I love posting articles controversial enough to warrant a disclaimer. Today I have the pleasure of bringing you another post by guest author Sean Fontaine. Sean is a graduate of Regis University and a Firefighter / Paramedic for The South Metro Fire Rescue Authority. He lives in Denver, Colorado with his lovely wife Oz and their two sons Jonas and Axel.

Today, Sean throws down the gauntlet on an issue that must be addressed by every emergency caregiver; the delicate balance between delivering objective, impartial medical care and the urge to interject our emotions into the often emotional drama that is emergency medicine. Can you make real emotional connections in the process of administering medical care, or does the emotional aspect of the job directly impact the effectiveness of your care? Some of us may address this dilemma only in our own private thoughts. Others may wish to publicly declare their position. To that end, here’s Sean…

Let me preface this post with the explanation that this topic comes straight from my discussions with paramedic school students and co-workers and the differing/agreeing viewpoints that resulted from those discussions.  These are my opinions (not Steve’s) and I know full well that there are many of you out there that will disagree and some that will think I’m an insensitive ass. So be it, we’re here to listen to different viewpoints and think through them for ourselves, deciding in the process what our own thoughts truly are on a given subject.

The Argument: Your level of objectivity effects the quality of your patient care.

I contend that when we emotionally care about our patients we become subjective caregivers and as such render subjective care, transitioning to reactive rather than proactive medicine.

This topic has come up with co-workers when discussing my history of sick and dying pediatric patients, traumatic or precipitous delivery OB calls, and violent sexual assault calls over the past 10 years. (In comparison to the rest of my calls.)  In addition, this topic inevitably came up when I spoke with last year’s paramedic school class at a local teaching institution. (I was speaking on the subject of pediatric death and dying, prior to their PALS scenarios.)

During those instances, I stated with no intended malice, that a sick, dying or dead pediatric patient demands the same mental cognizance as a sick, dying or dead adult patient.  As such, I see no reason to change my treatment or mindset because the pediatric patient is viewed as “innocent” or deemed “more worthy” of our efforts by some caregivers who then become emotionally involved with the patient.  All patients are “worthy” of our full and complete efforts and treatment. That’s our job.

Once we take that step and become emotionally involved with our patient, I believe we cease to observe and treat to the fullest extent of our ability. Hence the previous statement regarding the rendering of subjective and reactive medicine, rather than focused, proactive medicine. I believe that we are paid to think through patient’s current signs and symptoms and consider differential diagnoses, treatment options, appropriate destinations and the most appropriate continued course of treatment. Then, through the course of these actions…we care for our patient by acting in their better interest. We act as their “advocate” if you will.

As you can tell by my verbiage the line as I see it is, “Caring for your patient equals proactive/objective care, whereas caring about your patient equals reactive/subjective care.

Don’t think that I don’t appreciate the weight of this argument. I have had numerous sick, dying and dead pediatric patients with a myriad of outcomes, some of these patients have been carried in my arms to the ambulance, as I have likely carried my own children at some point. However, in acting as our patient’s advocate, we need to operate without our emotions. It’s part of the cost of doing business for us as caregivers.  That’s not to say that I don’t think about the potential gravity of the call, I just do it later.

Thinking through the call later is good for multiple reasons, such as addressing learning points, emotionally dealing with the gravity of the call, and ensuring that the crew are dealing with all associated issues in a positive manner. There is an agreement made when choosing this profession and this unspoken agreement is what defines that “mental cognizance” we are asked to bring on each call. This “mental cognizance” doesn’t recognize age, sex, color, religion, level of income, level of education or attitude. Every patient is deserving of our best and most objective efforts. The great part about this agreement though is that it’s nonbinding. We can opt out at any point and move on with our lives.

As I said earlier, I appreciate the weight of this topic. I do not intend to come across as callous in my stated opinion. I also don’t tread through unfamiliar territory. Quite the opposite, this is territory I’m quite familiar with and fully appreciate after some time running these calls. Additionally, I have come to a personal understanding about how to best work through these emotional issues, both during and after the call, to render the best possible objective patient care.

Now it’s your turn:

Thanks Sean. Now I’d love to hear what you think. Can emotions and objectivity be separated during the course of patient care or do they inevitably affect your care? Leave a comment and let us know.

Related EMS Awesomeness:

Five Tips for New Paramedic Students

Overcoming EMS Burnout

Connections

Coping With Grief and Tragedy

One EMT Can Make A Difference

]]> http://theemtspot.com/2012/01/22/objectivity-and-patient-care/feed/ 9 http://theemtspot.com/2011/05/06/five-tips-for-new-paramedic-school-students/ http://theemtspot.com/2011/05/06/five-tips-for-new-paramedic-school-students/#comments Fri, 06 May 2011 14:11:20 +0000 Steve Whitehead http://theemtspot.com/?p=4348 A guest post by Sean Fontaine.

I’ve been bugging Sean to write a guest post for the blog for a few years now. I don’t usually harass my friends about writing content, but Sean is so enthusiast about his work that I just couldn’t help myself. As a first year paramedic, Sean has a unique perspective on what it takes to make the transition from EMT certification to paramedic. In this post, he shares with you five things that can make the difference between success and failure.

Sean is a graduate of Regis University and a Firefighter / Paramedic for The South Metro Fire Rescue Authority. He lives in Denver, Colorado with his lovely wife Oz and their two sons Jonas and Axel. If you’re considering making the jump from EMT certification to paramedic practice, you won’t find better advice anywhere.

Steve and I have been discussing the possibility of my writing a guest post for The EMT Spot for a couple years now. So, after paramedic school and clearing as a new paramedic were done, he proposed that now was a great time to stop backpedaling and get on it. I’ve been accused of dragging my feet on getting this done. Shooting topics back and forth, we came to the obvious conclusion that an article discussing five tips for new or perspective students would be far more uplifting than the pediatric death and dying discussions that I’ve been having with the current paramedic school students.

With that said, here are my top five  tips for fledgling paramedic school students.

Tip #1: Get Ready for Paramedic School

Let’s start with the question I’ve heard prospective and new paramedic school students ask over and over again, “What do I need to read to ensure that I’m ready for paramedic school?”

Don’t worry, everything you need to read to be ready for paramedic school is in your EMT-Basic book. There’s a reason every EMS class and every EMS book you’ll come across stresses the ABCs; these are the basic essentials that we use to evaluate and treat every patient. These are the basics we need to be prepared to treat and have within normal limits before we move forward with our patient assessment. These are also what you should fall back on when your advanced interventions aren’t working or cannot be performed for any reason.

It sounds trite, but every good paramedic begins as a good basic. Without good assessment skills and the ability to use your five senses, instead of your machines that go ping, it will be an uphill battle to work up your patients. To re-emphasize that point, you should have a systematic approach to your physical assessment of patients when you’re arriving at the door of paramedic school. This systematic approach will save you time and again. It’s your job to find out what is wrong today, not theirs to tell you. Quite often, they can’t or won’t tell you.

Your EMT-Basic book also teaches basic anatomy/physiology, patient presentation, and how to address insults to the ABCs. All of these are foundations to what you will begin building upon as a paramedic student.

