Thursday, February 25, 2010

Don't take yourself too seriously

We interrupt this normally deep and serious string of blog posts for an amusing anecdote:

I've been starting to help with the recruit class for the latest group of rookies. I got my instructor I certification recently, and I've been wanting to put it to use, so what better way than to volunteer to assist with recruit class in my free-time, right?

Well, the officer in charge paired me with my old instructor from back when I was in the rookie program to act as his assistant instructor for the day when we were teaching SCBA donning and emergency techniques. After watching the old man work with the first couple crews that came through the class, I got a chance to take over and show what I could do with my own group of recruits.

Trying to be as serious and authoritative as possible, I carefully went through the parts-and-components lecture, and orchestrated some practice donning the SCBAs. Great so far.

Preparing to go outside and start our confidence maze, I addressed the crew:

"Are you getting this? Everything making sense?"

Nods all around the room.

"Ok, gear up! We're going outside to do this for weal."

Blank stares, then smiles. Damn it. You can't sound tough when you replace an "R" with a "W".

There was my old instructor at the back of the room, doubled up and shoulders shaking in silent laughter.

"That was my encouraging voice, you won't hear it again", I said, trying to shake it off and recover gracefully.

Oh well, no sense in taking yourself TOO seriously.

Sunday, February 21, 2010

My new article on FireLink

To anyone who has interest, I've written a new article that's been accepted to FireLink.com for my "Day in the life of a Probie" column. Check it out at the link below:

http://firelink.monster.com/benefits/articles/10545-how-to-save-a-life

Thursday, February 18, 2010

The Big Day

Today is a big deal for me. Since January of 2009, I've been preparing for the day that I'd get my red helmet. Today I found out I passed my written EMT-B exam, which was the last item on my list of requirements to move out of my probationary stage.

In my department, the color of your helmet signifies your rank, and is what officers use when deciding who to give tasks to on scene.

Orange = Recruit Firefighter

This is what I had during recruit class. It means that you shouldn't even be on a scene, it's just for training gear. It's a big thing when you get to graduation and get to adorn it with the decal that gives you the next level.

Orange w/ Green Stripe = Probationary Firefighter

I've been wearing one of these for almost a year now. As a probie, you get to fight fire with the best of them, but the officers will be sure to keep somebody experienced with you to make sure you don't slip up and get someone hurt.

Red = Firefighter

Less is more, as is evidenced by the step up in recognition you have when you drop the "Recruit/Probationary" from in front of your title. In our department, this means that you have your firefighter I & II certifications, your haz-mat awareness & operations certifications, you've demonstrated competence on every apparatus in your station to your company officers, and finally (the milestone I reached today), you've fulfilled all the requirements to obtain your EMT-B license.

It's a long road, but looking back on it I can't believe how quickly it's gone. Maybe next month I'll take a step back and plan what I'm going to do next. For now, I'm going to relax and revel in the afterglow of another completed journey.

Saturday, January 9, 2010

Sometimes it works

Nothing under the scope of emergency medicine is as exciting or dreaded as a full arrest. It's something we train for regularly with CPR classes, AED practice, and extensive analysis and practical skill time in EMT classes, but it's a comparatively rare call. In my experience, you've got around 70% of your medical calls coming from real emergency problems that don't even progress to the point of unconsciousness (diabetic problems, breathing difficulty, and chest pain/heart problem), 25% from non-emergencies (over-concerned parents, hypochondriacs, and poorer people with a small problem who don't know any other way to get medical help), and the last 5% are the adrenaline boosters. That's your severe trauma, or catastrophic medical call, and even out of those I'd say that only 1/4 end up in a full code (CPR, AED, intubation).

However, even noting how rare they are, I've worked on enough to know how they generally go. Check vitals, start CPR, apply AED, intubate, pronounce them dead and allow the police to take over. It's a sad reality, but most of the people we do CPR on don't come back. It's not because we're doing it wrong, it's just because they're usually too far gone. I know people who have been running calls for years who have never had one of their CPR patients end up being saved. Given how all the patients I've worked on have fared so far, I was willing to bet I was going to be in that same pool of people.

Until 12/31/2009.

