Sunday, February 29

Very Quiet

Home: Went to a "winter festival" - Sun, warm (for us - in 40's F) and still lots of snow. Kids had a blast at an obstacle course set up in the snow.

Ambulance: Sat. shift from 1800 sat to 0600 sun. NO CALLs.

Work: Should have gotten comments back to a student, but when you give me a paper on Friday at 1600 you are taking a chance.

EMT class: Trying to learn the "trauma station". Still hasn't quite clicked yet, but practiced sat night with the other people on the crew and that helped.

Spring MIGHT come, but it won't be soon enough.

Saturday, February 28

I think I am going to die

Work: Another day, another 1/100,000th of a grant proposal completed, another advisee gained (I have GOT to keep that door closed), another junior faculty member mentored, another paper to review, another NCAA application for an additional year of eligibility due to a knee injury (I am our institution's faculty representative to the NCAA), blah, blah, blah.

Ambulance Stuff: On as driver from 1200 to 1800.

Calls: 1

Went out ALS with crew of 5 (driver, medic, two basics and a college kid who is in my EMT class).
Call started out BLS and medic let one of the basics be "crew chief" and did a good job staying out of the way. The entire crew but me is college students, so you can see what I mean when I say my corps depends upon them a lot. Anyway, we leave the scene with the patient and I can not hear what is being said in the back, only the voices. One of the basics is running the call, with the medic not talking at all, when all of a sudden the medic is the ONLY one talking and things start sounding tense. In the mirror I see an IV getting started and the 12-lead EKG going in place. Hmmmm.

Get the hospital, do our stuff, and leave. On way home I ask the medic what happened. He states that things were going fine until the patient said "I think I am going to die", at which point her color changed and her vitals changed. According to him, when a patient tells you they are going to die you better believe them. I have no idea if this is just another superstition (just TRY saying "it's been quiet" around older EMTs or Medics!), but for now I'll take his word on this issue.

She was alive when we left her but the hospital page was going for the cardiac crew.

Friday, February 27

Where is my "Drunk Call"

EMT class last night: Overwhelming amount of information. Topic was the steps involved in running a trauma call. I clearly still need some time to work out the logical flow.

Ambulance Stuff: On call from 0000 to 0600. No calls for us. Had the pager set to “Monitor” and heard another corps get an alcohol poisoning call (they have a small state college in their district). Not that I want one, but I have yet to get an EtOH call. They are relatively common in my district (college students make up half the town from August to May).

The data are fairly clear (e.g., Wechsler’s work at Harvard) that while alcohol is a problem on most all college campuses (and has been for HUNDREDS of years), the following are associated with increases the severity:

1) Residential School > Commuter School
2) Selective > Not Selective
3) Rural Setting > Urban
4) Live in Greek Letter House > Not Live in Greek Letter House

“Binge Drinking” (as operationally defined by Wechsler) is statistically associated with less studying, more injuries, more run ins with law enforcement, more instances of un-protected sex, sex when sex wasn’t planned, sexual assaults, depression, etc., etc., etc.. In fact, people AROUND binge drinkers are more likely to be injured (among other things) than people who are not. The nature of the design of these studies prevents making causal statements. That is, it is too bold to say (based on these data) that drinking CAUSES injuries or that being in a rural setting CAUSES drinking, for example.

I work at a selective, residential college in a rural setting with a significant number of Greek Letter members. On top of that, most “college guides” list our school as a “work hard / play hard” school where EtOH is the drug of choice. Our kids, statistically, are at risk. The local ER and campus safety data are consistent with the concerns you’d have after having reading the alcohol literature.

My first drunk call? It is coming, I am sure. I selfishly hope it isn’t someone I know so as to spare us both the embarrassment.

Thursday, February 26

Learning Not To Act

What do EMT students and kindergarteners have in common? In both cases learning what not to do is sometimes harder than learning what to do.

On Wednesday night I coach basketball. I am not a very good basketball player, and would not profess to be much of a coach, but the organizers asked and I was too stupid to say no. When the players range in age from 4 to 6 the coaches are hard to find and any deficiencies are not noticed by the players.

Paint yourself a picture:

Location – Racquetball Courts (yes, a small space with rock-hard walls which reflect all sound!)

Baskets – 6 feet tall portable units.

Ball – Kid sized.

Kids – 8 to a team. High energy. Some played last year, some have never played before in their lives.

Format: 30 minutes of warm-up and drills and 30 minutes of “game” against another “team” (3 on three “full court”).

You can image I leave with no hearing and no patience (and the thrill of being able to windmill dunk does not go away…).

Give a kid who is 4 or so a basketball and the general goals of the game and the results are predictable. They run to the basket (without dribbling) and heave the ball at the hoop with full force. On defense they tackle the other player and knock the ball free. Not a bad initial plan given the goal of the game is to make a basket and not let the other team score. From the kids’ perspective the rules just get in the way. As a coach part of my job is to teach them the necessity of rules and the role the rules play in making the game more interesting (not to mention safe) for everyone.