Tip #2: Learn From Your Mistakes

One of the most important lessons you can learn early on in paramedic school (if you haven’t already learned it as a basic) is to learn from your mistakes. Mistakes are inevitable, they’re going to happen. No one is perfect. Perfection doesn’t exist in medicine. (Hence the practice of medicine.) There’s a learning point to every call, rookie or vet. Learning from your mistakes means recognizing where you’ve gone wrong, and likely 90% of the time you’ll realize it as you’re making the mistake, or soon there after The other 10% your preceptor will let you know. Then you can mentally bookmark what you did, why it was wrong, how to correct it in the future. Then move on and don’t dwell on it. Go on to your next call in two minutes or two hours with a clear head and treat the next patient.

Learning how to move on, so that you’re not dwelling on the mistakes you’ve made, will help you continue moving forward and learning, so that you can competently listen to and treat your patients appropriately. Dwelling complicates things, muddies your thoughts, and doesn’t allow you to learn from the mistake. It usually stems from that nagging need to be perfect. Again, remember that perfection doesn’t exist in medicine. It’s an environment where we’re constantly learning and can always strive to do better at something every day.

In addition, there will be numerous subtleties that you likely won’t clue in to yet, with regards to patient presentation.   Don’t beat yourself up over this – it is normal during school. The purpose of your clinical rotations and field rides is to reinforce pattern recognition and patient presentation; this is where you start learning the subtleties. This is why, when you watch your preceptors run calls, they may only ask a handful of pointed questions and seem to be confident in the direction they’re heading with treatment, while you’re still trying to figure out why the patient called 911 today.

Medicine has numerous shades of gray and you’ll learn that what was right to treat one patient may not be right with another of similar presentation due to subtleties of their disease process/injury.

Tip #3: Communicate Effectively and With Confidence

In order to begin running calls in any capacity (Meaning you begin, then your preceptor takes over or you run a call from initial contact to the final destination.) you will need to be able to talk effectively to your patients. This skill doesn’t come easy for every one and usually isn’t seamless early on in your clinical experience, but this is another skill that your clinical rotations and field rides will reinforce again and again.

Steve wrote a post around a year ago about how, if you actively listen to your patient after asking a question, you’ll likely hear some of the answers you were looking for. However, when your head is overloaded with material from class and your desire to find answers outweighs your patience to listen, you won’t hear this information.

Instead, after you ask a question, you’ll likely be distracted from the patient’s answer because you’re thinking of the next one you’d like to ask, and then as soon as they stop talking, you repeat the cycle again. This rapid fire questioning and not listening is very common during some portion of paramedic school for most people. Frustrating as it is, it will pass.

One of my partners described the paramedics who could seamlessly transition between different populations and have similarly good patient interactions with them all. (A social chameleon.) Eventually you’ll need to be able to speak competently, without jargon, to people of any age group, income or education level. Your ability to cultivate this skill directly correlates with how quickly and effectively you gain patient trust and build a rapport. Strong rapport is built quickly. Patients observe how you carry yourself, the respect with which you speak to them and others, the confidence that you convey, how you discuss their current situation, how you would like to remedy it and the calm manner of your delivery.

Rapport cannot be underestimated. Without it, calls tend to run with more difficulty and patients do not have as much trust in you or your skills.

Tip#4: Your Habits and Attitude Will Make or Break You

Your attitude can make or break your paramedic school experience. A positive attitude, a clean uniform and respect for your preceptor, your patients and the hospital staff will go a long way toward ensuring that your reputation is a good one. Along with the previously mentioned items, a strong work ethic and the realization that you don’t know everything will further cement that good reputation for you. This is a good mantra: work harder everyday than you did the day before. Whatever reputation you have, good or bad, everyone at the agencies where you’re doing your clinicals and rides will know that reputation before they know you. Reputations precede and follow you everywhere you go. A bad reputation is exceedingly hard to get away from.

Part of your strong work ethic should include learning the par levels and location of all of the equipment (on the ambulances you’ll be working on) as early as possible. It’s your job as a student to know where everything is. Your preceptors already know this stuff.

Another aspect of illustrating a good work ethic is a dedication to studying your classroom material. Bring your books on rides for slow times. Be cautious with reading them during clinicals, because there’s almost always something you can be doing instead of reading when you’re in the hospital. (The OR rotation might be an exception) You don’t need 100% on all of your exams, but you should be able to discuss and apply all of the material appropriately. Remember, your patients won’t care what your grades were; they will care that you can treat them with a solid, common sense approach.

The key to studying well is finding out how you learn most effectively and using this approach consistently throughout school. In addition, ensure that you budget your time wisely with regard to studying and scheduling your clinical hours. If you get behind in either one you will quickly feel overwhelmed. Then that focus on a positive attitude will suffer (as will your work ethic) because you have diverted your energies elsewhere.

Tip #5: Take Care of Your Family, Your Friends and Yourself

Lastly, all of the above things don’t matter if you don’t take care of yourself and your family. Though I just stressed the importance of vigilant studying, learning from mistakes, learning to talk with others, attitude, work ethic, and all, none of it matters if you’re a hermit with failing relationships due to stress and exhaustion.

You should have days where you put down your books and go out with your family and friends and decompress. You’re going to need it. One of my friends told me just prior to school that I should put my books in a box on those days, because he knew if I could see them I’d be inclined to open them. You’re also going to reach a point where you’ve studied enough and further studying will only stress you out instead of reinforcing the material. It took me a while to realize when I had reached that point. As time went on, I could feel it and I would walk away, go for a run, go out for dinner with my wife, get ice cream with my kids, even do house chores.

Hopefully, your family supports your decision to go to paramedic school and understands that you will be intermittently absent both mentally and physically. You will have periods where you can’t get away from school, be it clinicals or studying, and they may resent this from time to time. In those times, seeing the end goal is huge for all involved, even though, yes, the short term can suck. As your family supports you during school, you should support them. Let them know that you appreciate their love and support. Let none of it go unnoticed, no matter how exhausted or stressed you are.

The other crucial part to taking care of yourself (and I fully admit it doesn’t happen all the time) is ensuring you sleep, eat, and rest as best you can. My mantra became, “Sleep, eat, rest, repeat.” and when you can’t, stock up on your migraine meds. I refilled my Imitrex and Phenergan prescriptions a few times during school.

For all you’ll hear about paramedic school, including it being one of the most stressful times of your life, it’s entirely what you make of it. I had numerous migraines. (All atypical presentations and a handful during my clinicals and rides.) I slept anywhere between one and eight hours a night, but generally less than four. I frequently didn’t eat or drink during field rides. I often went what seemed like a week without seeing my family. I studied all of the time and increased my already elevated coffee intake exponentially higher.

Through it all, I smiled just about all day long during every clinical and every field ride. I made some great friends. I learned to stop over thinking my calls and I learned how to feel good standing at the front and walking into the call. I learned more than I ever thought I could file way in my head and competently use when needed. I found dozens of good and cheap Mexican food stands throughout the city of Denver. I enjoyed myself immensely and I had a great time.

In hindsight it’s a bit like high school. Would I do it again? …Not if I didn’t have to, but damn it was fun.

Today we have a guest post from Sally Davison. Sally is one of the masterminds behind the website FireScienceDegree.com. If you’re looking for a degree in fire science, Sally’s site offers what just may be the most comprehensive, no nonsense resources on the inter-web.

Sally also knows her way around the EMT field and has some advice for new EMT’s preparing themselves for the prehospital environment. She welcomes your comments at sally.davison091@gmail.com  Please give her a warm welcome.

