500

But I would walk 500 miles
And I would walk 500 more
Just to be the man who walks a thousand miles
To fall down at your door
The Proclaimers

Ok, I haven’t quite walked 500 miles, though a few days it’s felt like it. But I have reached sort of a milestone. I’ve worked over 500 hours as a tech in the Emergency Department. The PA programs I’m looking at require some sort of minimum number of “patient contact hours”. One only requires 750. The primary programs I’m looking at require 1000 hours. This has been the biggest single worry I’ve had in meeting my prerequisites. While there are a number of classes I need to take (and I’m almost done with those), this is the one that would take the most amount of time and was the hardest to line up.

But here I am, at the end of January and I’ve hit the half-way mark. This means that I’ll be well on my way to hitting the 1000 hours long before applications are due. So that’s good.

But, there’s more than that. Honestly, I’m loving it. Yeah, there’s a lot not to love. There’s cleaning up after patients. There’s being stuck in a zone with very little happening. One can get tired of doing their 20th EKG of the day and 17 nasal swab. But overall, I’m really liking it. And I think I’m getting better at it. I even “gave an order to a doctor” the other week.

Ok, let me be clear. Techs really don’t “give orders” to anyone. Sure we can ask another tech for help or even ask a nurse for help. But typically we’re the one being asked to do things. And we have no medical authority to “put orders into the system.” That said, we’re often closer to the patients and what’s going on with them than the doctors. This makes sense. We see the details, they see the big picture.

In this case though, several of us, including one of the residents, were cleaning up a patient that soiled herself. As I wiped, I noted she was raw and said she couldn’t feel when she was urinating, which meant she’d wet herself again without warning. This would only make things worse for her. When we were done, I turned to the resident and said, “I think you need to put in an order for a Foley (catheter).”

“Oh, you think so?”

“Yes, she can’t tell when she needs to urinate and ends up urinating without warning which ends up getting her skin irritated.”

“Ok.”

Sure enough about 30 minutes later a nurse was putting in a Foley.

I’ve said we often do the scut work. Which is true, and a few people have thought that I was saying that as a complaint. It’s not. It’s an observation. We’re doing the little stuff that needs to be done that the nurses and doctors don’t have time to do or often won’t notice. That said, actually they often do notice. A nurse will go in to do something and see the well stocked IV cart and thank one of us. Or they’ll ask for something and we’ll already have it in our hand, knowing they’ll need it. Again we’re thanked.

Last night for example, I spent probably close to two hours restocking IV cabinets. I’m not sure the last time that day they had been restocked, but some were pretty barren. When I was done, it felt good knowing that the next time a nurse went into the room to start an IV or do some other procedure, they’d have the tools they needed right there.

Then of course, there’s the big stuff. Helping out with a stroke page or a “leveled” trauma. This is where the experience comes in and I’m definitely 500 hours more experienced than I was just over three months ago. I still don’t have my “red badge” so I can work trauma’s on my own, but I’m getting the experience. And it feels good.

All this is a means to an end, getting the required hours to apply to PA school. But it’s also been great. I’m very grateful I’m getting the experience in an ED where my day can vary from restocking carts to handling not one, but two trauma patients in the same evening. And that was just one shift. In other shifts I’ve helped with multiple traumas.

Hopefully not just the quantity of hours, but the quality of the work will help my application. But no matter what, I’m still enjoy it.

Disclaimer: my works do not in any way reflect my Standard Disclaimer: my writings do not reflect the views of my employer, the Albany Medical Health System. In addition, any errors in the above descriptions are my own and nothing here should be taken as medical expertise or advice.

Winter Finally

I’ll have to admit, I actually tend to like the winter. Though I haven’t enjoyed it as much lately as I probably should. In fact, I should be more specific. I enjoy certain weather associated with winter. I don’t necessarily like the season unless I get that weather. Bluntly, I like snow.

I like the quietness during a nighttime snowfall. I love the white blanket over everything. I’m also one of those rare birds that actually likes driving in the snow. Of course since I have a Subaru with all-wheel drive, that probably contributes to it.

What I don’t like are the cold, dreary, wet days without snow. Those are the worst. I’d rather have it be 20F and snowing, then 33F and raining.

