A journey of a thousand miles begins with a single step
-- Laozi, Chinese philosopher (also known as Lao Tzu)
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.
Today was our final practical exams, a requirement for graduation from the EMT course. Designed to test our knowledge and understanding of all things EMT, covering medical and trauma assessments along with key skills including airway management, bandaging and splinting, CPR and AED usage, and pharmacological interventions such as EPI-Pen and Nitroglycerin administration.
And although the final practical exams were designed to test the skills I have gained over the past 4 months, in the end it taught me perhaps the most important lesson of all -- a reminder that being humble and keeping an open mind may just be the most important EMT skills I can master.
While the EMT course has been challenging, especially for someone who has been out of the day-to-day experience of classes, studying, and test taking for almost 30 years, I felt that I had done pretty well for myself. My quiz and exam grades were always high, and while there was a lot of memorization to accomplish, my own life experiences often helped to put class material in context and perspective. Eighteen months as a driver for the squad gave me an additional sense of how to interact with patients, and the experience of having observed other squad EMTs actually putting some of these skills in action in the course of our calls might have even offered me an edge in some scenarios.
Through the class, the practical exams had gone extremely well, with several instructors telling my that I appeared to have that special quality that would make me a good EMT. I passed through all the practical exams without requiring remediation or a second (and final) attempt to demonstrate a critical skill.
And then there was today. Final exams. And on the fourth and final skill station, I made a huge mistake, one that I won't quickly or easily forget.
As we come to the last few weeks of the EMT course, it seems that we are also coming full circle, revisiting early class materials on the lifecycle of human development.
One of the more interesting aspects of our current study is the process of childbirth, and the EMT skills that support it.
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).
Having just wrapped up the third exam, it feels like a great weight has been lifted from my shoulders. With a little more than a 40 hours remaining (a month of weekends, in my case), the end of the EMT coursework is within sight.
Most of our remaining classes are really going to be review, helping us to fine tune our skills at patient assessment and interventions for both trauma and medical emergencies. In talking with some of my fellow students, everyone seems to be more comfortable than we were just a few weeks ago, having recognized that by breaking down how to approach patient care in to a logical and consistent manner, we've grown both comfortable and confident in our own skills and ability to handle many different situations.
Of course, the instructors aren't going to just make it easy for us. The scenarios and situations they're starting to give us are more complex, often involving a mix of injuries and medical conditions, and requiring us to build upon our index of suspicion skills and determine which are serious life threats to be dealt with quickly, and which ones could have little or nothing to do with the situation at hand.
For example, just because a patient presents with high blood pressure and is known to be diabetic doesn't necessarily mean that either of these two conditions are linked to an underlying issue that we must treat. Where our initial scenarios were clearly set up so we could demonstrate an understanding of diabetic emergencies (and associated treatment options), instructors now want us to be able to treat our patients holistically, and not get overly focused on one specific piece of information at the expense of something more critical.
And I got a real-life lesson in this just the other week....
As class heads in to our third quarter, the materials and skills shift from understanding medical emergencies and associated Nature of Illness (NOI) to traumatic injuries and their associated Mechanism of Injury (MOI).
Trauma is generally considered the gorier part of EMS, and deals with direct bleeding, fractured bones, and other physical injuries to the body that generally result from the application of an outside force on the patient. As such, there are a wide number of practical skills involved in providing interventions to our patients, including proper techniques for bandaging and tourniquet application.
But trauma isn't always obvious. Car accidents, sports injuries, slips and falls can all cause traumatic injuries to bones, muscles and internal organs, often with no visible external injuries. Some of these internal injuries are treated almost exactly the same as internal bleeding caused by medical issues, such as acute abdominal pain due to appendicitis, or altered mental status due to stroke. .
But the effects of the MOI are supposed to guide us to an index of suspicion that there may be more going on with our patients, concerns that may require more care and a deeper assessment for injuries that just simple pain or confusion would appear to warrant.
So we get a bit more touchy-feely with our fellow students, and start learning to look for DCAP-BTLS.
Well, actually... don't!