There’s much more to being an EMT than just providing emergency medical care alone; in most situations, you are much more important than doctors and specialists because your timely response and actions help:

• Save lives
• Save limbs and prevent lifelong and debilitating disabilities
• Prevent brain damage and other consequences that happen when first aid is not provided immediately
• Prevent people from going into shock
• Stop uncontrolled bleeding

There are many other ways in which EMTs are extremely useful, and because of this, most victims are grateful for and satisfied with your work. However, there are some occasions when you are called upon to do much more than just administer first aid or provide medical care.

Many victims are in a stage of emotional distress because of the trauma they’ve gone through – whether it’s a case of an accident or a crime or abuse, they’re likely to be shaken up badly. Some are able to stabilize their moods and get back to a sense of normalcy; others however, could end up reacting badly. So when you’re preparing to be an EMT, here are a few things you need to be prepared for in order to cope with victims’ emotions:

• Unfair blame: If there are multiple victims and one or more of them die before you can get to the scene of the emergency, one or more of the survivors could blame you for their deaths because you did not get there in time to save them or because you did not do enough. It’s not that they do it deliberately, just that they are unable to act rationally and take logical decisions because of the trauma. They could rant and rave at you and call you names – no matter what they do, don’t let it affect your psyche because your job depends on your ability to hold your own and remain calm even under a great deal of stress.
• Uncontrollable violence: Some victims could get violent and attack you because of the adrenaline surge that rushes through them at the time of and after the incident – they are just blindly groping around for a way to release their pent-up emotions. If this happens, try to protect yourself and also ensure that the victim does not do more harm to themselves. Also, there may be times when the perpetrator of the crime or abuse is still around and gets violent with you. So you must be prepared for any eventuality.
• Resistance to treatment: Some victims are in a state of shock and may resist your attempts to stabilize them and provide them with the necessary first aid. You need to know how to talk to them and calm them down because their lives may depend on it.

Your job as an EMT involves much more than providing first aid alone, and you must be prepared to cope with victims’ emotions and not let them stress you out.

More Guest Posts:

The Greatest Generation By: Matthew Bergland

Back In The Day By: Chris Framstead

EMS Response to Sexual Assault By: Jimmy Futrelle

How Being Burned Out Can Ignite a Rebirth By: Jim Hoffman

I asked on twitter. I asked on Facebook. I even asked right here at the blog. And the answers poured in. Your responses represented the full spectrum of personalities that inhabit our workplace. There were poignant responses, cynical responses and a bunch of funny ones. The responses made me smile and frown and think.

Within this list of answers you’ll find feedback from 30+ year EMS veterans and newbies just getting their EMS feet wet. Everyone is represented. And the responses are telling.

I’m rather proud of how this little experiment turned out. I hope you find these responses as enjoyable and thought provoking as I did. Thanks for all your contributions. Aside from categorizing these contributions, I’ve made no further editorial additions. This post will become part of the guest posts category, because it was written by you.

Complete the sentence, “Behind every great EMT…”

The Humorous:

Behind every great EMT are 5 firefighters. – @isuhawkeye via Twitter

Behind every great EMT is a stack of empty pint glasses. – @MedicSBK via Twitter

Behind every great EMT is an Englishman in a green jumpsuit watching over them from a distance. – @MedicSBK via Twitter

Behind every great EMT is an ambulance. – Mark Daube via Facebook

Behind every great EMT is an adrenaline junkie. – Anonymous via the blog

The Cynical / Funny:

Behind every great EMT there’s a pissed off lawyer that can’t sue you. – @texaschef via Twitter

Behind every great EMT there’s a chief with a boot headed for your ass. – @texaschef via Twitter

Behind every great EMT is a partner who can’t drive. – @seanhfitz via Twitter

Behind every great EMT is a supervisor with a write-up for him. – @seanhfitz via Twitter

Behind every great EMT is an ambulance with a flat tire. – @seanhfitz via Twitter

Behind every great EMT is a line of bill collectors. – @Ckemtp via Twitter

The Egotistical / Funny:

Behind every EMT is chaos, brought under control, left in their wake. – @MedicSBK via Twitter

Behind every great EMT there’s a paramedic telling him to move so he can treat the patient. – @paramedicintern via Twitter

The Thoughtful:

Behind every great EMT is a role model, an excellent instructor, and sound judgement. – @hoplessromantic via Twitter

Behind every great EMT is a solid foundation of the basics. – @un_ojo via Twitter

Behind every great EMT is a conscience that whispers, “Is this in my best interests, or the patient’s? – @AmboDriver via Twitter

Behind every great EMT is a never-ending willingness to always learn more & strive to always put the patient first. @JustMyBlog via Twitter

Behind every great EMT is a very understanding & supportive family. – @EMTwicks via Twitter

Behind every great EMT there’s professionalism, patience, empathy, gentleness, and faith. – @dont39350 via Twitter

Behind every great EMT there’s an excellent instructor (or instructors). – @Bitzes via Twitter

Behind every great EMT there’s an ongoing thirst for knowledge. – @NJDiveMEdic via Twitter

Behind every great Paramedic is a damn good EMT. – @EMTDani via Twitter

Behind every great EMT is education. – @EMTDani via Twitter

Behind every great EMT is a mentor, supporter, and educator. – @Gfriese via Twitter

Behind every great EMT is a solid education and an extra dose of common sense. – @UKMedic999 via Twitter

Behind every great EMT there is a spectacular instructor. . .and a good team. – April DeGesualdo via Facebook

Behind every great EMT is a great mentor. – Anonymous via the blog

Behind every great EMT is a great mentor, a great education, and a great passion to keep learning. – Anonymous via the blog

Behind every great EMT are compassion and humility. - Captain Tom via the blog

Behind every great EMT are friends, family, a good head, the drive to keep going, and keep learning, and a love of what we do. – Jen D. via the blog

Behind every great EMT is the passion to always be improving through education, run reviews, and being a sponge with mentors and other EMTs. To learn to be humble, compassionate and remembering that every, I mean every call is important to the patient and we treat every call as such. If you don’t really enjoy what you do, it may be time to seek another career. – Randy via the blog

Behind every great EMT is the knowledge that it is all about the patients, not us. – Sean Fontaine via the blog

The Personal:

Behind every great EMT there’s a heart that cares and an inner drive that pushes you to always go above and beyond for your patients. – @PrRescue via Twitter

Behind every great EMT is a family that misses him. – seanhfitz via Twitter

Behind every great EMT is a great support network. – @NavyStingerDoc via Twitter

Behind every great EMT there’s a family and some friends that understand. – @Ckemtp via Twitter (With a bunch of accompanying retweets and affirmations.)

Behind every great EMT is a caring, and determined individual. The status of “E.M.T” is a means of developing skills and knowledge, paired with the legal ability to use those skills and knowledge, in a way that is true to the intrinsic nature of that individual. – Jeremiah Bush via Facebook

Behind every great EMT are their brothers and sisters in service. – Pamela Moore-Eaton via Facebook

Behind every great EMT are equal parts passion and compassion. – Steve via the blog

Behind every great married EMT is a great wife. – Anonymous via the blog

The Optimistic:

Behind every great EMT, there’s a long row of mediocre EMTs who need a little enthusiasm shared with them. – @FloBach via Twitter

The Hard to Classify:

Behind every great EMT is a confused but very lucky citizen to have encountered them. – @MedicSBK via Twitter

Behind every great EMT is an open door to escape through. – @CrazyMedic via Twitter

Behind every great EMT is a sandwich with one bite taken out of it. – Mike Taigman via Facebook

Behind every great EMT is someone just one hour of sleep short of being incapable of screwing up. – Joseph Schmoe via the blog

Behind every great EMT is The EMT Spot. – Anonymous via the blog (Thanks anonymous.)

