I've had a couple of weeks now to reflect upon the completion of the EMT course, and my successful certification by the state of New Jersey. I want to again thank my wife and son for their patience with me, and to everyone that offered their support and well wishes.

The experience was both easier and more challenging than I had expected. In all honesty, the course material wasn't particularly difficult to understand, even with the use of medical terminology sprinkled throughout. The hands-on and practical skills weren't particularly difficult either, whether it was applying trauma bandages, inserting airways, performing CPR, or just moving and lifting patients.

On the other hand, I was challenged to overcome an initial desire to simply 'help' a patient with what appeared to be an immediate discomfort or pain, and rather to slow down and assess the entire situation, looking for those more hidden issues that actually posed a greater life risk. It took a bit of time for me to not just understand the importance of this, but to actually internalize it to the point that it became natural to slow down rather than speed up in times of crisis.

Not that I was always perfect at it.

While the class and state test may be behind me, my journey has only begun. The last few months have been but the first step, and in order to re-certify in 3 years time (under NJ State rules), I will have to complete a number of additional optional and core Continuing Education Units (CEUs).

In fact, my first optional CEU class will be later this month, as I plan to attend an "EMS For Fire Scene Support" course (aka "Fire Rehab"), in order to have a better understanding and readiness when the Mendham First Aid Squad is called to support our local fire departments at the scene of a structure or other fire. 

While the EMT class covered the basics of care for burns, this additional course will cover operational and organization details, including how to assess and evaluate fire personnel who may have been battling the blaze and are in need of rest and recovery, before they can be released back to duty to continue their own activities. I'll be back in a couple of weeks to talk about that course, and perhaps share details later this summer when I help support the Mendham Fire Departments' own training activities, putting this new knowledge in to action.

Man, it feels really good to finally write this blog entry.

And terrified that it's going to be twice as challenging. So send your good wishes my way... I'll take all I can get. ..

EMS is not a solo sport. Sure, there will be times when an EMT may be the first to arrive at a scene, or the first person to greet and engage a patient. And yes, in some cases, you may be miles from help and relying solely upon your own skills to provide aid to someone else.

But under normal circumstances, we operate as a team in our squad calls, with each member of the team reliant upon the others to ensure that we are collectively doing the best things we can, whether deciding on how to move a patient, gathering background and history while someone else is collecting vitals, anticipating the need for additional equipment or paramedic support before someone else makes a specific request, or ensuring that we disconnect an oxygen line from our main tank to a portable one before we move a patient from the ambulance to the hospital door.

My failure today caused the students that were part of my team to similarly fail the testing station. As a result, we were remediated as a team, with one of our instructors walking us back through the scenario and giving us a chance to revisit, reconsider, and make corrections to our actions and activities.

I've been feeling guilty and angry about this ever since, since it was pure ego on my own part that drove much of this. Feeling perhaps a bit too cocky from my other successes, I forgot one of the most basic lessons and made a critical assumption that my index of suspicion, pointing to a specific issue, was undoubtedly correct.

As a result, while I recognized that the potential for a critical life threat existed, I didn't connect-the-dots with other pieces of information gathered by my team members during our individual assessment activities, and therefore under-estimated the level of risk our patient was actually in, putting their life closer to the edge (in a pretend scenario, of course).

The positive outcome was that, as a team, we were still providing proper treatments. The ommission, however, was that we didn't do it as aggressively as was warranted, which could have resulted in significant complications at a later point in time.

I goofed. I developed the dreaded tunnel-vision we were warned could happen, and while neither of my team members stopped me to suggest a full review of what we knew (signs, symptoms, vitals, history) or what other conditions could result in those results, I still feel like I let the team down.

My ego certainly took a beating today, because I should (and do) know better. I simply got complacent, and wanted to complete this final activity and bring closure to the final practical exams, because the scenario we were presented with seemed, on the surface, like a no-brainer situation.

I guess this is what being an EMT is like -- having to keep your ego in check, and make sure your opening your mind to considering all possible reasons that a patient can present symptoms, even when the answer seems almost crystal clear from the start.

It's now a lesson I won't be forgetting anytime soon.

We've one final written quiz to complete, and then we'll be able to schedule for the NJ State Certification exam or the national test. So if you'll excuse me, I've got a whole book to review, and practice quizzes to do,

The bad news, unfortunately, is that all these scenarios represent real-life situations that various instructors have personally faced. As one told us, "After 25 years as an EMT, I still learn something new on just about every call."

As an EMT, one has to be comfortable with the concept of death and dying. The five stages of grief (anger, denial, bargaining, depression, and acceptance) are introduced early in the classwork, and throughout the course we touch on the medico-legal aspects of DNRs and Advanced Directives, as well as the more challenging emotional aspects of palliative care and how to respond and comfort family members affected by the death of a loved one.

Even the after-effects on ourselves as EMTs is touched upon, because while we are (hopefully) going to focus at the task at hand in providing care, the post-traumatic stress is something we individually have to work through as well.

I can directly relate to this, as I recently learned that one of the patients I encountered during my clinical rotation with our paramedic unit, a 7 year old child, succumbed to his illness later that day. As a father with a son of near this age, the death of this near-stranger hit me a surprising amount. 

So we keep trying to drill on signs and symptoms, focusing our 'index of suspicion' skills on possible underlying causes for injuries and illnesses, and learning to treat the symptoms before us while anticipating the worst of what might come, all the while hoping that we've not missed a critical piece of our assessment that will have the world come crashing down around us.

As I wrote earlier, we're not studying to pass the test, we're studying for those moments where we are the only thing standing between the patient and the grave.

As one instructor put it to me after one particularly challenging scenario: "Death one hundred twenty six, EMTs... zero."

