidney stone. Time to start the I.V. right? Not yet. While you were performing your ultra fancy BLS skills, you had time to gather your thoughts and reflect on some of the drivel I was babbling about when you first started your student internship 2 hours ago. I was saying how patient assessment and information assimilation are underused, underemphasized skills because they don’t require any wrenching open packages, snazzy cap popping, or firing up the IO drill. On an emergency call, especially when there are concerned family members, or first responders that arrived prior to EMS, it is easy to become overwhelmed with the amount of information 5 people are providing at once. The ability to sift and assimilate these details is an important part of any and every patient encounter, but because this talent is so underwhelming few people give it a second-or even a first-thought. 

Elated with the success of your first call as a semi-ALS provider so far, you reach for the  monitor and prepare both limb and 12 leads for an EKG. Seconds after you acquire, the male clutches his chest with one hand, and covers his mouth with the other. Sinus tachycardia without ectopy is noted on the monitor, the 12 lead is unremarkable, and o2 sats are 99%. Nausea and vomiting clear emesis is observed, and the back/flank pain has worsened to 10/10 scale and is now radiating to the abdomen. ABD is soft and tender to touch on the lateral L quadrants. CSMx4 without deficit, deformity, or edema. Your suspicion of renal calculi has increased, and when you look up to confirm with your preceptor you find the stair chair assembled, and your EMS team packing up the equipment. It’s finally time to start that I.V. and practice all of your other ultra nifty ALS skills in the ambulance. The motivated student will also use this opportunity to practice calling in ALS notes over C-med, and prepare to give an expounded verbal report to MD/Nursing staff. En route you reassess, manage your interventions, and especially be calm and comfortable toward the patient. This whole scenario sounds eerily familiar doesn’t it? Almost like applying the exact steps for patient assessment in almost any medical text..

Something I want to stress to students is don’t buy into the hype and false counsel of “when you become a Paramedic, forget everything you learned in the book and see how real medics work in the field.” While I agree that making the transition from classroom training to applying knowledge hands on in actual emergency situations takes a bit of mindset and motor skill tweaking, by no means forget what you learned in the text! If you didn’t learn in the classroom first, you wouldn’t even have any knowledge to “forget”! Don’t let an arrogant, egotistical, or ignorant experienced clinician mislead you with this unsophisticated attitude. 

Some of this advice is specific to the department I work at and our procedures. The simple act of grabbing a set of vitals while you’re taking a mental step back and assimilating information you’re both observing and being told will convey to your independent practice as well. However, do not misunderstand: There are situations when a leisurely set of vitals must defer to treating the life threats. But, you already know that, of course! You’re more than well on your way to being Stupendous! So, to summarize the fail proof steps a medic student can take on their first call (s) with their preceptors: 

1. Greet the patient, and introduce yourself. 
2. MAKE EYE CONTACT!
3. Ask “How are you feeling/How can we help you today?” or offer “We can help you with that/We’re going to take care of you.”
4. Obtain a baseline set of vitals WITH A STETHOSCOPE.
5. Here’s a fabulous pearl of wisdom: While the scope is still in your ears, move it right over the lung fields...even on a patient in no resp distress. Get used to listening to all lung sounds: normal and adventitious, before and after treatments, when there is a respiratory complaint and when there isn’t. 
6. PALPATE pulses, don’t get complacent with fancy pulse oximetry (though certainly use it liberally). 
7. Information Scaffolds: it is established in layers like the construction of a good club sandwich. Make a conscious effort to train your mind to assimilate details of the patient assessment, call environment, and what is being said to and around you. 
8. Learn how to enter age, gender and other data before acquiring a 12 lead. It’s important to set it accurately for each patient, and it would be unwise to learn during the acute chest pain call. 
9. Don’t wait for someone to ask “What do you want to do?” Even a student can lead by example! (see #1-6 :)
10. BLS before ALS: You've heard this old adage a hundred times! Here's my take on it: BLS finds the problem, ALS fixes the problem! Keep that in mind when you suddenly have the I.V. started before you've acquired a basic set of vitals. If you don't train yourself to BLS find before you ALS fix, you WILL miss something. And it probably won't be pretty...                                                                                                                                                                                                         
11. BONUS ADVICE: In times of sheer panic or boredom, quell anxiety by thinking of or writing down the next recipe you plan on submitting to ParamedicCooks.com! 

Dear Stupendous Students 1,

To all the Interns..