There's no doubt that we've got to master the signs and symptoms, and associated interventions, of both respiratory and cardiac emergencies. Every situation we face starts with assessing the ABC"s -- Airway, Breathing, and Circulation -- as these represent true emergencies, where it really can be a matter of life-or-death.
Respiratory and cardiac emergencies are very closely related, as issues in one area can have a detrimental, even fatal, impact to the other.
While the heart is responsible for pumping blood through the lungs for oxygenation, and then moving the oxygenated blood itself to the tissues and organs throughout the body, it is itself a muscle that also requires oxygenated blood to effectively pump. So any disruption in how the body is obtaining and utilizing air through the upper and lower airways (including the lungs) can cause issues for the heart as well.
And things roll downhill quickly from there on... Because having to perform CPR means that someone is having a really, really, really bad day....
With the first set of EMT written and practical tests behind us (Ashley, our Cadet member, and myself both scored very well...thanks to all who offered their well wishes!), our classwork moves on to a more focused set of lectures on medical emergencies, and their associated care and treatment options.
While we are told not to diagnose underlying causes of illness, in practice, EMTs play a very key role in uncovering critical signs and symptoms of those underlying medical issues through our history-taking activities (the aforementioned "million questions"), which we provide to medics and hospital staff as part of our transfer of patient care. The questions also guide us in developing an index of suspicion for what may be happening with our patient, allowing us to be more aware of the risks for cardiac, respiratory or neurological issues that may develop while we are in transport.
Classwork this week focused on the various causes of respiratory distress. If you love to read a good detective story, this set of coursework is for you. The textbook almost reads like a good mystery novel, filled with similar signs and symptoms for many different potential causes of dyspnea (or shortness of breath).
And only by combining the practical lung sound skills we're learning to listen for, with other vital signs (including pulse rate and blood pressure), key medical history, and signs and symptoms from our observations and the patients own behaviors and expressed issues, can we reach a clear index of suspicion on key underlying possibilities to be aware of.
Part of the practical skills we've been focusing on in class are the primary and secondary assessments that EMTs do on patients. While the primary assessment is done on scene, and focuses on managing life threats, the secondary assessment can be done on scene or in the back of the ambulance while we are transporting a patient to the appropriate medical center.
The secondary assessment, if we aren't still actively managing life threats (like performing CPR), allows for a more through inspection of the patient, either for a specific injury or illness symptom (assuming they are conscious and alert enough to talk with us), or a full-body scan intended to ensure we don't miss any additional injuries (which is especially important with an unconscious or unresponsive patient, or even a conscious one with an altered mental status).
This also includes taking critical vital signs, including pulse and blood pressure, in order to determine if our interventions are producing the right positive results, or whether our patients are sliding towards dangerous grounds, such as shock.
So ... Who would have thought that one of the best study aids I could get for this stuff would be my 8-year old son and his imagination?
Well, not quite a million, perhaps. But a lot.
If you've ever had the need for an EMT's help, you've probably experienced the barrage of questions we ask. And we consider it a really good start when you're awake, alert, and able to answer those questions.
Before our EMT classwork can start to talk about interventions for specific injuries or illnesses, it's important for us to identify what, exactly, we're dealing with. And while it's often easy to get the basics when you have a conscious and lucid patient, that isn't always the case.
EMTs are drilled to take a specific step-by-step approach, called assessments, in order to ensure we first focus on critical life-threats, and then (and only then) identify and prioritize other issues our patients may be having. These assessments break down to the Primary Assessment (done when we first arrive on the scene), the Secondary Assessment (which may be done on scene, in the ambulance), and re-assessments as needed or warranted by the specific issues and interventions being undertaken.
At this point in my EMT course work, we're starting to practice these assessment skills, linking signs and symptoms to the knowledge of anatomy we've been learning, before we move and transport patients anywhere else. And it comes with learning a bunch of mnemonics, such as AVPU, SAMPLE/OPQRST, and DCAP-BTLS (just to name a few), to ensure we don't miss any critical information.
Jon Alperin, one of our MFAS volunteers, shares his journey to becoming an NJ certified EMT.
from the Start
Here is Jon's journey, presented in time order: