PJ's brain unfiltered. Now with more pulp!

Posts tagged “paramedic school

The Thing About Actually Finishing Paramedic School is…

The very day that you pass your last exam and realize that you’re now a paramedic, you hope to god that your National Registry card gets lost in the mail. You’ve spent 12+ months working 26 hour days and when it’s all over, you wish you had more time. “What the hell just happened? What do you mean I don’t have class anymore? I have to run cardiac arrests on my own now? Sweet zombie Jesus…”

I did pass and I am a paramedic, but the wave of shock has yet to hit. The waters are still pulling back like a tsunami.

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Quick little personal update

December was the crescendo of paramedic school — graduation on the 12th, my written National Registry exam also on the 12th, and my practical exam on the 19th. My written exam was very intimidating, what with all the digital fingerprinting required to get into the computer lab, the constant video/audio monitoring, the multiple forms of identification — but it was all over within 60 minutes.

National Registry has almost entirely gone to computerized testing for their written exams; they boast a question bank of ~30,000 questions that the system roots through and presents at an adapted level of difficulty in relation to the test-taker. It gives you a mid-level question: get it right and it will give you a harder question; or get it wrong and it presents an easier question. This process is repeated until the computer is convinced of your competency (or incompetency). It may take the student 60 questions to get the computer to decide, or it may take a full 160.

Anyway, I woke up on the 12th, played some Guitar Hero to get me zen, and took the exam. By the next day at noon, I’d already received my results. I passed!

Graduation was actually very enjoyable: lots of family, lots of fellow paramedics, lots of supervisors — I was very impressed with the level of support everyone has for each other. Everyone wants to congratulate me, and honestly, it’s the first time I’ve been sincerely proud of something I’ve accomplished. God dammit, I did everything I was supposed to without fucking up, lying about hours, failing out, getting sick, skipping work, or anything else. I finished paramedic school & all the clinical hours and still worked all my 13 hour night shifts. Screw you, day-shift! ::shakes fist::

Err, anyway, it’s been a great week! Wednesday the 19th is all that stands between me and the end.

Thanks for listening to my whining this whole year; catharsis helps!


Tips for starting IV’s

My suggestions:

  • For your patients that are scared of needles, let them know ahead of time that the IV site won’t have a needle in it once you’re done. It’s just a plastic tube and won’t hurt.
  • Don’t stop progressing the needle once you get blood flashback. Pause perhaps, but don’t stop. You need to advance the Jelco a TINY bit further and THEN you are in the vein. Remember that the needle tip sticks out from Jelco — just because the needle is in the vein doesn’t mean that the surrounding catheter is. So when you get flashback, progress a pinch further.
  • If you have a geriatric patient with paper-thin skin, don’t feel required to use a tourniquet (and use a 20–no reason to poke a giant hole if they’re not bleeding out).
  • Just before you use your Jelco, give the hub a little twist while it’s still fastened to the plastic; this will keep it from sticking when you attempt to retract the needle.
  • If you do want to use a tourniquet on a paper-grandma, tie it loosely. Also, you can use two (of the rubber variety). Two tourniquets overlapping each other tends to keep it flat instead of becoming thin & narrow — biting into the patient’s skin.
  • Look at your AC’s. Notice that on one arm, you have one “AC” in the dead center, while on the opposite arm, the vein bifurcates and forks around the center. 99.9% of the time, if the patient’s AC is in the center on one arm, it’ll bifurcate on the other one. You can use this to your advantage when blind sticking. (more…)

Notes from my HazMat class

Because I’m too lazy to take all of this and convert it into some sort of an interesting article. Maybe some other … year.