And thank you to everyone who contributed. Don’t worry if you missed your chance to add your two cents. that’s what the comments section is for. See you next time.

There are moments in life when everything clicks. Synchronicity. Poetry in motion. Bliss. Those moments on our journey when the map suddenly seems so clear and our destination so much closer. It can be a moment of insight or learning, a realignment of our priorities or perhaps just a stunning instant of clarity. Regardless, they are sacred moments in our human experience.

This month, in true EMT Spot fashion, I asked EMS bloggers from around the world to share with you their sacred moments of clarity when everything came together. I hope you enjoy the stories of these fellow travelers. All of us share the experience of stumbling down life’s road looking for a signpost to point the way. One of the most amazing things about breakthroughs is that they help us to point the way for others who follow.

Each of these stories is a sign post in-and-of itself. It’s impossible to tell the story of your own breakthrough without becoming a teacher to the weary traveler who chooses to listen. Perhaps that’s what makes these moments sacred.

Without a home for his submission, The EMS Professional, Jim Hoffman got things started with a guest post right here at The EMT Spot. (Is that cheating?) It’s interesting how our darkest moments can produce our greatest insights. Jim’s breakthrough came the day he discovered how being burnt out could ignite a rebirth.

Next on the road came Aimee, mommy, army wife, EMT. Aimee was a senior in high school with a year or so under her belt when she felt like she had found her EMS groove. A 21 year old boy in cardiac arrest brought her around to the moment when it all came together.

Nate’s EMT experience had mostly consisted of drunks and minor problems, until the day a tripoding COPD patient scrawled “Take me to the VA and Hurry” on a scrap of paper, and the world got cold, cold, cold.

Greg’s road to paramedic certification was seven months down and two more to go when a nurse gave him 45 precious minutes. “You two guys just wait here until Amanda gets back,” were her kind instructions. And Greg’s life was never the same. For Greg, an OB emergency was when it all came together.

Some breakthroughs take years to achieve. Some insights take a lifetime. For Chris Kaiser his moment of clarity happened in an instant.

Justin was still a rookie, traveling the road to being a damn good paramedic, when he started developing his theory about the three types of women in EMS. He thought he knew right where Roxy fit in his theory until an interstate wreck and a pulse…and that’s when it all came together.

Every caregiver who has spent their share of time walking the EMS road has struggled with questions about the sanctity of life and the dignity of death. Do we help prolong peoples lives or do we prolong their death? Mark Glencorse knows what it means to help someone die and he’s willing to tell you how, in that one moment, they can leave an indelibile imprint on your life.

Rescue Monkey, Joel Neild was 18 hours into his shift and running another routine nursing home transport when he got his swift spiritual kick to the head, or Shakabuku, that altered his reality and forever changed his idea of who he’s supposed to be caring for in EMS.

From the time he was a kid, Aled wanted to be a cop. Years later, after joining a mountain rescue squad, he found a new field of interest, medicine. But his true calling still eluded him, until he wrote to his local ambulance service and got hooked up with a ride along. That’s when it all started to come together.

The restaurant staff wanted to know when the grown-up ambulance was coming when Natalie Quebodeaux and her partner pulled up. She may have wondered that herself when she first encountered the patient. And then she made the choice to take charge, and that’s when her Aha! moment came.

For EMS blogging icon Peter Canning, competence didn’t show up in the form of a blinding moment of clarity but as a series of plateaus. He offers an insight for travelers who’ve wandered the road through the years.

Taking the patient back to the ER would have been the best idea, if the goal was to avoid responsibility and turf the liability on to someone else, but when it all came together for Tim Noonan, he decided that what the patient needed was a hospital with a cath lab and doing the right thing for the patient was why he was there.

And how could I forget (Even though, OK , yes, I did forget.) Fircap5. Firecap was a new EMT with a jump kit when the local nursing home called for a man in cardiac arrest. The timing couldn’t have been worse. He was alone on scene, with backup a long way away. And then he took a deep breath, and remembered the basics, and then everything clicked.

Thanks to all the EMS bloggers who participated in this month’s Handover. It was a pleasure to receive so many outstanding contributions.

Next month, everyone’s favorite EMS blog carnival moves to everyone’s favorite clothing optional blog. The ever irreverent Jeanette Kozlowski of Tactical Pants Blog wants to know what you do when you’re not saving lives. The theme for the June Handover Blog Carnival is “Down Time.” Get your fingers typing and get your sumbmissions in to Jeanette over at her blog. You’re not going to want to miss this one.

Now it’s your turn: What was your moment of clarity when it all came together? Leave us a comment. We’d like to hear your story too.

Read more moments of clarity:

“I’m Only An EMT Basic”

6 Reasons Why You Should Be A Better EMT

Ten Things You Can’t Learn About EMS From Your Computer

Unconventional Thoughts On Emergency Services

Patients Define Their Emergencies

“The EMS Professional,” “The Paramedic Mentor,” Today’s guest author, Jim Hoffman has more nicknames than a retiring prizefighter and he’s earned every one of them. From the streets of The Big Apple to New Jersey and now the secluded mountains of upstate New York, Jim has been a paramedic for the better part of two decades.

In his down time, Jim runs EMS-Safety.com, a one stop shop for low cost EMS training resources. He’s also part of the team behind The EMS Boot Camp series. After a little cajoling I talked Jim into letting me post his Handover contribution as a guest post. So this is me, stealing all of Jim’s literary  goodness for you. (Thank me later.)

And now Jim:

As an EMT in a large EMS system I found myself becoming burnt and indifferent to the patients I was responding to and treating; all too often being annoyed at the calls that obviously just didn’t require an ambulance and more often didn’t even require a doctor.

While attending paramedic training in the hopes of doing more serious calls that would be true emergencies and require an ambulance, I had yet another call that seemed to be a waste of my time and energy.

I responded to a general illness call and upon arrival found a bed bound young woman in her early thirties who had a history of brain lesions.  Her primary issue that day was abdominal discomfort. While assessing the patient and getting a history, the family advised us that she rarely spoke or made any type of acknowledgment to her surroundings.

How they were able to tell she was having any complaints is beyond me. I did not note any distress but they were the family and I figured they knew better than I.

As this emergency became a “two flight of stairs carry down” and a transport to hospital, that the family could have done or perhaps utilized any number of other means to get her to her doctor or emergency department, I slowly began to get more and more annoyed with the non-emergent call my emergency ambulance was dispatched to.

Being a professional though, I refused to let my inner thoughts seep through to the family.  I did my job with a smile, asked appropriate questions and gave informative answers. Once complete, it was just me and the patient in the ambulance with my partner driving to the hospital.

Alone with the patient, I took better stock in the situation. Noting her obvious struggle with her disease; I thought how she may have felt living in this helpless condition.  Did she feel like a burden on her family, friends and even me?