So you want to be a Paramedic? Here’s a funny story: One of my favorite partners in the world, EMT-Paramedic Dave Gordon and I went to a call for a male possibly overdosed. We had a student that day. Also on scene were a few Police Officers and Firefighters. It is worth noting that the ambulance had to double park against a row of cars in front of the residence, then enter up several stairs and across a very long porch to the front door. The front door also happens to be situated poorly in the architecture of this residence, and has to be fully closed for admittance behind it, and up the stairs, down another long hallway where a male was scattered across his bed. The male, for reasons solely the responsibility of prescribed medications and ETOH, was shall we say, less than cooperative. Because of his state of altered mental status and other circumstances EMS determined it necessary the male seek medical attention at a definitive care facility. However, because of his altered state, the male determined any intervention into his current condition would not go unchallenged. 

The next 15 minutes proceeded thusly: 2 Paramedics, 1 Paramedic Student, 3-4 Police Officers, and a sprinkling of Firefighters wrestling one raging, belligerent, and ruggedly strong male out of the bedroom, down the long hallway, down a flight of carpeted stairs, past the front door to get it open, then through the door, down the long porch and wooden outdoor stairs, across the row of cars and onto the ambulance stretcher where he finally, blessedly began to calm down. It took that many of us only to ensure we did no harm to the innards of the residence, or to the male himself. The ungraceful shuffle through the indoors and out, with hands fluttering, hair whipping, elbows flapping, spittle flying, backs flattening up against the wall then peeling themselves off to dive back into what resembled the dusty tumbleweed of the Tasmanian Devil’s approach, was a visual commodity I will never be able to un-see! By the time Dave, the student, and I collapsed on the vinyl covered bench seat of the ambulance we were sweating, panting, and looking like the three finalists of an IronmanTriathlon. It was then that Dave asked the funniest question in history: He propped elbows up on his knees, and chin up on his hands, looked at the student and asked poignantly, “So you want to be a Paramedic?” LOL!

Field Internship on the ambulance with experienced Paramedics is necessary for every student to pass into practicing Paramedicine. To lessen the pain for both the students and the preceptors, here’s my official guide to Being a Stupendous Student: Let’s begin with before you begin: 

1. Be on Time! Duh, right? No. Be on Time! Don’t know where Medic 2 is located? Find out before you ever think about traveling there and Be on Time! Not sure what traffic is like because you live an hour away? Google it, take a test drive, ask your instructor...whatever it takes to Be on Time! Not only does it reflect heinously on your professionalism, we often get called out 30 seconds or less after reporting for duty so Be on Time OR (see #5 for what might happen if you’re not!) Oh, and by the way folks, Be on Time!!!! 
2. Your uniform should be: clean and free of fading, staining, and holes. It should absolutely represent your school, college, or training center where you received your PARAMEDIC training!  NOT your department, volunteer squad, or favorite beer. 
3. Your paperwork should be in a neat binder, or folder that is easily portable. When it is time for signatures, present it in an organized fashion, already completed with times, dates, and patient care reports written. Not only does the department refuse to pay employees overtime to sit there and redundantly sign off on skills, the employee is not too keen on sitting there and doing it for free! Follow the pattern of the crew you’re riding with: when they document you document, while one crew member is waiting for the other to finish documentation, get that crew member to sign the skills you did with them, etc. 
4. Pack your lunch and snacks. Be prepared to run back to back calls. We may or may not be able to take you to the store for lunch or snacks. The hospital may not be offering your preferred vittles. Set yourself up for success by having food and drinks handy, especially on long shifts where we may run 10 or more calls. 
5. Bring reading materials, study/field guides, or other small items for your personal entertainment. This is not because we are mutes and want to ignore our students, we all love to get our gab on. But if we are 2 or 3 calls deep and have alot of documentation or organization to do, it’s best if you’re not fidgeting around or worse, wandered away somewhere when we get another call. If that does happen, let me apologize in advance: you will get left at the hospital or EMS station! Students are important, but patients come first. Stay with your preceptors!

So, you were on time (yay), you’re wearing appropriate apparel, your paperwork binder is ready to roll, and you have a book, lunch bag, and already introduced yourself to the offgoing and oncoming crew. I like you already! So, what to do now that you’re here...