I saw the picture above the other week, and it has stuck with me....

While the EMT course can be a lot of work, my push to excel is driven from within. Coursework and certification alone won't make me a good EMT.

What will make me a good EMT is never settling for giving my patients anything less than my very best efforts.


[Thanks to @insomiacMedic for the image]

Needless to say, this has made for some humorous practical skill sessions,mostly involving EMT students trying not to laugh as their peer is arm deep in the abdomen of the mother (delivery) mannequin, trying to emulate the birth process by pushing the baby mannequin out (with appropriate grunting sounds made entirely by accident in most cases).

Actually, this whole course has been a series of cycles, where basic human anatomy and EMT assessment skills are introduced, and then reviewed and re-introduced with deeper levels of understanding in terms of how to care for both medical and trauma-based emergencies.

So it seems fitting that we once again revisit how our patients come in to this world, grow and age, and leave us as well. Pediatric patients, from newborns to toddlers, school age kids to adolescents, all present differently when experiencing physical, emotional, or psychological crises that often require EMS intervention. Some of this is due to cognitive differences, while others are purely physical ones.

Similarly, our older adult and geriatric communities present their own challenges, in terms of age-related diseases and normal sensory and musculo-skeletal changes that take place as we grow older.

As a result, we are now learning to focus on the different "new normals" for vital signs and patient care that come when dealing with both our older and younger patient populations, in order to hone our 'index of suspicion" skills and ensure that we are providing appropriate care that "does no further harm." Geriatric patients can present specific challenges with lifting & moving, such as the potential to cause injuries in patients with osteoporosis. Similarly, assessment of infants and children is often performed in a slightly different way, due to their limited developmental capacity to directly answer questions that are often better answered by parents or caregivers.

So we keep going 'round and 'round in our practical exercises, being pushed to keep an open mind while at the same time learning how to prioritize the critical life-threatening elements of the situation as we perceive them at any specific point in time. The situations and scenarios are a bit more real-life now, and as students, we're starting to see our instructors crank up the stress levels a bit for us to complete tasks within allotted timeframes, much like we often have to move with urgency in the field.

We were dispatched to a local resident for a fall.  Upon arrival, we found our patient sitting up, alert and communicating to us. Their friend indicated to me that our patient didn't exactly fall, but rather slowly slid to the ground and hit their emergency alert button (the "Help, I've fallen and can't get up" kind) before they (the friend) was able to help our patient back to their feet.

Normally, with no loss of consciousness, a soft landing on carpet from a standing position, and no other reported aches or pains, our patient could be well within their legal rights to decline further care (what we term an RMA - Refused Medical Attention). It was only when helping our patient remove their sweater so they could get more comfortable, did we noticed a laceration on their arm, one that required bandaging and possibly more care.

The EMT course teaches us that we have options as to whether to conduct a focused or detailed exam of our patients, based on the signs and symptoms being presented. In this case, the age of our patient (elderly) and their overall physical condition (i.e. paper-thin skin) contributed to a secondary injury that could have easily gone unnoticed if we had gotten overly focused on the (lack of) signs and symptoms for neck and back pain (along with loss of consciousness) typically associated with a fall.

And this actually brings me around to some of the materials we'll be covering in class next, namely caring for geriatric and pediatric patients, who present EMTs with additional challenges over their own, be in a decreased sensitivity to pain, or under-developed musculature and skeletal systems.

But that's for next week. Right now, I'm still kinda celebrating the fact that all these EMT skills are starting to feel natural to me.

As we learned earlier in class, altered mental status (AMS) is a sign and symptom of a number of medical conditions, from relatively simple hypoglycemia (low blood sugar) to more life-threatening stroke from insufficient perfusion of oxygenated blood to the brain.

If you were to come across a patient with AMS sitting on a park bench, you may initially suspect a medical condition, especially if they were in exercise clothes and wearing a medical alert bracelet indicating a history of diabetes. But put that same patient in a car seat (driver or passenger), add a deployed airbag and a cracked windshield, and the situation changes. The MOI is now more indicative of a traumatic injury causing bleeding in the brain, which can also lead to stroke and AMS.

More importantly, the MOI increases suspicions that there may be other underlying physical effects, including cervical spine injuries, that need to be managed as well.

We continue to build on the skills we learned from doing medical assessments, with a greater focus towards "hands on" evaluations, through both rapid and detailed full-body scans that require us to learn to feel, listen and look for unseen and often hidden injuries. Using the mnemonic DCAP-BTLS, we're guided to recognize Deformities, Contusions, Abrasions,Punctures/Penetrations, Burns, Tenderness, Lacerations and Swelling,

Interventions, including c-spine immobilization and splinting are being practiced along with related skills for extractions and moving & lifting of patients to that we continue to "do no harm". As part of this, we're practicing using backboards, cervical collars, and a Kendrick Extraction Device (KED), used to safely remove patients from cars or chairs when there is a suspected spine or neck injury.

My experience with the Mendham First Aid squad over the last 18 months is that the number of medical issues we are dispatched for generally outweigh those dispatched for traumatic injuries. But even a medical issue that causes a patient to faint (or have a syncopal episode in EMS-speak) can lead to a fall. And the fall can lead to traumatic injuries that are just as critical, if not more life-threatening, that the medical issue itself.

Obvious traumatic bleeding is actually relatively easy to control with direct pressure and bandaging. Being able to recognize the hidden, more crucial injuries that are the result of a traumatic event acting upon the patient, however, is a far more critical skill for am EMT to master.

And this is what our current classwork has been focusing on -- building our powers of observation and deduction for MOI, and our skills in establishing proper index of suspicions and detection of potential issues requiring interventions on our part.