Without consciously knowing, I put my hand on her shoulder and said “I know it must be hard”. Without missing a beat she looked at me and said “It really is – it really is”, in a voice that was part sob and part plea. These few words, spoken by a patient that rarely spoke or acknowledged her surroundings to an EMT who was beginning to doubt his role and career choice, resonated in my mind, silenced my doubt, and renewed my faith in the role of an EMT.  This heart wrenching call stays with me on every call I go to.  That brief moment of connection is what I think of regardless of what level of emergency care is required.  I became a better EMT and even more, I like to say I am a better human being – just for touching her shoulder and trying, with a few words, to provide a little comfort.

This one call stands out for me above so many others, big trauma, severe pediatrics and even 9/11. It always reminds me that it is the patients’ emergency we respond to and not ours. Whether they call 911 for chest pain or a cut lip; to them or their family it is an emergency and they called for help – even if that help is a band-aid, a ride to the hospital or a few words of comfort.

I like to think that perhaps acknowledging this patient’s situation let her know that she was not a burden on me. I wish I could tell her that in those few moments the small gesture I made ended up being so much bigger to me; and how it has helped to make me into a true EMS professional. It was like a reset button I needed then, but one that has never had to be pressed again.

More guest posts (And other cool stuff):

The Greatest Generation By: Matthew Bergland

Back In The Day By: Chris Framstead

EMS Response to Sexual Assault By: Jimmy Futrelle

What Makes A good EMT?

Patients Define Their Emergencies

I’ve gone live with the book and newsletter sign up and it appears that everything is running smoothly. I’ve already had a half dozen sign-ups and the link has only been posted for a few minutes.

Thanks for your patience. This writing project took me nearly six months to finish. I had an idea of what I wanted this book to be and I wasn’t willing to stop until I’d succeeded.

The result is The Non-Conformists’ Guide to EMS Success. This is no pamphlet or power point slide show. This is 48 pages, almost 16,000 words, and chapter after chapter of compelling ideas designed to challenge the way you think about your job, your leadership, your life, and your role in EMS. And it’s all free.

If you’re ready to stop listening to me talking about it and get the book for yourself, just click the newsletter sign-up at left. The EMT Spot practices a strict, double opt-in, anti-spam policy. We’ll never reveal your e-mail to anyone, ever.

You’ll receive an e-mail confirming that you really did sign up for Splatter and the e-book. Once you click the confirmation link you’ll received your welcome edition of Splatter and the .pdf version of the e-book will be attached. It’s as simple as that.

The newsletter will also have an opt-out link at the bottom if you’d rather not be on the newsletter mailing list. (But I hope you’ll decide to stay)

I also hope that after you’ve read the e-book, you’ll come back here and post a comment, or send me an e-mail, letting me know what you thought about it.

I look forward to your comments, I look forward to providing you a behind the scenes look at the web site in the monthly newsletter and I look forward to continuing to provide you with quality content right here on the blog. Thank you for stopping by.

Now it’s your turn: Will you be signing up for the e-book and newsletter? Why or why not? If you’ve read the book, what did you think? Leave a comment before you go.

If you’ve worked in EMS anywhere near the Denver Metro area in the last 20 years you’re probably going to really like today’s offering by EMT Spot guest author Chris Framstead. I’ve had the pleasure of knowing Chris for over a decade now and I’ve hounded him to put his fingers to the keys for The Spot. Chris is an uncomparable teacher and an insatiable student of all things EMS. Is his twenty year career he has been an EMT, a paramedic,  a firefighter, an EMS administrator, a chemical weapons and explosives specialist and a teacher at various colleges around the nation.

Today Chris is the International Training Coordinator for the famed Texas Engineering Extension Services, the worlds largest emergency responder training facility and a division of Texas A+M. If you happen to be one of the 80,000 responders who pass through the facility for one training or another, you might run in to Chris. Buy him a cup of coffee and ask how things were … back in the day.

Back in the Day

I’ve been in EMS and fire service for twenty years now, and have been a certified EMS provider for the past eighteen years. Over this time (which is not all that long compared to my other friends in the Denver system who have been playing the game a lot longer), I have seen a lot of change. Lately I’ve heard, what feels like, a lot of brand spanking new, right off the lot new Paramedics, and EMT-Basics, standing outside the EMS classroom, or outside the volunteer fire station, talking about “back in the day”. I have to laugh, not to belittle their stories, but because “back in the day” to a twenty year old EMT-Basic, was….well…..2007. So my mind started racing and memories started flowing, as I thought back to my wonderful career and the “back in the day” memories I have.

So as I was sitting in my kitchen this morning drinking my first (of many) cups of coffee….and I thought…what a cool article….”back in the day”. I am certain if I presented this article title to any one of my friends who have been around the Denver system for as long, or longer than myself, they we could easily write a book about “back in the day”. I simply had my memories flowing this morning and wanted to share them with you readers, in hopes of striking up your memories of “back in the day”.

When I got my start in emergency response, it was 1987, and I was a snot nosed kid who wanted to be a firefighter, or a paramedic, or someone who got to ride on a big truck with a loud siren and go real fast. I started out with the Arapahoe Rescue Patrol (ARP). Now…ARP, “back in the day”, was an all male, high school aged members, search andrescue team, led by the legendary Stan G. Bush (God rest his soul). We all know that in 2009, all male, or all any gender groups, clubs, etc… just don’t exist.  If you ask around, you may be shocked at how many of the “old farts” you work with, also got their start in ARP. As a member of ARP, I was part of the “fire team”. This was a group of kids, who chose their focus to be firefighting, and learning more about what it takes to be a firefighter.

As a member of the “fire team” we did ride-alongs with either Littleton FD or South Metro Fire Rescue, which “back in the day”, was called Castlewood Fire Rescue. At this time, “back in the day”, Castlewood Fire Rescue consisted of stations 31, 32, 33, 34, 35, and 36. We all know that in 2009, the growth of the area served by South Metro Fire Rescue has grown to the extreme, requiring massive growth of the department. The department has been greatly expanded to far beyond just the six stations I remembered in 1987. In 1987, the Castlewood Fire Rescue was under command of a great man by the name of Chief James Etzel. Station 33 was the station I chose to do my ride-alongs at, and B shift was the shift I loved. B shift at station 33, “backin the day”, consisted of Lt. Bob Brannan, and Engineer Jerry French on E33. On R33 it was always a shuffle, but the medics I remember the most were Dave Zude, and Andy Kirwin. Also at the station were Keith “King Kong” Gundy, John White, and John Armstrong. The Battalion Chief of B shift was Chief Larry Wright. At station 33, I rode on E33 with Lt. Brannan and Jerry French. Yup…you heard me right…just those two gents made up E33. If you remember, in 1987, “back in the day”, we didn’t have this thing called “minimum staffing”. I mean, I guess we sort of did, Jerry needed an officer, and Lt. Brannan needed a driver….that was the minimum. When I rode along, I was the third. (And only a 15 year old third-rider!) In addition, “back in the day”, I rode in an outside jump seat with no retaining bar, no ear protection, no heat, etc… on E33. I think the retaining bar came in 1990, and enclosed cabs became the standard in the same era. I’m happy to say I was a part of this era in the fire service, to be able to write about outside cab jump seats, and two person engines. When you talk to firefighters who have a great deal more that 20 years in, they will tell you about “back in the day” when they did this thing called “tail boarding”. Heck…at 15 years old, Jerry French let me back E33 into the station. This was my first time actually driving a fire truck. Granted I only went 50’, but it was an experience that today I cherish to this day. Think about that…. In 2009, a 15 year old kid is riding along at your fire house, you have a $500,000.00 + apparatus on the apron, are you going to let that kid within 5’ of the cab??…I think not! But “back in the day” things were different.