What if your goal is to help others in need? In EMT class Monday we talked about scene safety and extrication. There was a lot of squirming in seats as the “rules” were explained to us. Few people in the room got involved in emergency medicine in order to watch from a distance as people need help or to say “that isn’t my job”. But the rules say there are times when that is exactly what we are to do. Person shot with the “actor” still around and no police presence? Wait at a safe distance until the police secure the scene. Truck turns over spilling a caustic on a minivan full of kids with the kids screaming from the burns? Wait at a safe distance until a decontamination team arrives and can deliver your patient to you in a decontaminated state. Even if that means the kids die in the interim? Yes. Really? YES!

Apparently some subset of three things can happen if you violate the rules:

1) You are called a hero by the press.
2) You die, or worse, get injured and take up valuable rescue resources that could have been given to the original victims.
3) You get reprimanded or kicked out of your corps (or fired).

Six weeks into basketball and my charges are learning to play by the rules and are having fun. But it is still hard work for them to avoid the impulse that comes naturally.

In EMT class scene safety is being driven into us relentlessly and I dare say all of us are going to be slow learners on this issue. I have to assume that it is better for the EMT, and in the long run better for the patients, if we follow the rules. Clearly, however, my peers and I want to run without dribbling and heave the ball at the hoop, as our gut impulse is not to sit and wait while people are in need.

Maybe I need to go back to kindergarten to relearn self-control.

Tuesday, February 24

When is "Good Enough" not Good Enough?

In response to my last entry Maddog wrote:

Every time I've taken a test in EMS, especially in a class run by the local government, everyone always says, "The only thing that matters is that you passed."

Thanks to this comment I am now in vent mode (you only have yourselves to blame for reading and commenting on this stream of consciousness crap I spew forth)…

A student in my class last night said to another (not me) “They give the same EMT card to the person who scores a 75 as they do to the person who scores a 95”. Indeed they do. The comment caught my attention as I had heard something like it before. My first year in grad school I lived with a bunch of Hopkins med students. A common statement from these guys (usually around test time and in response to someone else doing better than them) was “You know what they call the person who graduates last in the class”? ………. “Doctor”.

My Hopkins housemates were joking in that they all killed themselves to learn as much as they could and it hurt them not do well. Maybe I am misreading some of my current classmates, but a few of them seem to really have the attitude that passing is all that matters and they are pleased to get by with as little effort as possible (that is, they are under-performing their potential). They make statements indicating that they did not study because this chapter was boring or because a great episode of a favorite TV show was on or because they knew they could pass by just skimming.

I do not understand. My concern is not the test score. If you score a 70 after trying hard to master the material and the state has determined that a 70 is a sign of competence, then I am happy to ride with you and call you a brother or sister.

My concern is the effort and attitude side of the equation. How can some of us not want to put in our best effort (within the constraints of day-job, home life, etc.)? I know I am a newbie and must be naive in many ways. Maybe all I really need to know about being an EMT will come from the field and all this classroom stuff won’t matter. Even if true, though, what can the knowledge and effort hurt? How can it be a waste of time to know normal respiration rates, the differences between NRB masks and cannulas, the major bones of the body and how to describe them, etc.?

My goal is to get the patient to the hospital with as good a prognosis as possible. The thought that I will not know or perform something that is within my scope of practice and that I cost someone the best outcome possible scares the heck out of me. Not because of litigation, but because if I am going to treat people I should be treating them within the best of my abilities. Note that as far as I am concerned “best of my abilities” is NOT just of a function of the present but also the past and future. That is, I am responsible for what I have and have not learned in the past, for implementing my knowledge and skills in the present, and for learning from my current patients so that my future care can be better. I know I will make mistakes, forget things and wish I knew more. But I do have some control over these future events, and part of that control is doing the best I can in class right now. I have limitations. There are smarter people and learners better suited to the instructors teaching style. I have a professional job, kids, and social responsibilities, and some people have more and some less. But to purposely slack and try to titrate effort to just get passing scores? Again, I do not understand.

My Hopkins housemates knew their joke was a joke in two ways. First, internally they wanted to be the best they could be within reason. Second, they had external demands. They may have all been doctors at the end of med school, but they all knew that they were going to compete with other doctors from across the nation for desirable residencies. Residency programs were going to see their test scores and read letters of evaluation of their clinical skills. How much did this external motivation play a role in their work ethic (I have never seen anyone work the hours those guys did)? Are there equivalent external demands on EMTs (my volunteer corps, which is hurting for members, is not going to screen me based on my performance in class as long as I pass)? Should there be?

More importantly, does any of the above relate to being a good EMT? If not, how can the classroom experience be made to be so important to what we do in the field that everyone can agree that the effort is worth putting forth? If so, how do we set the system up so that people can see this and act accordingly?

This is all Maddog’s fault :-)

Monday, February 23

Sick Test Results

I had a teaching evaluation last semester that read: "Dawg, your teaching is sick". I was crushed, of course, until I read the rest of the form. In context, sick can only be interpreted as a positive thing. Damn kids today.

This weekend sick has been bad. I have been sick as a dog with a virus that I can't shake. Chills, fever, GI distress. Pure pleasure for all around me, I'm sure.

Fri EMT Shift: One call. Tummy ache at "older folks home". They called, I'm guessing, because they had a full arrest that morning (which I didn't go on) and were still tweaked.