  • hazmat site “zones” are generally tear-drop shaped in relation to wind directionPerfluoroisobutene
  • ANFO” = most common explosive used in the US
  • Matchbook strips = phosphorus = collected in large quantities for methamphetamine labs
  • Newport, TN : 4 M’s — marijuana, meth, moonshine, methodists
  • C4F8 – Perfluoroisobutene – Russian hemorrhagic agent
  • Pentaborane (1380) — post-WWII experimental jet fuel
    • worse than nerve toxins
    • untreatable thus far until 2000. No safe methods of disposal. (storage was in SC)
    • 500 Montgomery Rd. 1993 – 1994 (Divex??)
  • Paper-mill smell : sulfur dioxide, which can be in poison-crude-oil wells
  • “halo climb” <– [no idea]
  • Hydrocarbon inhalation – fumes generally heavier than air (ex, phosgene— smells like newly mowed hay)
    • heavier than air gases fill up lower lobes of lungs & asphyxiates patient slowly
  • NIOSH: Pocket Guide to HazMats (1800 35 NIOSH)
  • International vs. trans-national vs. domestic terrorism
  • Dugway (?) -> isolated test site in Utah
    • open-air testing of chemical & biological weapons
    • reason #1 not to live anywhere near Utah
    • million times worse than “Area 51”
    • I don’t even want to link to their .mil website, so here’s the wiki-entry.
  • Chlorine gas = lvl 1 toxicity gas. Used as the standard for hazmat toxicitiy
    • gas with lvl 3 toxicity is 3 x toxic as chlorine gas = “Toxic Index Factor of 3”
  • Phosgene Oxime (CX) — garlic-like odor; solid; toxic index factor of 6
  • “G-series” nerve agents were produced in Germany.
  • “V-series” nerve agents were produced in the US. (ex, VX [which is 600x toxic])
    • V-series > avg. toxicity of G-series
  • SLUDGEM [Salivation, Lacrimation, Urination, Defecation, Gastric Distress, Emesis and Miosis]
    • Miosis – pupil constriction to the point of blindness; may take up to a month to go away even with immediate kit administration
  • Suspected nerve-agent exposure
    • Phase 1: Miosis, salivation, lacrimation
    • Phase 2: gastrointestinal disturbance, emesis (2 kits) Mark I kit
    • Phase 3: urination, defecation [practically grand-mal seizure equivalent] (3 kits)
  • Sarin 200 x toxic
  • Protective sprays — OC is the most effective. Don’t bother mail-ordering sprays; not worth it protection-wise if it’s legal to mail.
  • Deta-sheet: thin explosive, like C4, but uh, thin?
    • hallmark greeting cards used as detonators (wtf — happy birthday, motherfucker)
  • Bat guano = salt peter = used to be given to new military recruits to decrease libido.
  • 70% of all terrorist exploits involve explosions
  • Doxy – broad spectrum antibiotic (used for plague)
  • smallpox vaccine still available — free to EMS personnel (still that huge circular scar?)
  • Rickettsiavs other bacteria
    • rickettsia bacteria requires host (like viruses); carried by parasites; responds to antibiotics; example: typhus
    • bacteria – warmth, food, 02, no host
  • Russians have gender (rumored) & race specific anthrax. (wtf! again)
    • 10 yrs ahead of world biological agents
    • re: Alibek
  • Between 2,000 to 300,000 soldiers died constructing the Chernobyl cement cover (allegedly)

When I finished typing up all my notes, I reread it all and decided that I didn’t want the FBI to watch me sleep, so I’ve censored it a bit (EVEN THOUGH all this information was legally provided for me in a classroom setting and is easily accessible on public government websites and wikipedia). The only hazardous materials that I generate come from my behind. I’ll swear to Zombie Jesus that I’ll never involve myself in HazMats of any kind; I like my skin on my person instead of sloughing off and sitting in piles around my body.


Currently

One of the more difficult aspects of paramedic school is getting all your clinical & ride time hours done [while managing to work full time, go to class full time, and sleep/study when you have a few hours]. We’re required to have 260 total hours on the trucks, and approximately 180 clinical hours. Clinicals are roughly comprised of 72 hours in the Trauma-1 Center ER, 16 hours in Triage, 24 hours in the pediatric ER, 12 hours in Labor & Delivery, ~12 hours in the OR (for intubations), 12 hours in CCU [Coronary Care Unit], 12 hours in ST-ICU [Surgical Trauma ICU], 8 hours in NICU & PICU, and ~6 hours in the morgue [an autopsy or two].

Along with all those hours, you’re required to have a certain number of patients with varying complaints:

  • 75 Adult patients (minimum)
  • 20 Geriatric patients
  • 30 Pediatric patients
  • 10 OB patients
  • 10 Psychiatric (not enough)
  • 10 Altered Mental Status patients
  • 20 Abdominal Pains/GYN patients
  • 40 Trauma
  • 30 Chest Pain
  • 20 Respiratory
  • 15 Syncope

It’s not a bad list; I think it’s more than reasonable — it’s just a matter of getting it all done in about 5 months while juggling all your other responsibilities. And thank christ, I think I’m finally done with it all.

We’ve finished all our major modules and have moved onto the “canned classes”: ACLS, PHTLS, PEPP [instead of PALS?], & AMLS. We have review days from the last week of November until December 13th. We graduate the first week in December and take the National Registry exam the week before Christmas. So it’s all winding down. December seems like next week, but god damn if it’s not still a month and a half away.