So, overall, this winter has basically been a bust around here. In fact, over the decades, we’ve had more winters that I didn’t enjoy than when I was younger. It’s not so much because I’ve gotten older, but because they have for the most part gotten more mild.

So I can genuinely say, I’ve appreciated the snow that came over the weekend for us. Finally some real snow. Snow that if I were more inclined, I could make a snow man out of. Or I could make a snow fort out of. Or, had I made the time, driven in when the roads were still covered.

So, I’ll enjoy the snow we got.

The picture that should appear with this post is back from 2003!

Being Lazy, or is it Efficient?

My main client the other week decided to update an ETL I had created for them over a year ago and add another couple of imports to it. This basically meant creating some PowerShell code and SQL code and schema to import the data.

I had started to write stuff out by hand when I suddenly remembered a PowerShell Script I had previously written and later wrote about for Red-Gate’s Simpletalk.

I won’t rewrite the post here, but basically if I give it the name of a CSV file, it’ll attempt to create the table schema, an import stored procedure and some of the object information for PowerShell. I still have to make some edits usually but this saves me a lot of work.

And it’s a good thing because after creating and testing the two imports that they requested last week, on Friday they scrapped that approach and decided to combine the data into a single file which means I needed to ditch all that work and start from scratch.

I wrote all the necessary PowerShell, SQL, and did the testing in less than 30 minutes. It was fairly trivial and fairly efficient. Or perhaps I was just being lazy.

But the time it took me to write the original script to create the scripts has definitely saved me time and as a result saved my customer money. So in the long rung, it’s well worth it!

And that’s all for this week!

“Ok, Push the Roc…”

This isn’t a story about Sisyphus, but rather something very different.

There’s a saying in the EMS field that “Air goes in and out, blood goes round and round, any variation on this is bad.” It really reduces medicine to a very critical base level. If those things aren’t happening, your patient is in very bad shape. They may have broken bones, be in acid ketosis or have a variety of other major medical issues, but if they’re not breathing or don’t have a pulse, none of that matters. I’ve mentioned CPR previously and plan on writing a longer post on it in the near future (especially in light of Damar Hamlin’s collapse on the field). But today I want to talk about something that can only be done by experts and that’s intubation.

Before starting as a tech, I was aware of the general concept of intubating a patient, but had never seen it done, let alone assisted in any way. At a VERY general level, a patient is sedated and essentially paralyzed while a tube is inserted through their mouth and into their trachea. Once this is done, the patient is either ventilated by a machine or by the use of a bag-valve mask (BVM).

A patient may be ventilated for a variety of reasons, for example, they may be unable to maintain a patent (open) airway and the ability to breath on their own, or in a very recent case, the doctors made a decision to sedate a patient who was moving too much to be placed in the CT scanner. Given his risk factors, this meant that he’d probably lose his ability to maintain his own airway, so he was intubated as a precautionary measure.

I mention all this because there’s something important to to understand. Once a patient is intubated, basically the medical folks are breathing for them. The first few times I watched or assisted, this fact didn’t really register with me. Since then I’ve come to realize how important of a factor this is. In the recent case, the decision wasn’t made lightly. The patient actually was breathing fine, but the doctors couldn’t evaluate for other, possibly life threatening, injuries until he had been scanned. So they made the decision to basically take away his own ability to breath for a short period of time. That’s a pretty heady decision.

Roc is short for rocuronium, one of the common drugs used to help temporarily paralyze the patient. Its name sticks out in my head. There’s generally at least one or two other drugs all administered in a very short sequence (basically to relax the patient and then inhibit things like the gag reflex) period of time, generally under a minute and then the doctor has less than a minute to get the tube in. Once the tube is in, then either a BVM is temporarily attached to the tube, or a ventilator is attached immediately. In either case, we’re now breathing for the patient.

As a tech, obviously I’m not the one pushing the drugs or inserting the tube (I’ll get to that in PA School) but I’m often involved with squeezing and releasing the BVM to provide airflow. I also get to watch all this.

As for the actual placement of the tube, it’s definitely an acquired skill. Since Albany Medical Center is a teaching hospital, often it’ll be a resident or similar attempting it the first time around. Only once have I seen a failure (which was very quickly followed up by a success by a more experienced provider). Even this part is fascinating since they will use a tool known as a Glidescope. This is essentially a curved plastic piece with an LED light and camera at one end. This goes in first to help restrain the tongue and epiglottis. The image is displayed on an LCD monitor. Once it’s in place the actual tube is inserted. All this can be watched if you’re standing in the right place (which often I am.) I have to say it’s rather amazing to see all this. And to watch an experienced provider do a tube is amazing. They do it so quickly.