Weekend: Too sick to do much but go to "Sesame Street Live". That Elmo rocks. Mr. Noodle rocks. Cookie monster? Over-rated in my book.

Today: Still sick, but went to EMT class as I figured I wasn't spreading viri around anymore and I needed to get out. Plus I wanted to get my test back.

My score: 96%
Questions missed I should have known answer to: 1
Questions missed no one should care about: 2
Questions I got right due to dumb luck: 2

Mean, SD, Min, and Max for class: Don't know, as this was not reported. Why? Requires math? Makes people feel bad? Helps people judge where they are compared to their peers? Can't really say, but it strikes me as odd.

Today we learned about scene size-up and initial assessment. Things are getting interesting.

More when I return to full strength.

Friday, February 20

12 Hour Weeks and Summers Off?

I am on sabbatical this semester. Sabbaticals are designed to allow academics to immerse themselves in their scholarship without the distractions of the classroom, committee work, etc. Today I met with a student who wondered why I needed a sabbatical when I only work 9 to 15 hours per week (his math was based on the time I spend in class and class-based labs). Such comments usually start me on a 15 minute diatribe, but someone just sent me this link and I think I will now use it and save my breath: What Does a Professor Do All Day?. The author does a good job of describing how academics spend their time. In my case, you can replace his discussion of books with a description of work in the laboratory and the writing of articles for peer reviewed journals, and at my institution undergraduates get the attention he pays graduate students. Overall, though, he hits the nail on the head.

No doubt I have a sweet deal. The students are a pleasure to interact with (for the most part), the institution is self-governed meaning you can make very valuable contributions if you’d like, and I am well paid while allowing me to spend time thinking and helping others develop their ability to think. As good a deal as it is, I am not, however, working 12 hour weeks. And I DO work summers (just not teaching).

Thursday, February 19

No Real News

Nothing really worth posting but it has been a few days.

EMT class tonight:

Module 1 Exam (75 questions) and Practical Stations (Oxygen therapy, Single Rescuer Bag-Valve-Mask, Pocket Mask with O2, airways and suctioning).

I’ll find out how I did on the test Monday. I know I missed some from the test (I aced the practicals) but would be shocked if I scored below a 90%. I hate missing questions… This whole process is good as it gives me a feel for what my students go through all the time.

On call tonight from 0000 to 0600 and tomorrow from 1200 to 1800.

No school for my kids this week so the wife and I are taking turns staying home. My kids decided it was “underwear” day and ran around mostly naked all day. I did not put up a fight because if I could I would do the same (though it would cause major cardiac events wherever I went).

Department meeting this week to discuss fall teaching assignments. I’ll be teaching statistics in the fall. I’ll explain some other time why this is good (no, it isn’t because I am a sadist).

I just got a great paper to review for a journal. What a pleasure to read a well conceived and written paper by someone who knows what she is talking about. You would think that all scientists would submit papers to peer-reviewed journals that fit the above description but you would be wrong.

Thanks for reading.

Tuesday, February 17

Sebaceous gland to the left of me, dermis to the right, here I am...

Home, Ambulance Stuff and EMT Class all in one vent.

2 year old acting like a two year old. I remember that she used to be so sweet :-).

5 year old acting like a five year old. I am told he used to be sweet, but I do not remember this nor do I remember being single, married with no children, or for that matter, married life without children. We used to think we were busy…

Wife still pretending it is a good idea that I take on more responsibilities with my job (e.g., in July will start a three year stint as a “University Professor of the Liberal Arts and Director of the Scientific Perspectives Program”) + volunteering my time with an ambulance corps + taking an EMT class. She’s a keeper.

Ambulance Stuff:
Due to some unexpected events in other people’s lives I was asked to be on call as a driver from 1800 on Sunday to 1200 on Monday. One call – seizures followed by “erratic behavior”. Terminal cancer patient with lesions in his brain got a little grumpy. Grumpy last week meant waving a loaded handgun around at significant others + law enforcement. Control asks us to wait to enter home until law enforcement arrives. No need to transmit that idea twice. I am still thinking about this guy and his family. Clearly was a warm and nice guy before tumors invaded his brain and changed his personality. Son thanks us at hospital and all I can think is that I hope I can be as thoughtful when the world of crap rains down on me and my family.

EMT Class
Twenty question quiz tonight on the following systems: muscle/skeletal, cardiovascular, nervous, endocrine, digestive, etc. Twenty questions. Think of all and EMT-B could want to know about these systems and then ask yourself where you would place this one in order of importance for emergency medicine: What layer(s) of skin contain the Sebaceous glands? Yep, that is the one I missed. Vote early and vote often if you KNOW the answer without cheating.

After class I get beer and wings with my friend "B" who is taking the class with me. We see students we know and try to ignore them but they keep looking our way, seemingly shocked that college professors can have fun at night. We drink enough to be legal but happy. I drive home and almost die due to another driver's speeding. I wonder if one more beer on my part would have removed the almost from the previous sentence as I could not have reacted in time. Never know...

Sunday, February 15

Rural EMS, Response Time and Standard of Care

How much time should elapse from when you call 911 with a medical emergency and when help is on its way? To see where I am headed you need to know a little about how volunteer systems work where I live (if you are a volunteer EMS or Fire worker you may want to page down a several paragraphs to skip the background and get to the main point of this vent).