I owe a great deal of how my career panned out to these men. These men not only helped me be the Firefighter I wanted to be, but also showed me the values of being a man, which made me the husband and father I am today. That is my “back in the day” memory of Castlewood Fire Rescue.

On September, 10, 1989 I learned what the “ultimate sacrifice” meant in the fire service when Castlewood lost one of its finest. Captain John Patrick Hagar made the ultimate sacrifice at the Paradise Cleaners fire on September 10, 1989.  I’m happy and proud to say that there is truly no “back in the day” for a Firefighter loss. We hurt today as much as we did in 1989, mourn today as much as we did in 1989, cry as much today as we did in 1989, and both celebrate, and cherish life today as much as we did in 1989. In some sense, after the horrific events of September 11th, the meaning “ultimate sacrifice” has a whole new meaning, and the joy of being a Firefighter, and an American, is indescribably a new sense of pride. What I learned on September 10, 1989 is truly what kind of family the fire service is, and that the profession I wanted so bad to be in, was dangerous. Was I ready for that? At 15 years old, that’s a heavy question. But nonetheless, I proceeded on my career goal of becoming a firefighter. 

In 1990, I was fortunate enough to become firefighter with the Castle Rock Fire Rescue. “Back in the day”, station 151 was located at 310 3rd St. in Castle Rock. I think it’s a window store or something now. “Back in the day” at Castle Rock Fire Rescue, I remember Minitor I pagers, Norris Croom was a Paramedic on the AMR ambulance based at station 152, as was Paramedic John Mason. Chief Norris Croom is still with the Castle Rock Fire Rescue.  Craig Denhard was an officer (now with South Metro Fire Rescue last I knew). The department was under command of Chief Joe Schum , III. Castle Rock was an all volunteer department in 1990. Things have certainly changed, as Castle Rock has grown to be a Denver suburb practically, the department is all career, and you’d never know the department was as small as it was only 20 years ago (which to me feels like last year), “back in the day”.

After a wonderful college period as an intern with the Berthoud Fire Protection District, and going to college at AIMS Community College in Greeley, in 1993-1994 I started EMS in the Denver system. This was an odd turning point for EMS in Denver (at least for a new EMT). I was technically hired as a Haley Ambulance EMT, yet at the time Haley and Foothills Ambulance, out of Golden, were in the process of being bought out by Laidlaw and thus was born Med Trans of the Rockies. I say it was an odd point in time for a new EMT because; you want to talk about confusion.  “Back in the day”, I wore a Haley Ambulance uniform white-shirt; Med Trans of the Rockies pants (evidenced by the “Med Trans of the Rockies” rocker on each on the side cargo pockets); and rode around in a Foothills Ambulance rig. Who the heck do I work for again??? Try and answer the question from a patient when they ask “what service are you with?” I just had to give the “deer in the headlights” look at the patient because I was about as confused as they were. “Ummmmm…..technically I work for Med Trans of the Rockies (I guess…)”, I would say.

Haley station 1 was at Colfax and Tennyson in an old house. Our neighbor, “back in the day”, sat on his porch with a rifle on his lap, and popped off a few rounds just randomly when he felt like it (not at us of course). Our dispatch center (or something that we called a dispatch center), was in the Colfax and Tennyson house in a back bedroom. Our dispatchers were the masters Chris Smith (now with Air Life Greeley), and the shirtless, rapper looking, Chris James, also known to the crews as “G”. Chris James is now a very successful Firefighter (and maybe an officer now for all I know), on Denver Fire’s elite Rescue 1 company.

In the Foothills station, “back in the day”, was a grouchy as hell EMT going through Paramedic school named Pat Ryan, an incredible teacher, yet a bit on the “sit on the X”, kind of medic named Billy Kraft, a blonde EMT named Tony Diedrichs (who last I checked was a successful Denver PD Officer), Steve Steele (now with Platte Valley Ambulance), and Donny Branning (now a station officer with West Metro Fire). It was here that I learned that Golden EMS, and Denver EMS were two totally separate beasts. It was here where I for the first time heard Billy Kraft (the “triage master”) get on the radio andrequest every ambulance in the city of Denver for a tour bus that was struck by a boulder in Clear Creek Canyon. I listened to the radio as the dispatcher, Chris Smith calmly asked, “OK Billy…just to confirm, you want EVERY ambulance in the city of Denver?”. Andjust as calmly as Chris Smith’s confirmation of his gutsy request, Billy said in a calm, yet stern voice, “that’s affirmative”. “Copy that Billy”, said Chris. I don’t believe he actually had every ambulance in Denver, but Billy had a bunch up there that day, and ran the scene like the pro he was.

A welcoming “back in the day” as the “new guy” at Foothills, involved Billy Kraft dumping a 5 gal bucket of water in your lap as you sat in the recliner in the living room of the station (yes…that was my welcoming by Billy Kraft…aka…”The Reverend”).

The station to be at during the Haley/Foothills/Med Trans days was Commerce City. Commerce City was known “back in the day”, as “the hood”, or “Combat City”, and at the time was rated as the time as the 2nd most violent city in Colorado. It was when I was assigned to ambulance 29 in Commerce where I met some incredible friends, who taught me how to be an EMT (in hopes of my being a Paramedic someday). Verne Ullrich (now with SWAC Fire, and to this day one of my closest friends and fishing buddy’s), Colby Allen (now a successful Police Officer…last I knew), and Richie Sanchez, and Renee Dominguez (known at the time as the “Paramexicans”).

In 1993-94, we all worked what came to be known as the “Summer of Violence”, where during the year there were 74 homicides in Denver, and believe me; everyone got their share of seeing the trauma.  Anyone who worked in Commerce City “back in the day” could tell you what facility was located at 7373 Birch, and that “Russel, Russel, Fir, Poze” was the little rhyme we used to remember the short cut of streets used to get from Commerce City to Thornton to cover their district when it got busy in the system.

Now in 2009, the old Med Trans/Haley/Foothills are all called AMR. Pridemark, Rural Metro, and Action Care have all joined the mix of the privates. Northglenn Ambulance is the EMS provider in Commerce City, which by the way, Commerce City has grown so much that you almost couldn’t imagine what it use to look like in 1993-94.

But as we all look back at our individual “back in the day” memories, it’s amazing how everything we all remember has changed so much. I hate to even mutter the words “we’re getting old”, but as Chris “G” James told me long ago when he was a Haley dispatcher, in a land far, far away, “never forget where you started”. All of our personal “back in the day” memories have shaped us all into the people and professionals we are today.  All the folks I have spoken about in this article have progressed to bigger and better, yet never forgetting where we all came from “back in the day”. Never forget where you came from and always remember the incredible memories known as “back in the day”.

Note from Steve: EMS is an industry that moves and changes so fast, it’s remarkable how quickly we all develop or own, “back in the day” memories. Before you move on, click on the comments box and tell Chris and I your favorite memory of an EMS time that’s come and gone. We’d love to hear from you.