See #4 :)

1. See that comfortable chair over there? DO NOT sit in it! Help the crew with whatever they’re doing: cleaning quarters, rotating the AutoPulse battery, organizing the stock cabinet. If you’re not assigned a task, offer or inquire where your help might be needed. Even though you’re not getting paid (we’ve all been there, done that...yawn), it’s never ok to watch your preceptors hoof it while you chillax! Within reason, of course! Don’t let anyone make you clean their P.O.V’s, or knit their grandmother a pretty new scarf, or install the latest whacker lightbar on their souped up ride...not saying I’ve seen it attempted...just saying! :)
2. The ambulance is your office. Step into your office and acquaint and acclimate yourself to the environment. Most EMS situations are dynamic, and the inside of the ambulance is no exception. It may look like a purdy little hospital-on-wheels-now but throw one acute patient back there and watch it transformed into a frenetic, mobile snow globe, raining 2x2’s. Make every effort, while you’re helping the crew check off and restock the truck, to know where everything is, including the first-in bag, advanced airway and O2, I.V. therapies, CPAP, spinal immobilization, auto pulse, pediatric/broselow supplies...and pretty much any and everything else that is on the ambulance! 
3. Be courteous and respectful to us, our equipment, and especially our patients! If you feel you are being mistreated or are uncomfortable around a patient, back off and explain later, or go ride up front with the driver. Under no circumstances will disrespectful, unethical, immoral...or any other kind of inappropriate behavior be tolerated. If you have judgements, criticisms, or snarky comments to make about the personal choices or lifestyles of the patient, keep them to yourself or speak to us privately AFTER the call. If you feel like posting personal details about your experiences with us on Facebook or prattling to your friends, DON’T. You will be sent home from the shift, and unwelcome to come back and finish ride time. I have a zero tolerance policy for any molecule of perceived or actual mistreatment of a patient. Be nice!
4. Restoring the ambulance to its ready-for-a-call splendor after a bad trauma or cardiac arrest is a time consuming task, usually the responsibility of the driver on that particular call. You will find yourself with more BFF’s than you can handle if you’re out there helping that medic clean the bloody equipment, disinfect the stretcher, and replace the I.V. start kits from the first-in bag. Know where the garbage is, and empty it. Know where the documentation computers go, and plug them back in. Know where the long boards are kept at the hospital, and replace them. Keep yourself in the mix at all times! Learn how to use the C-med radio, and call in a few med reports over the air. Not only will you learn more by doing, you’ll be helping and gaining the respect of your preceptors, patients, and interactions with hospital staff.
5. This goes without saying, but be knowledgeable! It’s perfectly ok to carry and use your resources...that’s what field guides are made for! If you freeze up and forget the mcg/min for an epi drip, I expect you to have the resources available to look it up.  I always have mine, and even when I’ve been a medic for 20 years I will still carry my resources around. It’s naive to think you will ever know, or ever remember it all. Now, if you forget how to apply a non-rebreather...well, that might be a different blog. ☺

Being a Paramedic Intern is an exciting and stressful time! Remember that every Paramedic preceptor you have has been in the same exact situation! Follow these 10 steps and I promise you’ll be starting off on the right boot. Tune in next Tuesday to my expanding blog for more information on How to be a Stupendous Student. Next week will feature my advice on how to act on a call, and the importance of good assessment. The week after, Stupendous Student 3 will feature every students favorite subjects: starting I.V.’s and “getting your tube.” See you on the ambulance :)

Snowmobile Part 3

Frankie, on her perch :)

Driving a snowmobile doesn’t seem like that difficult of a task. They look similar to a jet ski with about 4 feet of snow skis jutting out from the front, and a continuous rubber track in the back. A driver has to do no more than hop on, insert the key, pull up the kill switch, push the electric start button or pull the starter cord, and depress the throttle to go. Easy, huh? A child could, and does, do it! If all trails were in a perfect straight line with no twisty turns, slopes, or uneven terrain a person could probably drive with their eyes closed. What a yawn that would be!

Because I crashed twice last year, scared my daughter, and busted up my sled a bit it occurred to me I might be doing something wrong, or at least not doing it as right as possible. Tipping over while speeding around a sharp corner is expected, and people get tossed from their sleds like rag dolls often so it’s not uncommon to have a few crash survival stories under your belt. Unfortunately, my second crash was scary, and expensive to fix. So on my last snowmobiling escapade, I paid careful attention to what I was doing, and why. I also did some internet research, but that didn’t yield much more than the basics such as Put on a Helmet, Have a Snowmobile with Key, Give the Motor some Gas, Use Handlebars to Steer, etc. Yawn.