Most emergency medical services around my area are run by volunteers. Down at the station house is a “board” where people sign up for shifts. If you are “on the board”, you are expected to respond to every call that happens on your shift. You do not have to be at the station, you just have to make it down within a fixed amount of time from when a call comes in.

When there is a call the flow of information goes something like this:

Person with or witnessing an emergency calls 911.

911 dispatcher determines nature of call (police, fire, medical or some combination).

If the emergency is medical or fire the dispatcher obtains basic information and then makes a preliminary warning announcement over a radio frequency monitored by the volunteers. The volunteers have “pagers” that can be set to constantly “monitor” (play out loud) this radio frequency (in which case they would hear the following) or set to only alert the user if their particular squad is needed (in which case the would not hear the following). The initial announcement sounds something like: “Blank ambulance monitors, you have a call for a 70 year old male with chest pains at 5555 Main Street, the Jones residence”.

The dispatcher then plays a series of “tones” (a unique combination for each corps). Every volunteer ambulance and fire group has pagers that “listen” for their particular tones. When the pager detects the tone combination it is programmed for it beeps and, if it was set for alert only, becomes active (starts to play subsequent announcements). The dispatcher then re-announces the call, usually with more information: “Blank ambulance monitors, you have a call for a 70 year old male with chest pains at 5555 Main Street, the Jones residence. Bystanders report patient is unresponsive and not breathing”.

Right before the call, spread all over town, the people on the board were working, eating, playing with their kids, in the bathroom, sleeping, etc. Between the onset of the initial announcement and the end of the official call coming after the tones, these individuals will be in their personal vehicles trying to safely but quickly make it to the station. Many of us have flashing lights (in my state green for EMS and blue for fire) that are supposed to make this trip easier and safer for everyone. The fact of the matter is that the lights are “warning” lights only and (again, in my state) the public has no legal obligation to yield to a volunteer responding to a call, and the volunteer has the legal obligation to obey all traffic laws (we are not supposed to speed, run stop signs, etc).

One of the first people to arrive at the station, even if he or she is not a driver, will open the garage bay, start the ambulance, pull it out, and close the door. This person will also check the board to see if there is a full crew listed (there are “gaps” in the board – demand outstrips supply). Unlike most professional EMS systems, we have people who are pure drivers as this lets people who do not want to be directly involved with patient care (for whatever reason) contribute and allows the medical personnel we have to be spread across more shifts. When the ambulance is outside and running with the garage door closed, the person can respond (acknowledge the call) to the dispatcher. Without this response the dispatcher will keep sending out alerts until an acknowledgement is made or the decision is reached to send another ambulance (“mutual aid”). The timing of this is very important. If the call is acknowledged before a full crew is on its way to the station, someone who missed the first call (because the radio didn’t pick it up, or a lawnmower muffled the noise, etc.) may have no way of knowing they are needed and people are waiting on them. On the other hand, people besides those who are on the board monitor the radio and listen attentively for the acknowledgement. This is because we all understand that the board may not have had a full crew, and additionally things can and do happen that make it impossible for someone to respond. If enough time goes by, people who were not on the board try to get down to the station so the call can be served. Thus if you acknowledge too soon you risk not having a full crew and if you acknowledge too late you risk having 15 people stop what they were doing and drive quickly to the station thinking things are desperate. Since we have two ambulances and only one crew on call, any call requiring two rigs, or a second call while the first is being served, means people who were not on call have to show up. Combined, the above results in lots of ears on monitors, even those who are not officially on call.

When the full crew is there, 911 control is told the rig (ambulance) is “out of service” meaning they are on their way to the scene.

Thanks to the help of the college students, our corps almost always can get two rigs out when needed. We are lucky in this regard and every summer or break (when the students are gone) reminds us how much we depend upon student support. Other local corps are not so lucky and do miss calls or take too long to get out.

So, how long is too long? One night my wife was monitoring the scanner (I was out) and heard a call from outside our district that took too long by anyone’s measure. The alert came for a 20 year-old with a suspected overdose and depressed breathing. The call was acknowledged within a few minutes. Then nothing. For many, many minutes, nothing. Since the call was acknowledged the dispatcher, who has a lot of things to do, is on to other business. More minutes pass without the crew calling “out of service”. Someone from the crew in question then radios control and asks them to re-page for a driver. This is not good. Hard to know if there was no driver on the board and the crew did not notice this at first or if the driver on the board did not show. More time. Crew in question radios control and asks them to send another corps out on “mutual aid” as it is clear they are not getting out.

My wife guessed the above took 15 minutes. Note that the other ambulance needed to be toned out in the same fashion, starting the whole process over again. In addition, since the call is now being handled by someone from outside the district the transit time would be longer.

The above is not good and is rare around these parts, but it happens. Is this acceptable? What is the alternative?