In any event, I have to say, it’s pretty amazing to watch as the providers take over the “air goes in and out” part.

In a future post I’ll cover the “blood goes around and round” part, which is something any of my readers can (and should) learn how to do anywhere they see someone in cardiac arrest.

Standard Disclaimer: my writings do not reflect the views of my employer, the Albany Medical Health System. In addition, any errors in the above descriptions are my own and nothing here should be taken as medical expertise or advice.

Freedom House

A little over two weeks ago I was leaving the ED after a 12 hour shift. It had been a particularly grueling one. The drive home is often a time I’ll put on the radio for background noise and get lost in my thoughts. This drive started the same way but very quickly I started to listen more intently. I had heard the words Freedom House.

Now as some of my friends, and perhaps some of my readers know, I’ve had a keen interest in the history of paramedicine. I had watched Emergency! growing up and loved it. It wasn’t until years later I started to learn some of the history of it and how it mirrored the development of paramedicine in general. Later I learned of what’s know as “The White Paper“. This was a landmark 1967 report that among other things concluded a soldier in Vietnam who was shot was more likely to survive than someone shot in a city inside the United State.

Back then the idea of an ambulance was often the local police, or even the undertaker, simply transporting the patients to the hospital as fast as they can. (An undertaker may seem like a strange choice until you realize they had vehicles designed to onload and unload people in horizontal positions, such as tied to a stretcher.). Actual treatment until hospital arrival was often a quickly tied bandage at best. If the patient was lucky someone on the ambulance might have had a first aid course, but that was it. There were no standards and a definite lack of equipment. Beyond that, it was a matter of how fast they could get the patient to the hospital. And to say that what little quality in service did exist was very likely based on the area of the city lived in would be an understatement.

This was the state of emergency medicine on the streets in most places until an interesting confluence of events in 1967 happened in Pittsburgh Pennsylvania.

There a doctor, Dr. Peter Safar, the father of CPR, Phil Hallen, the head of The Falk Fund, which among its goals had one to create employment opportunities for African-Americans in Pittsburgh, and Jim McCoy, the head of Freedom House, a grass roots organization in the Hill District that among other things delivered food to locals, were all in the right place and the right time. Initially Hallen approached McCoy with the idea of a basic ambulance service similar to what was in existence elsewhere at the time, but this one run and controlled entirely by folks from the neighborhood. Basically an African-American run ambulance service for African-Americans. But, when they collaborated with Dr. Safar he had far bigger plans. Combined with a grant from the DOT of all places (because of their interest in reducing deaths due to highway accidents) they started with two ambulances and a 300 hour training program. Thus began Freedom House Ambulance Service, the first real modern paramedic program in the United States.

I had known they were “among the first” I didn’t realize they basically were the first. And I didn’t realize in how many ways they were first. Dr. Safar literally designed the first modern ambulances as a current EMT/Paramedic would recognize them and created the first training program. And these men (the first few trainees were all men) were the first paramedics.

The NPR radio program I was listening to was an interview with Kevin Hazzard who was talking about his book, American Sirens. I knew I had to order the book as soon as I got home. In fact, I ordered two copies, one for myself and one for a close friend who is a paramedic. I started reading it as soon as I got a copy.

The focus of the book is on several of the key players, the ones mentioned above as well as Paramedic John Moon who started in the program after a few years and survived the end of the program and Dr. Nancy Caroline, who literally wrote the textbook on paramedic training: Emergency Care in the Streets.

American Sirens is well written and easily accessible by anyone. You don’t need a medical background to appreciate it. It also answered a question I had had about Freedom House since I had heard about it; namely what happened to it?

I’d love to say it was still around and thriving and that it had a strong name recognition among modern paramedics and EMTs. Sadly that’s not the case. From its start it faced opposition from the local police and politicians. In 1975 it was facing a complete shutdown due to underfunding when Dr. Safar convinced the mayor to fund it one more year and brought in Dr. Caroline. But the writing was on the wall. Within the year, it was replaced by a city-run, city-wide ambulance service staffed almost exclusively by white paramedics, all who had far less experience than the Freedom House Ambulance Service paramedics and who had taken classes developed by Drs. Safar and Caroline. Dr. Caroline was initially brought over as Medical Director with the understanding that all Freedom House paramedics would be brought over and given jobs. And initially they were, but very quickly racism raised its ugly head and they literally were often left holding the bags while their much less experienced team members took over.