On that day, I was lucky enough to be performing CPR on a man who did not die immediately thereafter, and I have to tell you that it was invigorating. I was suprised beyond speech because I had just never seen anything like that happen. We showed up and he was grey and cold, no discernible pulse. By the time he was in the ambulance he was awake. A new years miracle.

But what I found most interesting was not the play by play re-enactments, although those are fun. What I continue to think about even today, over a week later, is the reaction we all had afterward. "Great job in there", we say. "Nice work". As though it were through our superior efforts that this man was brought back to life. As though we were so incredibly skillful on this day that our will and talent alone carried him back from the grave.

In truth, we did nothing different or more for our patient that morning than we had done for many patients before. Same pattern, same rhythm, same tools, even most of the same people. The difference was the patient. His body wasn't ready to go, and it responded to our efforts as others hadn't. If anyone were to be congratulated, it was our friend with the IV in his arm for having such a resilient body.

And within that truth lies the reason behind our training. We train for hours and hours every year on the proper sequence for a full arrest, knowing that most of the recipients will never benefit from it. It's only in the knowledge that every so often, every once in a while, there's that one person who's not QUITE so far gone yet, and he deserves a chance to come back. This week we found that person, and it's made me that much more willing to try just as hard on every man down hoping to find another one.

Saturday, November 28, 2009

Helping those who don't want to be helped

Although firefighting is where the real excitement is, the majority of the calls we run are medical in nature. That's ok, though, I actually really enjoy medicals. I like the times when we're able to make a difference in a patient's life when things are going really badly. Helping someone out of a wrecked car, keeping an unstable patient alive until they get to the hospital, or even just providing a little comfort to someone who is dealing with a scary illness or injury; those things are all good experience and are their own reward.

Admittedly, there are many people you can't do much to help. Plenty of people are just not savable (already dead for too long, injury inconsistent with life, etc), and many others are not true emergencies and involve people who are just in a hard socio-economic group and the only way they know of to get medical help for any condition is to call 911.

But then there's a third class of medical call, one I had not experienced until just recently. You see, some people for one reason or another don't want your help at all and are angry at you for even being there. That's new to me.

The day of Thanksgiving, I ran a call to a middle-class neighborhood residence. It was dispatched as "Unconscious", and on the way we got enough information to know that this was a young guy who was visiting his parents for Thanksgiving, and who had gone into a really heavy state of sleep. So heavy that when he rolled off the bed and hit his head, he didn't even wake up. We were advised that he was taking Xanax, and one of the side-effects of Xanax is possible drowsiness, but this level of unresponsiveness was a little bit past "drowsy".

When we arrive, we walk into a bedroom and see...nothing.

"He's behind the bed!", the dad notes from the hallway.

We peak over the bed, and there he is, facedown and contorted up, wedged between the bed and the wall.

"Check his breathing, please" the Captain murmurs as he begins to open the med-bag.

Leaning close to the kid I can hear respiration and can feel it on my face. Smell it, too. Definitely breathing.

"He's breathing, but it's a little shallow, probably due to his position. Shall we move him?".

We each grab a body part and move him out into the center of the room. He moans and moves a bit as we move him, but goes flat out again as soon as we lay him down.

"Let's get him on some O's", I hear from over my shoulder.

I pull a non-rebreather out of the packaging and hook it up to the oxygen bottle that's already been primed for me, then apply it to the patient's face. He doesn't like that.

Sitting up groggily he yanks the mask off his face and asks what's going on.

"You were pretty unresponsive there, for a while", the captains says to him, checking his pupils (which are currently small pinpoints).

"I wass nnnapping" he slurs.

Now we have a paramedic from the ambulance in the room, already briefed by the parents, who asks what's been going on, pointing out that the heavy sleeping, The grogginess and slurred speech seem to indicated something is wrong.

"I'mmm sleeeepy" he manages to get out.

"Well, your behavior is not quite what we'd expect from someone who is just sleepy."

He REALLY doesn't like this

"Well! I didnn't knnnow...that..that...that therrre was a RIGHT wayyy to be SLLLEEPY!"

"Calm down, buddy..." the medic says

"NO! see, you'rrre starting to piss me off herrre! Herrre's what's going on...", his speech is improving a bit as his new found anger cuts through the haze, "...you all are in THIS house...telling ME how to be f***ing sleepy!....and I don't apppppreciate it....So all five of you motherf***ers can just take a flying f*** out the g**damn window....cause I swear if I find out where YOU live...."

by this point the medic's motioned everyone out of the room and were back out front, police on the way. Once someone starts to get potentially violent we are supposed to have law-enforcement on scene to handle that kind of stuff.