The EMT text we are using in my class has a spiel about “equal access” to EMS for the entire U.S. The argument is that all U.S. citizens should have emergency medical service and that where you live or how much money you have shouldn’t influence your care. Of course states implement their EMS and EMS costs money. When considering response time and standard of care we are a long way from equality. Rural EMS is not going to be the same as suburban EMS. In the ideal world your driver, or soon-to-be (I hope!) EMT, would not be a volunteer 38 year-old college professor working 45 to 65 hours a week at his day job with a wife, kids and other distractions. There is no way I’ll EVER be as good a driver or EMT as the pros, if not for any other reason than call volume. My agency handles, at most, 500 calls a year. Many people take “just” one 6 hour shift a week. While this is 6 more hours of community service than many members of society put in each week, it clearly won’t give you a lot of experience driving or providing patient care (on average you’ll get about one call every three weeks if you take one shift a week).

Volunteer systems provide EMS and fire coverage where people will not or cannot pay for it. The alternatives, as far as I can tell, involve trying to make the current system the best it can be, paying higher taxes or having even higher health care costs. The family of that overdose may well wish they had paid a little extra in their taxes or health care premiums over the last 20 years so that they could have had an ALS ambulance at their door in a reasonable amount of time. Their daughter’s life was likely worth it to them. It clearly isn’t worth it to most of us or I would be looking for another way to try and give something back to my community.

As a society we make tradeoffs between costs and benefits. Obviously it would be a mistake for each of us to have our own trauma doc following us around “just in case” (besides, this would result in some sort of infinite recursive function where each doc needs a doc following them around, etc.). Standard of care issues are real tradeoffs with costs and benefits I am not used to thinking about. I do not know the answer. I do know it is like a reverse lottery. You decide NOT to pay and you run the chance of “winning” a delayed BLS response instead of a timely ALS response. Every once in a while the outcome will be radically different in the two systems and those of us in the know will realize these types of outcomes are the result of decisions made based on money. That is a cost society is willing to pay but it has to be hard to swallow if the currency is your child.

Saturday, February 14

Don't Complain

Friday 2/13, 1200-1800 - On call as a driver and spent day at work analyzing data and meeting with an honors student who is a coauthor on this project...

#calls while crunching data: 0
#experiments that producted data that failed to replicate previous work: 1
#honors students spending weekend trying to figure out what the data mean: 1
#professors spending weekend trying to figure out if experimental design or student are to blame: 1

As a newbie I want calls (I don't want people to get hurt, but if they are going to get hurt I'd like them to do it on my shift!). Old hands clearly think this is funny. Yesterday I was told not to complain about the number of calls as when I stopped by the station I was filled in on a call from a few days ago: Massive rectal bleed. Quote from medic: "Once you have smelled the mix of fresh blood and fecal mater you will not forget it". I'll take his word for it. He also pointed out that the driver cleans the back of the rig.

Friday, February 13

Origin of the Spines (sorry Darwin)

EMT class last night and then a shift of being on call as a driver.

EMT class: Last night was anatomy and physiology all in one three-hour lecture. Ouch. I was feeling for the people who have had little biology. While overall there wasn’t much to note, I did learn that God designed the spine. Not evolution, not some deity designing a system that led to the evolution of the spine, but HE [instructor’s words, not mine] directly designed the human spine. I saw my fellow students write this down! Not to trample on anyone’s beliefs, but it seems easy enough to have a lecture on this topic without promoting one view over another. On science's side are the huge advances we have made in medicine once we started using the scientific method to evaluate claims and ideas. And this is in a state sponsored course…

A very large percentage of the EMS/Firefighters in my area smoke cigarettes. Is this universal?

On call from 0000-0600. Roads were bad and I wondered if I should sleep at the station, but decided to risk it from home.

Number of calls: 0
Number of calls dreamt about that I can recall: 4. Percentage involving my wrecking the ambulance or almost doing so: 100. Best one involved my taking a shortcut across a field ala Lance Armstrong in last year’s Tour de France.

You’d think at 38 I’d stop having anxiety dreams. At least I didn’t dream I went to class naked.

I’ve got a boat load of work to do in the “real” job today and am on call as a driver from 12:00-18:00 – This should ensure I get a call!

Thanks for reading.

Wednesday, February 11

Whose call is it anyway?

If the following had not ended with no serious injuries it may not have been funny to me. Being new to EMS I just assumed agencies worked together in a friendly and professional manner to ensure the best care possible without interpersonal or political concerns. I am clearly in need of some schooling…

“X” = one local volunteer fire/rescue squad
“Z” = another local volunteer fire/rescue squad
111 – X’s ambulance radio call number
110 – X’s chief’s radio call number
221 – Z’s ambulance radio call number
220 – Z’s chief’s radio call number

Remember – These are all volunteer units, including the chiefs.

Control sounds the tones for “X” and then:
Control: “X ambulance monitors, reported 2 car MVA with personal injury at intersection of routes “A” and “B””.

111: “111 to control”
Control: "control’s on for 111”
111: “111 is out of service ALS”
Control: “111 out of service ALS 13:22.”

[context: 110 and 220 are not on the scene and do not respond to the call – they just get involved via radio]
220: “220 to control”
Control: “control’s on for 220”
220: “control, cancel 111 and tone out for Zs ambulance as the accident is in our district.”
Control: “220, our map shows location indicated by 911 caller is in X’s district”
220: “It’s on the line. The call may have been in theirs, but the accident is in MY district! Roll 221!”