Meanwhile, in Los Angeles, in 1972, Jack Webb (also of Adam-12 and Dragnet history) had created the show Emergency! which was a fairly fictionalized, but also fairly accurate, portrayal of the development of the EMS/paramedic program in Los Angeles. One can’t underestimate the impact this show had on popularizing EMS in America. I know a number of folks who got into paramedicine because they watched this show. It deservedly has a place in the history of EMS in the US. However it’s just one part of the history. Sadly a key part literally has been white-washed. As of the late 90s, 98% of the paramedics in Pittsburgh were white.

I wrote a few days ago that I wanted to read more this year. Well this book is the first.

For anyone interested in a more complete understanding of the history of paramedicine in the United States, including the racism if faced, I highly recommend this book.

2023 A Year in Preview

Another quick post because another day where I have to be in the ED acting as a tech.

As I mentioned yesterday, I need a minimum of 1000 hours of patient contact time to apply to most of the PA schools I want to apply to. I’m literally hours short of 1/3rd of that. I’ll pass the 1/3rd mark today. This is just over 2 months. I’m confident I’ll make the deadline and add many hours to spare.

  • So that’s goal 1. Getting enough patient contact hours to apply to PA school. I’m well on my way!
  • Next, is finish my academic prereqs. I had to add a class to my list. I had taken Microbiology as an elective for my undergrad. In fact, it was my final exam of my undergrad career. However, to save money (since I was paying for this class out of pocket) I elected not to pay for the lab. Well, the professor made it clear he expected us to show up for lab anyway. So, I’ve done Microbiology, including the lab, but the transcript doesn’t show the lab portion and I need that. So I’ll retake micro. I’m OK with that. It was a fun class after all.
  • I’ll definitely keep working on my TOTS class I want to present at the NCRC. We’ll see how that goes.
  • Continue Blogging: I’ll continue my switchover from a focus on SQL and IT related posts to PA/ED Tech type posts.
  • Biking: We’ll see how my schedule works. Perhaps only 600 miles this year, not 700 as a goal. Ironically, one benefit I get at work is a secure bike storage area. Sadly, my shifts end at 11:30 PM so I don’t think I’ll be biking home much, so it means I won’t be biking to work much!
  • Hiking: Since my schedule is every other weekend on, it also means every other weekend off. I hope to squeeze in some hiking.
  • In fact: I expect to slowly wind down my IT work over the coming year so I can focus on applying to PA School and focus on other skills. Honestly, two big reasons I’m continuing my IT work is that it pays much better which helps since I’ll need the money for PA school and other expenses over the next few years (goal is to avoid as much debt as possible) and also because I do have some commitments to existing customers I want to fulfill.
  • Read more: I’ve found myself for a variety of reasons reading less in the past two years than I’d like. So I resolve to get books off my reading list. Right now I’m reading American Sirens, which is basically a history of how the paramedic service started in the US. I highly recommend it.
  • Speak at least once in the coming year. I’ve got a great talk in mind. But I won’t drop hints just yet.
  • Get Accepted into PA school. This of course is the big one. It’s what I’ve been working towards for the past 12 months. I’m confident that with my background and the experience I’m gaining I’ll get in someplace. It’s just a matter of where and what if any aid they’ll add.
  • See friends: Again, with that every other weekend off, I’m hoping to travel to see more friends. (That said, my schedule currently has me working every Friday, which I’m hoping to change so I can ensure a 3 day weekend.)
  • Get our new septic system in. Yeah, I didn’t mention it before, but the old one has basically failed (though not horribly so) so it’s time.

Finally, I realized I should have done this yesterday, but I want to thank EVERYONE who has given me encouragement and support in the past year. It’s meant a LOT. From blood family, to #SQLFamily, and NCRC family and others, I’ve had more than a fair share of folks say they believe in me and support me. It’s given me a lot of confidence. Thank you.

And with that, now time to shower, get into my scrubs and head back into the mix.