And in the end, I could have become a phlebotomist and probably been just as happy. It turns out all I wanted to do was be able to stick people. That’s all I look forward to these days… that and psych-patients.

 Note to self: write up a post on the HazMat class.


Answering googled questions

  • “how to insert a jelco”

A jelco is actually a Jelco [see below]. It’s the IV catheter that pretty much everyone in the medical field uses. It basically consists of a plastic tube (the catheter) slid over a hollow needle, which is attached to a clear plastic handle. The tip of the needle sticks out just barely from the end of the tube — you use that tip to pierce the skin and insert it and the surrounding tube into the vein. Once both are inside, you use the plastic handle to retract the needle out from the tube. At this point you can detach the clear plastic handle from the green part [** in the diagram]. The green part sits on the outside of the skin and acts as a port into the vein; you can attach IV tubing, syringes, or other items directly to it.For people who are afraid of needles, I find it helps to explain that the IV site doesn’t actually have a needle in it once I finish with it. It’s just a thin, plastic straw that can mostly bend with your arm.

jelco diagram

When I first started paramedic school, my “big threshold” was starting my first IV and getting the hand motions down right. I found that the best way to practice (besides sticking people) was getting a few of the expired jelcos and practicing on a drinking straw.

The most basic “how to” follows: find your potential vein, tie a tourniquet above it, let the blood accumulate for ~15 seconds so that the vein will become more conspicuous, clean the site [alcohol, betadine, alcohol], “let it dry”, hold the jelco between your thumb & middle finger, push it into the vein, use your pointer finger to hold the hub while retracting the plastic with the thumb & middle finger, occlude the vein with your left hand, detach the needle casing. Minus the details, that’s how I’ve learned to do it and it works for me.

  • “how long does it take to finish autopsy”

About 30-40 minutes, unless they suspect foul play or things get complicated and they can’t find the fragmented bullet.

  • “can i have long hair as a paramedic”

Yes, you can, but only if you wear it in a pony tail or something similar. You don’t want that shit flying in your eyes when you’re carrying someone across the highway, getting in your mouth while giving CPR, potentially catching vomit, or existing as an attractive head-handle for a psychiatric patient to yank. Our service doesn’t allow us to wear earrings for that last reason alone.


Tell me about Paramedic School

I’ve noticed that I have been getting quite a bit of search-engine traffic focused on paramedic school. I don’t pretend to have all the damn answers, but here are a few of my opinions on the matter.

  • How long does paramedic school take?

These days it is usually seen as a two-year course. In the end it entirely depends on where you take it, but usually it is two years. I’m told that the first year is mostly anatomy, physiology, math, or somesuch, and the last year is all specifically emergency medicine. My instructor admitted to us that he compresses it down into an intense 10-month course largely because he just cannot stand to put up with a single class for 2 years.  (And looking at some of my classmates, that is entirely understandable.)

  • What does it take to make it through Paramedic School?

Diligence. Like I said, we do it all in 10 months, complete with working full-time and 490 clinical/ride-time hours, so we have to constantly reinforce each other. The other paramedics you work with probably are not going to give a shit about the struggle you are going through. “I already got my patch; now it’s your turn.” They entirely disregard that the class is much longer, has more material, more requirements, and more clinical hours. But fuck them, you can do it and you will be a stronger person because of it.

This is nothing like college or high school; the material is critically important. If you coast through, you could miss something seemingly trivial and someone very well could die along the way. Yes, you really do need to know every little bit of information on that drug sheet. You really do need to memorize your state’s entire drug formulary. No, you can not just learn your service’s protocols; they will never be able to cover every issue your patients will have.

This is not a job for mediocre people. You want to half-ass something, be a fireman. [Ooooh, burn.]

  • What is Paramedic School comprised of?

For some, you have to start off with about 5 weeks of anatomy/physiology. I do not know why they bother to teach this separately because it is incessantly reiterated as you progress through the modules. Dead horse, and all that.

We started off with legal nonsense, radio transmissions, landing zones, etc. Then was a big dose of Airway (endotracheal intubations of every flavor). IV starting. These are covered early so that you can go ahead and get started with intubations and IV sticks during your hospital clinical time. Next was Cardiology, specifically EKG strips. Be prepared to read thousands of strips in the next few weeks; you’ll be identifying the rhythm in every single one of them. Tedious, but once that light goes on in your head it turns into a delightful puzzle (the one and only time I will ever use “delightful” genuinely.) Mixed in with strips is cardiopathology, ACLS, and other related topics. This is also when you learn how to shock people. Good times.