Control sounds tones for Z: “Z ambulance monitors reported 2 car MVA intersection of routes “A” and “B” with personal injury”.
Control: “Control to 111”

111: “111”
110: “110 to control”

Control: “110 please wait one. 111 you can stand down and return to quarters as the call is not in your district”
111: “111 copies”.

Control: “Control’s on for 110”
110: “111 KEEP GOING! Control, that call is in X’s district. Please tell 221 to stand down”.

220: “110 this is 220 - The call belongs to us!”
110: “220 the call originated in our district and you are not even there to know whose call it is!”

More childish bickering combined with some understandable confusion on the part of the crews involved, all displayed proudly on the public airways listenable to anyone with a scanner. In the end both ambulances responded to a scene where everyone signed off (refused treatment).

I don’t know why the turf war broke out between the two chiefs or why it wasn’t handled more professionally.

I do expect that
A) We have a real east-county/west-county “thing” going on here.
B) Drivers and medical personnel will now start wearing bandanas in their pockets and flash signs to their peeps.
C) Soon people in EMS gear will be selling glucose on the corners and using drive by intubations to protect their turf.

Got to do what you can to keep them giving you your props. Word to you and peace out.

Tuesday, February 10

Practical Translations

A one-armed legless person could read, understand and memorize every published book on bicycle riding and yet have a very difficult time riding a traditional bicycle.

There is a lot of book learning in the initial part of the EMT class I am taking. Some of this learning is knowledge we need, but some of it refers to skills we will need to carry out. I have been curious as to how well I will be able to carry out the skills component of being an EMT as I fully understand that reading about artificial ventilation techniques, for example, may be very different from performing the ventilating. You just cannot tell until you try.

EMT class last night involved “lab”. Lab, in this case, does not involve titrations and acid stained lab books. “Practical skills stations” are set up to test our ability to carry out a series of steps necessary to perform some basic life saving procedure (for example, use an oral airway adjunct and bag-valve-mask [BVM] to ventilate an unconscious individual). What a blast! To get to actually do something instead of taking notes for three hours of lecture is a treat. The fact that what we are doing involves cool lifesaving tools is a bonus. I do not mean to demean these tools or the skills required to use them to by referring to them as “cool”. But whether you want to call them “neat”, “keen”, “cool”, “rad” or even “bad” [in the way my students mean “bad”], they rock. Really. Oxygen setups, one way valves, and sticking tubes through the nose to the nasal pharynx are all fun stuff, at least in this low risk environment.

Most of the skills stations give you a scenario and ask you do deal with it. There are a series of steps you are expected to do from memory. Some people in my class are acting like you have to memorize a bunch of random bits of information in order to succeed at this task. They miss critical steps because of this approach. I see this from my students a lot. Imagine having a can opener, can of chili, stirring spoon, pan, stove, bowl, and a spoon to eat with placed in front of you. You are told “heat the chili and eat it”. This is the rough equivalent of a skills station. Do you try to memorize the steps? If you think about what you are doing and why you are doing it, it is not that difficult (at least so far). Sure, there are things to remember, but the information is all related to a major theme and instead of being random bits the information is more like a semantically related linked list. For the stations we have done it is very easy to remember what to do because you just have to think rationally.

I know the more difficult practicals are yet to come (e.g., the trauma looks scary and wicked interesting all at the same time), but I am now confident that they will be doable. What I am left wondering is how well these skills, once acquired, will transfer to actual situations. Is opening the airway on a “dummy” that is not turning cyanotic and puking all over you the same as dealing with a live (barely) person in the back of a moving rig whose family is on the way to the hospital and will be there before you leave? How can it be?

Monday, February 9

Imposter Syndrome

“Bob” stopped by my office last week for a chat. I am on sabbatical this semester and Bob caught me in a rare state of weakness (my door was open). Bob, who was in a sophomore level class of mine last semester, felt overwhelmed with the academic expectations of the institution we are at and wondered if the school had made a mistake in accepting him. Bob is clearly qualified to be here and will excel. In fact he is excelling. As I tried to explain all of this to him I could see that my words were not making him feel any better. Bob and I have the same problem: Imposter Syndrome (or here). Over the last few days my experience with Bob has consumed me.

A slacker in high school I was shocked to get accepted at Washington University in St. Louis. My first few years at Wash U were spent waiting for them to figure out the mistake they made when they let me into that fine institution. I just knew I did not belong with these smart, hard working kids who had all (seemingly) gone to private school and therefore were not only smarter than me but considerably better prepared. I felt like an imposter. Somehow I fooled them and I got out with decent enough grades to consider graduate school.

I went to Johns Hopkins University for graduate training. I was one of 9 accepted to my department, and I knew from the first day I would be the first to leave. My classmates were WAY smart and I did not measure up to them in any way. Four of us survived to finish our Ph.D.’s at JHU. I did not feel triumphant, accomplished or successful. Instead my consciousness was consumed by the knowledge that they mistakenly believed I had talent and drive worthy of a doctoral degree.

Same experience for my post-doctoral fellowship at the National Institutes of Health.

Obtaining a tenure-track job was unbelievable. Each review I passed shocked me. I now have tenure. I am asked to take on responsibilities that should be reserved for the accomplished and talented. Reviewing papers for top-notch journals, reviewing grants for NSF, chairing cross-departmental teaching programs, etc. They are crazy to let me do these things.