The main thing I have trouble with is the throttle lever. It’s a thumb throttle mounted just below the right handlebar, so four fingers wrap around the handle for maneuvering and the thumb controls the gas. I don’t think I have freakishly small or girly hands, but my hand has to stay stretched open to be able to hold on and push the throttle, and it gets cramped and fatigued. Plus, I just don’t feel like I have proper control of the vehicle because my right hand can’t grip the handlebar entirely. That’s how I crashed twice last year. When I really needed all of my strength to control the sled, my thumb unintentionally fully engaged the throttle in my attempt to grip the handlebars, giving the sled maximum power and catapulting it out from under me. The best way I found to address this problem is...<don’t laugh>...to chant “Get in a jam, thumb off the throttle, thumb off the throttle,” (repeat obsessively). Ha! I know it’s hardly NASA quality technical advice, but it’s what works for me. There is a throttle extender that can be purchased, but it’s not really the length of the lever that gets me, it’s the orientation of it to the handlebar. I’ve also heard of changing the whole thing to a twist throttle, but firstly I’d lose my heated hand warmer, and lastly I think that would probably be worse, especially going down a hill when alot of forward pressure is placed on the handlebars for controlling and staying on the machine. I imagine a tight and hasty grip on a twist throttle might also accidentally engage it wide open. Also, I doubt “Get in a Jam, don’t twist the throttle” would work since my hand still has to be on the handlebar. So, for now “thumb off the throttle,” is my catchy tune for safety and to prevent Frankie and I from being hurled ungraciously through the air, again. ☺

Another thing I realized I wasn’t doing is engaging my leg muscles enough. Sitting astride a snowmobile for countless hours can get fatiguing. It’s important to remind your legs to stay alert, and hugged up to the machine, not flopping about like a fish’s leg out of water! The same rules applies to the abdominal area, or your “core.” Keep those muscles occupied for better posture and therefore better maneuverability of the sled and a less aching back. When you keep the core muscles flexed and your back straight, your arms are in better relation to the handlebars. Plus, I like to think of it as getting in my exercise: Sled Pilates! I also experimented with different sitting positions. The snowmobile is designed with foot stirrups on each side, a covered retreat for the feet carved into body of the sled useful for keeping feet warm and out of the wind, snow, or rain, and for leverage around corners. Previously I almost always sat with my feet in the stirrups, but I learned that I am also comfortable sitting with my legs at a 90 or a 45 degree angle, and I feel way more in control of the snowmobile that way. 

Taking corners is the trickiest, and most dangerous part of the journey for me. Partly because I always have my daughter riding behind me on our 2 seater snowmobile. She’s learning to lean into the corners with me, but it’s a work in progress since she can’t always see the turns coming, and might be gazing off at some majestic foliage and not paying attention to my body movements. She has a comfortable perch with a back rest and heated hand warmers, and she loves to be in charge of Snowmobile hand etiquette. Because sledders always ride in a single file line, and some are faster than others, or the trail is twisty and visibility is poor, it’s not always possible to see how many sleds are in the oncoming group. It’s an expected courtesy to use a hand signal to display the number of sleds behind you as you pass approaching riders on two-way trails. Because my daughter and I are slower than riders with only one person on their sled, we usually have 1 or 2 people behind us, so she holds up 1 or 2 fingers. If the lead person has more than 5 riders behind him, he can show 5 fingers, then the person behind him will show 5 and so on, until the 5th person from the end will hold up 4, the next person will hold up 3, then 2, then 1. The last person will hold up a closed fist, palm forward, to signify they are the last in procession. 

Corners are probably the trickiest parts of a trail to navigate. Oftentimes, my sled goes up on one ski when I’m twisting around a sharp curve. I always thought angling my body toward the levitated ski was the best way to correct it, and land myself back on both skis. On our last trip, I learned from another rider tapping the brake is also an effective maneuver. I didn’t get a chance to try that out, but I can’t wait for our next trip to put it to use! 

Here’s a numbered list of my top How to Drive a Snowmobile Tips:

Helmet Heads :)