A good bit of Trauma and finally a giant textbook of medical problems (strokes, seizures, diabetes, allergic reactions, etc.) and you will enter into the special considerations portion of the class. The beginning of the end. Geriatrics. Pediatrics. Bariatrics. WMDs. Bioterriorism.  HazMat.  A series of certification classes similar to ACLS and you are in the clear.

All this time that you have been in class, you will have been going to various hospitals for 240 hours of ER clinical time. There is also an autopsy, OR time (for intubations), Coronary Care Unit (critical cardiac patients), Surgical Trauma ICU, Pediatric ER, Neonatal ICU, Pediatric ICU, uh… triage time, something else I can’t remember and possibly 12 hours at your area’s burn unit.

There is, of course, ride time. 250 hours (for us) of being the second paramedic on a truck. Enjoy it while it lasts. When the shit hits the fan, it will ultimately fall on the shoulders of whoever you are riding with. It won’t be long until you hear, “Need anything?” *SLAM SLAM* with you and your patient alone in the back.

  • How much does Paramedic School cost?

Depends! My answer for everything. Usually it is in the realm of $4000 to $6000 . If you are lucky, your service will shoulder the costs and send you for free. Don’t let them make you feel guilty for it; chances are they’re probably getting a hefty grant from the government thanks to all the 9/11 nonsense.

  • What’s the hardest thing about Paramedic School?

I had the total misconception that it would be IV sticks. I don’t know where that came from, but I was entirely wrong. IV’s are ridiculously easy compared to the rest of what you’ll be going through, and I actually have a 78% success rate at this early stage of my career (dialysis and obese patients :argh:). The hard part is remembering all the drugs and their associated dosages and contraindications. Or taking all the information from the various medical portions and piecing it together to form a quick diagnosis. But really: staying awake at work or at class. Give up on having a social life. Don’t start any new relationships. If you work night shift (as I do), kiss your sleep cycle goodbye.

I don’t feel like I’ve been very helpful, but if there are any more questions that anyone might have about paramedic school or EMS in general, please feel free to leave a comment and I’ll get back to you.


Go lions!

Tomorrow morning is my ultra-huge cardiology module exam.  A chunk of broad spectrum heart anatomy combined with specialized portions on nerves, biochemistry and signal conduction make up a good half of it.  The rest is comprised of dysrhythmias, cardio-pathology, related pulmonary topics, 12-lead EKG data, and a 150 EKG-strip exam where if I miss a single lethal dysrhythmia, I fail the entire thing (which I actually find to be reasonable).  All these portions combine to form the megazord, Voltron, a giant cardio-based robot who will fall from the heavens directly onto my car and use his Blizzard-Star Sword to stab my heart and rip it from my chest.

If the giant robot/exam doesn’t destroy me, I have plans to get completely shitfaced afterwards.  Actually, I think I’ll end up doing that either way.


Nakid

I didn’t notice until very recently that I’ve slowly developed some strong Type A personality characteristics. It used to be that I didn’t really fit into any category, but since I’ve started EMS I’ve plinko’d right down into A.

Specifically, every time I make the slightest mistake, whether it’s saying the smallest wrong thing in front of a patient or missing the first IV stick, I kick myself over it for hours. My supervisors and most of my crew-chiefs are aware of this and have almost entirely stopped reprimanding me if I ever make an error; they know that I’ll beat myself up much more than they ever could (and quite frankly, their added criticism might break the camel’s back).

If you were to sit down and read all the paperwork I write up for the field-calls I ride (for paramedic school), you’d notice that every one of my IV sticks are single attempts. If I don’t hit the vein within about 15-20 seconds on the first stick, I get ridiculously annoyed with myself and have the paramedic present finish the stick for me. Mind you, I’m getting good enough that I rarely miss–especially in a controlled environment like the hospital.

That reminds me–last night we picked up a nurse that worked in one of the many local hospitals and she required two bilateral IVs. By the time I was starting the second IV in her right hand, she had mentally cleared up enough to ask how we could possibly start an IV [“insert a Jelco”] with the ambulance still moving. I smiled and said something about specified training. And thank god I proceeded to make it on the first attempt because that would have been awkward. Because, you know, it wasn’t already awkward to be standing spread-eagle across this woman’s stretcher while she’s completely naked from the waist down, bleeding out, and throwing up.


Surgical Sociopaths

Paramedic school requires clinical hours at the ER and OR, the latter specifically for ventilation and intubation experience. Thursday, May 17th was my scheduled run in the OR, and I’m up at 0500 reviewing my textbooks in small degree of terror.