Psychopathology cracks me up (double-entendre intended). Bob should know he is skilled and talented. The objective signs are there for all to see. I don’t think I convinced him, and wish I could have helped him. Ironically, Bob helped me. As a scientist and rationalist I tend to demand data to support claims and assertions if at all possible. When a student claims “X” I ask “what data could we find to disprove X and what extant data currently support X?”. Bob needs to start listening to the objective data. So do I.

Time for a Stuart Smalley moment! (I'm Good Enough, I'm Smart Enough, and Doggone It, People Like Me!) --> Bob, you are not an imposter. Come to think of it, neither am I.

Saturday, February 7

12 Hours?

I was on ambulance duty (as a driver) from noon to six today. We had one call. Guy’s mother, who lives out of town, is concerned and calls law enforcement to find out where he is located. Claims she had spoken with him at 4:00 AM (as in the morning) and he said he was having a medical emergency and had called the ambulance. At 4:00 pm (yes, as in the afternoon) she decides to figure out how he is. Can’t find him at a local hospital so calls police. Police check with 911 dispatch, figure out no ambulance was sent, and figure the guy might need some medical attention (no kidding). Dispatch police, fire rescue and us. We drive one block, literally one block, and control calls us off. Dude was on the phone with control, in his house, fine and dandy.

What I don’t get:

1) 12 hours between your son saying he is deathly ill and has called the ambulance and you wondering where (not even how) he is?
2) What medical emergency occurs at 4:00 am that gets you to tell your mother you need help desperately and then spontaneously reverses?
3) Why the veteran medic who went on the call with me was laughing when he heard the address and said “this won’t be a real call”.

My guess is that the above are related and that with more experience I’ll come to know and love this individual as a “frequent flyer”. In my newbie state I assumed there might actually be a problem.

Twelve hours…

Thursday, February 5

Complex Math

In my last EMT class we were given a simple linear equation to guesstimate the normal systolic blood pressure of a child (i.e., age x 2 + 80). Combine this with the knowledge that not everyone in the class is playing with the same intellectual cards and we come to today’s example:

Instructor: So with this formula you can estimate the normal blood pressure of children of various ages.

Student X with quizzical look on face: Um, I think there is a problem with your formula.

Instructor: How is that?

Student X: Well, an 8 month old would have the same predicated BP as an 8 year old.

It is at this point I begin to feel sorry for the guy, but to my surprise nobody laughs. Even more surprising are the couple of heads nodding in agreement and/or pleasure that X has found a flaw in the instructor.

It gets better…

Instructor: No, No, I see your problem. No, see in the case of an 8 month old you’d multiple by 0.8 (no, this isn’t a typo and it isn’t rounded – you had to be there for the tone).

I’m waiting for someone to catch the instructor’s mistake. And waiting. Given the defensiveness and ego of the instructor I’m not about to challenge him on something that makes no realistic difference (we are talking about differences in numbers that are not meaningful in any kind of EMS setting). However, I did have a powerful urge to ask him how we would handle the math for an 11 month old.

Wednesday, February 4

Don’t think that way!

Last night I had wild and amazing sex with a college student. Well, to be more accurate, I had a dream involving a student I know. I woke up feeling like an evil old man (I am twice the age of my students).

For the record, I have never had (nor will I ever have) a sexual relationship with a student. I am happily married, and besides, my institution’s policies are very clear on this subject. What I find curious is that my colleagues and I pretend like we don’t find students attractive. Maybe it is just my department or the guys I hang out with, but we never discuss having attractions to students (though sometimes we discuss the logistics of how to handle students who have expressed interest in us). If you are thinking “Good, that’s the way it is supposed to be”, you think like many of my peers.

Here is the problem. Like most college campuses, more than half of the students are female. Most of these females are healthy, active and between the ages of 18 and 22. If you are a typical American heterosexual male, a good chunk of your sex drive is driven by visual stimulation, and any particular combination of visual cues that happen to float your boat will likely be found in droves on a campus (and in your classroom, office, lab, etc.). The extent that this visual orientation is due to genetic codes versus socialization is a meaningless question in this context, because it is what it is. Of course the whole reason we have frontal lobes in our brain is to CONTROL our impulses. But controlling something and not having it are two different things.

My colleagues must occasionally find some sub-set of their students attractive to the extent that it is at least temporarily distracting. Given all of the other things we talk about, why not this? I am not saying we should have these conversations in a lecherous manner as certainly that is wrong. However, have we reached the point where it is harassment to discuss with one adult that we are attracted to another adult? Is it productive in the long run to have normal humans pretend that their impulses are nonexistent because those impulses are socially or politically dangerous?

Tuesday, February 3

“You do know where you sent your kid to college, right?”

Irate Parent (IP) on the phone: Prof. DJ?
Me: Yes.

IP: My Mary informs me that she wants to major in Blank. How, as her advisor, can you let her do this?
Me: Because Blank fits her interests and strengths. (the unstated second part of this: What do you suggest, I slip a ruffie into her drink and fill out her forms for her?)