Related Posts:

The Greatest Generation By: Matthew Bergland

 Wrong Medicine

What Is The Good Samaritan Law?

The EMT Spot would like to welcome Jimmy Futrelle to our guest post roster. Jimmy s a Paramedic hailing from Scurry County Texas. Jimmy has been responding on calls long enough to remember the Lifepack 5 and using D50 as a diagnostic tool. His unique background working for private and public EMS as well as for local law enforcement makes him uniquely qualified to teach on the subject of sexual assault.

This detailed guide to responding to these challenging calls is well worth reading. I sincerely thank him for this contribution.   

Responding To Sexual Assault

Introduction

Sexual assault is possibly the most devastating form of assault perpetrated on another human being.  The legal definition of sexual assault is “any genital, anal or oral penetration by a part of the accused’s body or by an object, using force or without the victim’s consent.”

The U.S. Department of Justice’s National Crime Victimization Survey reports that over 500,000 women and approximately 49,000 men report being sexually assaulted each year. It is estimated that 1 in 5 women will victims of rape by the time they are 21 years of age.  61% of reported rape victims are less than 18 years old. 1 in 7 women will be raped by their partners. Only 16% of rapes are ever reported to the police.

Let us not confuse sexual assault with sexual abuse. Sexual abuse is repeated instances of sexual assault occurring over a period of time, generally by a person familiar to the victim. Whereas this crime is no less devastating, we are going to focus on the act of sexual assault.

Assessment and Treatment

 When dealing with sexual assault victims, as with any assault, we must assess the physical and mental status of the patient. The psychological trauma af rape can be more severe that the physical injuries sustained. Since intimidation can be a more predominant factor in female assault, physical injuries may be more subtle. On the other hand, in male patients, we tend to see more severe physical injuries. Attempts to assault men are more frequently initiated with a severe physical assault. We, as health care providers, must be aware of these differences and treat the patient appropriately.

There are two assessments we must perform the physical assessment and the psychological assessment. Each is done congruently and treated accordingly.

Your priority is to the patient’s physical status. The ABC’s apply here as they would to any other acutely injured patient. We assess airway, breathing and circulation. Then briefly assess for any problems such as respiratory distress, shock, or any internal or external injury or hemorrhage that may require immediate treatment.

Common injuries seen with sexual assault are as follows:

1.) Abrasions and bruises on the upper limbs head and neck.

2.) Forcible signs of restraint–rope burns on wrist or ankles, mouth injuries sustained during gagging.

3.) Petechiae of the face and conjunctiva, secondary to choking.

4.) Broken teeth, swollen jaw or cheekbone, torn frenulum of the lip or under the tongue, eye injuries from being punched or slapped in the face.

5.) Muscle soreness or stiffness in the shoulders, neck, knee, hip or back from restraint in postures that allow sexual penetration. Pain or bleeding from vagina or rectum, indicating possible tears in the delicate tissue in these areas.

Each or these injuries must be treated appropriately. Oxygenation, control of bleeding, stabilization of fractures, and fluid replacement, where necessary.

Our next priority is to create a safe environment for the patient. Remember that sexual assault is about control, and the victims currently feel as if they no longer have control over anything. It is imperative that no further assessment or treatment be given, without informed consent. The only exception to this rule is if the patient has an altered level of consciousness and/or a life threatening injury is present and implied consent is called for. Be very familiar with the guidelines of implied consent in your system.

Privacy is a big issue here. Move the patient into the ambulance or into a private area for the remainder of the exam. Some considerations for performing a physical exam:

1.) Explain all of your actions to the patient.

2.) Explain what a secondary survey is and why it is necessary.  

3.) Avoid whispering things to others such as police, family or other medical professionals, in the presence of the patient. This can lead to feelings of paranoia.

4.) Do not perform procedures (setting up oxygen, or an IV) outside of the patient’s view, without explaining them first.

5.) If the patient wishes to have someone present for emotional support, make the arrangements.

6.) To open up a dialogue with the patient and establish a rapport of trust, begin with questions regarding the patients current use of medications, allergies and past medical history. 

Avoid questions about the specific assault, unless the patient chooses to provide you with details. Only ask questions if the answers are necessary for medical treatment of the patient. “Sexual assault is a circumstance of such magnitude that it does not respond during the acute phase to emotional release or catharsis.”

Pertinent questions can include:

1.) Did the patient take any drugs (prescription or otherwise) or consume any alcohol before or after the assault.

2.) Did the patient urinate, defecate, or attempt to clean themselves following the assault.

3.) Did the patient bath, wash their hands or face, brush their teeth, gargle, or change their clothes following the assault.

4.) Has the patient smoked, drunk any fluids, or eaten anything since the assault.

If possible, do not allow the patient to perform any of the above actions. Inform the patient that it could effect the collection of evidence later at the hospital.

If medical treatment is necessary, explain all procedures and insure that the patient understands. The patient’s physical condition is paramount, but we must guide our treatment with some common sense.

If the need for oxygen arises, then try using a nasal cannula if possible. A mask may give the feeling if being suffocated. Avoid invasive procedures when possible, such as IV’s or blood draws. These are painful procedures and should wait till the patient arrives at the hospital. This way, medical and evidence samples of blood can be taken at the same time. These priorities should never jeopardize the patient’s condition.

Transport the patient to a medical facility capable of performing evidence collection. Not all emergency departments can perform this function, so be aware of the standards in your area. If the patient wishes to go to a hospital not capable of evidence collection, advise the patient of this. Offer an alternative facility. Transport the patient quietly and gently. Avoid use of lights or siren when at all possible.

Evidence Preservation

Preserving evidence is vital if criminal charges are pursued. Take necessary steps to preserve evidence in all sexual asault cases. Medical stabilization must be balanced with the need to protect rapidly decaying physical evidence. Emotional support from a friend, family member or rape crisis counselor is preferred, but excessive delays should be avoided. It’s helpful to be familiar with the evidence collection procedures in your area. Patients will quite often ask you about what will be done with them when they arrive at the hospital. Be as informative as you can. Let them know that nothing will be done without their consent. If you do not know the answer to a question, be honest. Do not give false expectations.

Sexual assault is a crime and the location the assault occurred is a crime scene. Be careful what you touch and where you walk. If the police are present, have an officer escort you and be with you while you are inside the crime scene. This gives you a witness to your actions, and helps to secure you from moving or disrupting any evidence vital to the police investigation. If medical treatment is provided to the patient on scene, do not leave any treatment materials on the scene. Keep all wrappers and containers together. The officer in their investigation must explain anything you leave behind.

Wear your gloves. It reduces the chance of you leaving fingerprints, which must be explained later by the police. If an officer is not present when you enter the scene, then let them know what you did, where you walked and what you touched or moved, prior to there arrival. Document these movements in your report. Do not delay treatment or transport to await police. The police can obtain information from you and the victim, just as effectively at the hospital, as they can at the scene.

If any clothing or jewelry is removed from the patient, have the patient place each piece in a separate bag. At the hospital, place your linen and gloves in bags. Particle evidence may have fallen onto the linen or come off on your gloves. Place evidence in paper bags rather than plastic, to avoid moisture build up. Label the bags with time, date, contents and name of person who collected it. Turn all evidence over to the receiving physician or the investigating police officer. It is crucial that the chain of evidence not be broken.