1. Be aware of all of your muscles. Especially, keep your legs and core engaged. 
2. Have a helmet with a heated shield. If you can’t see properly, you can’t drive properly. 
3. When navigating downhill or around corners or other places that are difficult, remind yourself to take your thumb away from the throttle and wrap it around the handlebar grips.
4. If your sled goes up on one ski, shift your weight toward the levitated ski, or tap the hand break.
5. Experiment with your legs in different seated or reclined positions.
6. Be alert, but relaxed. Too much tension in your arms, hands, and legs is fatiguing and no fun.
7. Teach your rider, if you have one, how to follow your body movements and use hand signals. 
8. ALWAYS use hand signals to alert oncoming riders of how many sleds are behind you.
9. Pay close attention to the sled in front of and behind you. If you see the sled in front use hand signals, you’ll know there’s oncoming sleds. Keep tabs on the rider behind you in case anything happens. It’s better to know sooner than later if they crash or break down. It’s not hard to freeze to death in 20 below weather. 
10. Don’t be too nervous. Riding at night or in low visibility can be scary, as can sharp turns or uneven terrain. Make sure you’re not tensing all of your muscles or gripping the handlebars to too tightly. Relax, and go with the trail. It will lead you to places you never dreamed of! ♥

Snowmobiling Part 2

Snowmobile trails stretch for miles across flat land, around and up mountains, even across major highways. Sometimes they’re a wide open field, and sometimes just narrow enough to squeeze a sled through. The most beautiful trails are encased in crystallized snow, canopied by branches that cuddle each other in a snowy embrace, sometimes huddled so close to the ground snowmobilers have to stoop down to pass through these frosty tunnels. 

We usually embark on our sledding journey around 10 AM and sometimes don’t return until 7 PM! We stop for lunch, and fuel, and I always squeeze in as much shopping as I can fit into the little trunk of my Ski-doo. Sometimes we stop miles and miles into a mountain trail where it is several degrees below zero, for a rest or to take in the incredible sights. Last year, we stopped right in the middle of a trail to let an enormous Moose cross from one side of the frosty forest to the other, through about 4 feet of snow. On a smooth trail, the ride can become hypnotic. Peering out through the angled rectangle of a helmet windshield, keeping a keen eye on navigating the trail and watching the white forest fly by in peripheral vision is a little like being on a roller coaster, without the nauseating corkscrew inversions. My mind invariably wanders to the possible and potential injuries that could be sustained from a crash, frostbite, or becoming entrapped in the snow, or under a snowmobile. Of course I don’t carry any medical supplies with me so I catalog what little resources I have, and how I could put them to use for treatment, rescue, or extrication. Pretty morbid and lame way to spend a day vacationing, huh?! I guess it’s the Paramedic in me, always crouched and alert, expecting the unexpected. :)

Last year, I had to depend on the extrication and rescue abilities of my fellow riders when I crashed insanely, was ejected off my sled, and entrapped underneath a fallen tree with the added 500lbs. of my snowmobile on top of me. I was coming around a hairpin curve, not going very fast but an oncoming rider was flying and losing control of his machine. To avoid a head on collision, I swerved and intended to plant myself in a shallow ditch on the side of the trail. The force of my grip on the handlebars caused me to depress the thumb throttle wide open, and the sled rocketed into the air like a bullet, tossing both my daughter and I into the chill air. She landed in a fluffy pile of snow, buffered by many hefty layers of winter gear, unharmed. I slid on my back for several feet, finally wedging my body under the thick trunk of a fallen tree, and the airborne snowmobile landed on top of the tree and I. While I was gliding ungracefully over the snow, the ski mask under my helmet shifted to cover my eyes and mouth, rendering me blind and suffocating me. The weight of the snowmobile over the tree trunk across my torso compressed my chest enough that I could barely take in a breath anyway. Believe it or not, I wasn’t hurt at all but I couldn’t move or see, and I could hear my daughter screaming and my father calling my name. Probably the scariest part of the whole thing was not knowing if my daughter was screaming out of fear, or if she was hurt. In a matter of seconds I felt some of the pressure on my chest relieved, then hands grasp my pant legs and drag me out from under my wooden captor. When my vision and vertical alignment with the earth was restored, I could see that my daughter was uninjured but terrified, and I had busted the windshield, mirror, and hood of my snowmobile, and bent the ski. 

Our 2 youngest riders, Frankie and Logan

My dear, sweet little snowmobile forgave me for bashing her up a bit, and my beautiful, plucky daughter didn’t lose all faith in my maneuvering abilities, though she was quite nervous for awhile. She persevered, as did my sled and I, and we have seen many trails since my unfortunate Evil Kanevil stunt! Because of that, and one other crash I have done a fair amount of research and technique-gathering on how to handle a snowmobile. Most of it is from my own girlish observations on how to maneuver my sled around, with consideration toward the fact I always have a rider. Tune in next week, for what is now becoming my 3 part Snowmobile Blog to read about my advice on operating a 2 up (two-man) sled! Happy (snowmobile) Trails! :)