IP: But how many job adds do you see in the paper that ask for a Blank major?
Me: Well, zero I guess. But you do know that the important thing is that your daughter can think qualitatively and quantitatively, express her ideas well orally and in writing, and that she knows how to solve problems, acquire new skills, THINK and LEARN, setting her up for a lifetime of success? You'll note that many of our students go on to graduate or professional school, and the others, as a rule, get well paying jobs that were never advertised in the paper. And if they change jobs at some point in the future (as most Americans do at some point), they have a generalized skill set that transfers well to other arenas.

IP: That's just a bunch of crap.
Me: I am sorry you feel that way. Out of curiosity, you'd have her major in...?

IP: I don't know. Accounting?
Me: We don't have an accounting program.

IP: WHAT? I pay $3X,XXX (yes, gentle reader, they really pay this per year for tuition, room and board) and you don't have an accounting program?

The school I work at is a liberal arts college. We have a clearly stated educational philosophy that is impossible to miss if you are paying any kind of attention to our printed materials or to the presentations made to perspective students and their families. Our curriculum is made public for all to see. If you can read, you can find out what courses we teach, what majors we offer, and what we think a college education is all about. I believe we do a good job and I am a firm believer in the liberal arts tradition. I do understand that there are individuals who want a college experience that is more akin to a professional degree program (e.g., accounting, applied engineering, computer programming, etc.). If this is what you want (or want for your child), why in the name of all that is pure would you go to (or send your kid to) an expensive school with stated goals that conflict with yours?

I admit I am very slow as I really do not understand how people who can amass enough wealth to spent well over $120,000 U.S. dollars on an education do not take the time to evaulate what they are going to get before they sign on for the long haul.

Monday, February 2

“Know your right from left”.

I just got back from my EMT (emergency medical technician) class tonight. To set the stage, there are currently 50 people in the class, many of them local to the area, several college students from the school I teach at, myself and my friend who is working on his Ph.D. (at a far away university) while he works full time at the college. The IQ range in the room has got to be, and I’m not kidding, 40 points or more.

The good news: There are some very well-meaning and kind hearted individuals who want to donate their time and energy to helping their fellow humans, all for no monetary remuneration and, in most cases, no thanks.

The bad news: The class is run at a pace set to keep as many people on board as possible. Some of these people will fail out due to a lack of basic skills that a decent society should be conveying to 8th graders.

Example level of teaching issue: If I tell you someone has a laceration on his right arm, to which arm do you think I am referring? Yes, of COURSE you know where I am going here. However, just in case you are lost, here is a rough translation from class tonight: “this is really confusing because their right is your left, and the other way around, so when you think right, think left, but be sure when you say right you mean the patient’s right”. Ten mintues of this. Really.

When referring to the patient refer to things relative to the patient. That’s all you need to say. Say it once. Say it twice for all I care. But for goodness sakes, WE GET IT. Or at least I hope we do.

Side note:
I do not mean to demean anyone by the IQ statement. Certainly our worth as humans is not IQ dependent. Indeed, we all know “smart” people that are socially retarded, odd, or just plan nasty. In addition, I fully appreciate that beggars cannot be choosers. You call 911 in this community and need the help of the fire department or emergency medical services, and you’ll get your neighbors. Professors, students, mechanics, snow plow operators, food service workers, farmhands, the unemployed, engineers – you name it. They come, they do the best job they can do, and you get help. Most of the time you get damn good help from caring, well trained people. The alternative is to go back to the 50’s when the “ambulance driver” was just that, and it was scoop, drive and drop, with no treatment. When there are more cows than people in your county you take what you can get and we have it pretty good. I just think an EMT class should be taught at the lowest level you’d want for decent EMTs, not the lowest level of the people in the room.

“Because he was the designated driver”

Context: I drive an ambulance as a volunteer. I like driving. I like alcohol. I think the two combined are a mistake (and the extant data support this idea)...

Situation: I’m on call from 6pm to 6am (Saturday night to Sunday Morning). Pager goes off at 3 something AM for a motor vehicle accident (MVA).

I jolt awake to the pager, and begin to get worried when I hear the location – Almost certainly a head-on collision at highway speeds. When we get to the scene fire and rescue is already there and the fire chief directs us to where he wants us to park the rig. He looks pissed. Not worried, or sick to his stomach, or even resigned. Pissed. I’m thinking maybe no head-on but instead someone woke him up for no good reason. Good call on my part...

The scene consists of a car off the road stuck in the snow. No real damage, though if a tree had been there the story would be different. Six VERY drunk individuals (18 to 21 year olds) tell us they are fine and stumble out of the car into the back of the ambulance for evaluation. They are all indeed fine, except they are all intoxicated. The guy who was driving seems to be the most intoxicated. I overhear a very distraught woman (it was her father’s car) tell the police officers that she will be in deep trouble. A police officer asks her why the guy was driving given he seems the most messed up. She says “He was the designated driver”. Officer says “yeah, but he is very intoxicated, so maybe someone else should have been driving”? She says, as if the officer did not hear her the first time, “HE WAS THE DESIGNATED DRIVER”. The officer nods and smiles in mock understanding. Clearly her definition of what it means to be a designated driver was different than mine or the police officer’s.

Note to all playing along at home: The goal is for someone SOBER to drive, not to have someone else take the risk of getting the DWI.

More later.