I want to make a good impression, so I stop at Dunkin’ Donuts beforehand and pick up two dozen donuts — one for the ER department and one for the OR. I stop by the front desk in the ER to drop off the donuts and to get a pep talk from some of the nurses and receptionists. It helps, but only a little.

My instructor’s directions only get me to the third floor of the hospital, which is apparently a giant maze devoted to surgery. I step off the elevator and have no freaking idea where to go. My cell doesn’t get signal inside the hospital (what the crap?), so I can’t call anyone for directions. Instead, I take to stopping anyone who makes the mistake of walking within five feet of me. The sixth person I stop turns out to be the right woman; she kindly leads me right into the OR lounge, shows me where to get scrubs, gives me her personal locker combination so I can store my uniform, and tells me where to go to find my preceptor. And then I never see her again. I change and store my uniform. I get accosted by a surgeon in the locker room for using someone else’s locker. I offer her donuts.

It takes me five minutes just to put shoe-covers over my stupid combat boots, and then I discover that I look like a huge dork in the long-hair surgery caps. Everyone keeps asking me if I’m a freshmen from medical school and they seem to deflate when I say I’m a paramedic student. I seem to blend in alright: I’m familiar with most of the drugs they administer, with their charting and computer systems, with the anatomy and general procedures I get to view. I hear more than a few times that usually the paramedic students are pretty dumb and that I should go into nursing; I’m a bit insulted but refrain from responding.

Surgery’s Apparent Conception of EMS:

  • No patient interviews whatsoever.
  • We don’t know what an airway is.
  • Bagging a patient? Isn’t that what the coroner does?
  • Blood pressure: two numbers that mean nothing unless they’re really high or really low.
  • Shut the hell up and drive, EMT.
  • Albuterol: the only drug EMS uses on live patients.
  • Epinephrine & Atropine: drugs given only to dead patients.
  • People go into EMS because they couldn’t make it in nursing/med school.
  • Paramedic school is a two year course that uses coloring books instead of textbooks. It’s true; I’m constantly running out of red and blue crayons.

At 0700, 100 people materialize out of thin air and converge on the narrow hallways outside of the lounge. Somewhere in the chaos is my preceptor, and I find him, but I don’t realize who he is until much later when I see him sign some paperwork. No one introduces themselves. No one addresses you before speaking to you. People will just spontaneously walk away and you stand there wondering if you’re supposed to follow; sometimes you are, sometimes you’re not.

I never see any of the anesthesiologists do much; their CRNAs seem to do it all for them: patient interview, chart research & review, intubation, IV, ventilation, medication prep. The CRNA attaches the four assorted syringes required for general anesthesia to the IV line, the anesthesiologist pops in for 45 seconds to push the plungers in and to watch the intubation. Then, like a ninja, they disappear.

Two of the CRNAs kindly take me under their wings and let me follow them around as I’ve long lost contact with my preceptor. They hunt down a few patients for me to intubate, which is an unfortunate few simply due to that day’s scheduling. I wait for the next series of surgeries by watching a spinal fusion. A surgeon with a fiberoptic tail screws metal into an old woman’s spine, using 2-D x-rays to develop a 3-D map in his head. One of the CRNAs explains to me that the patient still experiences pain, they just don’t realize it. However, their body reacts to it — every time the surgeon does something that makes me cringe inside, the patient’s heart rate and blood pressure increases. I’ve known this fact for years, but there’s something to be said about witnessing it.

There are 26 ORs on this floor. Surgeries are scheduled within tens of minutes of each other. As soon as one finishes, the patient is quickly wheeled out, the cleaning staff swoops in and sanitizes the room, and the next patient is soon wheeled in. The staff appears to be mixed and matched randomly for each surgery; I don’t see the two of the same nurses in the same OR more than once. Only three hours pass and it feels like seven. I have no idea how these people can maintain this seemingly frantic assembly line for 12 hours straight.

At 0900, I declare that I need a calorie recharge and slip downstairs to the cafeteria. I have some sort of magical timing because I just happen to come across one of my fellow paramedic classmates doing clinical time in the ER. I’m so overwhelmed that I run up and hug her; I don’t even know her name, but I’m so happy to finally see a face I recognize. She gets a free favor in the future for letting me unload on her.

I stick around after my last intubation to watch the full surgery from start to finish. I help move the patient a bit and assist with basic surgical necessities. It feels nice to help instead of just stand there watching. By noon I’m completely exhausted and resigned to the obvious fact that I’m going to have to come back another day. I get two endotracheal intubations and one LMA out of the experience. At least I finally realize what I’m doing.