Reporting and Documentation

It is a requirement in all U.S. states to report the sexual assault of a child, or adolescent under the age of 17 or an elderly person above the age of 60. It is not a requirement in all states to report sexual assault in person’s aged 17 through 59. This is the case in the state of Texas. Doing so without the patient’s consent, can be a violation of the patient’s right to privacy and a breech of patient confidentiality.

Where does our obligation to the patient’s right to privacy start and end? This is a question in which the answer varies from state to state, district to district, system to system. You must be familiar with the laws of your state and the requirements of the system in which you operate. Let the patient know up front the requirements placed on you, before initiating a secondary assessment. This gives the patient the right to disclose only the information they wish.

How and what do we document? Everything but our opinions. If criminal charges are pursued, then our documentation of the patient’s condition becomes a vital piece of evidence. We must document a detailed and chronological report of our assessment, findings, treatment and any information obtained about the assault. Detail must be given specifically to the physical exam.

Note any injuries and/or markings in meticulous detail. Describe the size, shape and location of each injury. (e.g., “Five red bruises are noted on the patient’s upper right arm. They are oval shaped and approximately one inch in diameter. Four are located on the lateral side of the arm and one is located on the medial side of the arm”). Document the patient’s mental status, and quote the patient wherever necessary. Do not make judgments or assumptions. Note if any evidence was collected and document the names of the persons receiving the medical report and the evidence.

Summary

We should take care to treat victims of sexual assault with the utmost compassion.  We are tasked to preserve, protect, treat and comfort, all in a very short period of time. It is important that we allow patients to give informed consent to any and all treatment and assessments we perform. We must provide a safe and comfortable environment for them without distraction. We must preserve all evidence, no matter how insignificant it may seem. We must document all findings, procedures and assessments in meticulous detail. Most of all, we must be as honest with our patient’s as we can. Remember, were the victims first impression of medical assistance. We set the pace. We make the patient’s transition to the sterile hospital setting an easy one or a difficult one.

References

Strategies for the Treatment and Prevention of Sexual Assault Guide, American Medical Association

H.D. Grant, R.H. Murry, Jr, J.D. Bergeron, Emergency Care, 4th Edition.

Matthew is a street paramedic from Colorado Springs, Colorado. I first met Matt well over a decade ago when he was an EMT for Pridemark Paramedic Services. Today he is a flight medic for Memorial Star Helicopter and also works with American Medical Response. I think Matt’s story deserves a place in “The Big Get It” category here at the spot.

In this piece Matt expresses the frustrations that many of us working in EMS feel each day, as well as an insightful revelation about the value of human beings and the meaning of service.

The Greatest Generation

I have been in EMS for fifteen years. I say this not to evoke in the reader some undeserved sense of awe in my longevity, rather to illustrate the depth of my ability to be exceedingly grumpy and “burned out” when it comes to the more routine aspects of pre-hospital EMS. To expand on this sentiment I’ll provide you with what is, most likely, a common thread throughout our industry.

I work long hours and I am expected to stay past my off time should the EMS system be busy. The pay is less than glamorous and I am routinely forced to sacrifice time with my family to spend time at work to make ends meet. Many times it is very difficult to even eat because we are so busy. To add insult to injury the lion’s shares of my “emergency” patients are drunks, psychs, sore throats and headaches. That being said, I also routinely stand witness to people that have been devastated by illness or injury and the impact that it has on their families.

Many people take advantage of the fact that we provide the care we do. They have no room in their criticisms for the understanding of our sacrifices and the constant training and hardship that we endure to bring our skill to their side. The expectation of those that we serve is, many times, far too high. When you fall short of those unreasonable expectations people tend to take it out on you in a personal manner. We all endure these high prices for our commitment to humanity.

It is easy to become cynical by these long hours and lack of sleep, food, family contact and human suffering. The sound of ambulance tones indicating another call no longer excites me. It merely means more work, less sleep and the potential to take on more of other people’s problems or misery. Many times it means another assault or traffic accident. Often it’s another gang banger that has been shot or stabbed. But more often it is a nursing home patient. It is with this patient population that I have found myself becoming very frustrated at the prospect of another sick, elderly person and have struggled, at times, shore up my compassion so as not to inadvertently treat these patients from the context of that frustration.

It wasn’t until one night that I was dispatched to yet another nursing home for an 88 year old male with flu-like symptoms that I really took stock in these octogenarians. As we set out to the nursing home I caught myself becoming very frustrated. Why, at three in the morning, was I travelling emergent to a nursing home to transport a patient who has a “routine” complaint? The patient was very embarrassed and repeatedly apologized for bothering us. He proved to be a very difficult IV stick and calmly accepted the repeated attempts. He apologized for not being able to move himself to our cot. It struck me that this man was so accepting of our repeated assaults on his body!

Once in the ambulance I asked all the standard questions and then I asked one more. I asked the question that truly opened my eyes to the sacrifices of this gentleman and those of his generation, the generation that has been coined “the Greatest Generation”. The question I asked was what he did before he retired. Truly, I was just making conversation so as not to have to deal with the uncomfortable and awkward silence that tends to accompany two people separated by so many years.

He told me that he had been a bomber pilot. He would have left it at that if I had not been curious enough to ask the follow-up question. “Did you see any action?” It is at this point that I must inform the reader that I have taken some literary license with the forthcoming description! What he told me was that he’d been shot down over Germany. He was the only survivor of his crew and had parachuted from the burning wreckage of the aircraft. Upon landing he broke his leg and then spent two days avoiding the German’s. When he was finally caught he was placed in a cell and left for weeks with minimal food and water.

He had been away from his family at that point for three years and he told me that he wondered if he would ever lay eyes on his wife again. I quickly realized that my frustration and complaining about my job was nothing in comparison to this mans sacrifice to our country. Moreover, his generations sacrifice to this country. For it was not only the sacrifice of the men that shipped off to war, it was, in fact, the sacrifice of their wives and families as well. They kept this country active and solvent in the face of nearly the entire workforce going to war. They gave up their loved ones for years, many gave them up forever. As a whole they, quite literally, held this country together for later generations.

If you have the opportunity, I highly recommend that you watch the series ‘Band of Brothers’. This remarkable series should, in my opinion, be required material for all young Americans so that we may understand the great and noble sacrifices that the “Greatest Generation” made. We run on these frail and elderly people everyday not realizing that, while their generation is passing, their impact on our lives will not. It can not be allowed to pass.

Most of them will silently sit in your ambulance and make no attempt to educate you to their history. I will tell you that I routinely ask these patients about their past and their service to our country and I have heard some remarkable stories. I always end my conversation with these patients with this, “Yours is truly the Greatest Generation, thank you for your sacrifices and thank you for my freedom.”  Without exception the response I get is the same. They always humbly say that they were just doing what they had to do for their country.

Oliver Wendell Holmes, Jr. said, “I think that as life is passion and action, it is required of a man that he should share in the passion and action of his time at peril of being judged not to have lived.” This is definitely the culture in which they lived and they should absolutely be heralded as heroic and be respected by us. These people have, most assuredly, gone above and beyond to earn the right to be compassionately cared for by us. I have developed a profound sense of honor in relation to being able to care for these people. I have found much humility in being given the opportunity to be with these people as they pass on. Next time you go on that nursing home call or elderly fall victim, before walking into the scene take a moment and reflect on their sacrifices and what they did, selflessly, for you.

Matthew Bergland