While we're talking out front, I'm still trying to figure this out. I mean, I don't even know this guy, so I shouldn't care, but the fact that he's so upset at us for coming in here to try and help him is bothering me a bit. It stings when you reach out with compassion and get met with anger.

As I though about it, I began to see why the guys who have been on the job for a long time seem more likely to be rather unconcerned regardless of the situation (almost to the point of being dispassionate). Apathy is hard to offend. If you don't care about someone that much, nothing short of a physical assault is really going to hurt you. But if you put yourself out there emotionally; if you try to feel some empathy for someone who's having a rough day and you do your best to have concern for them and help them, and they reject you, it feels like pretty much any other relationship where you get something nice pushed back in your face. Far safer to not care that much in the first place.

But is that unfairly punishing the patients who need empathy for the actions of those who are going to be a jerk about it? Certainly the number of people who call 911 who would benefit from some reassuring attention far outweigh those who are going to lash out at you. Should we dispense compassion based on nature of the call? Cardiac patients get sympathy, drug-addicts don't? That doesn't seem quite right either.

I guess I don't really have answers yet, just questions. Hopefully they'll come to me before the day arrives when I too start looking at patients with empty and uncaring eyes.

Sunday, November 15, 2009

Bigger than you and me

I went to my third firefighter graduation at my department this week. This is the ceremony where the new recruit who have been training for the last 5 months are finally given their badges and released to start running calls. It's a big deal for those who are participating, because it's the realization of a goal that used to seem to far into the future, but what's less talked about at the time is what a big deal it is for the department.

My first graduation was as an outsider, when my brother was just joining up. I didn't know anybody there except him, and I didn't have any particular interest in firefighting at the time, but I remember being very moved by the ceremony. Afterwords my eyes were a little wet as I congratulated him and it was a silent drive back to college for me as I thought about what I'd seen.

My second was as a participant, a new firefighter excited to start doing stuff that mattered. After my brother pinned my badge on me, I could hardly wait to get out of the building and to start doing all those things I'd been training for all those months.
Now I've just been to my third, as a member of the department welcoming in the new blood. It's emotional, but in a different way: I'm proud to be part of such an organization, one that was important enough and meaningful enough to these outsiders that they decided to invest and sacrifice of themselves in order to be part of it as well.

And it will keep happening. Year after year, new men and women will take up the mantle as the most experienced ones start to step down. Logically it would seem that this adds up to a department that is of a constant status. Like a glass of water, some is poured out, some refilled, and you're always looking at basically the same thing. But this is inaccurate; any organization like this is actually cumulative. It's more like a river: individual drops of water travel through on a seemingly set course, but slowly the water as a whole continues to erode a new path for itself, shifting the banks and making it's way as a result of all the drops that has ever flowed through it.

The department will always have one chief, but it's current culture and structure is the result of layer upon layer of past leadership. We will always have new recruits, but our training and policies improve every year as a result of experiments on and suggestions from each group of orange-helmets that step up to do their part.

The continued existence and renewal of this entity, this fire district, is an ongoing validation of the fact that what we are doing here is worthwhile and necessary. The life of this department reaches far into the future, as long as there are people in this area to protect, and each firefighter through his participation gains for himself a piece of the immortality that such organizations by their nature preserve for their alumni.

It's bigger than you and me, and in a way this humbling realization makes you want to pay tribute to such a cause. But what to do? What do you give an entity with no emotion or consciousness? How do you show loyalty to an intangible abstraction? In my opinion, the only show of appreciation that has any lasting effect is the kind of participation that only makes us better.

Do nothing to detract from our reputation, but in all encounters give others reason to respect us. Teach the new generations of our ranks not just with the knowledge that you were taught, but also with the wisdom gained from your own mistakes, and let them start off knowing more than you did. Most importantly (for my department anyway), continue to provide a helping hand as long as there is even one person out there who needs it.

Monday, October 12, 2009

Pedagogy of the fire-ground

In a fire department, there are a lot of skills for new guys to learn. Fire suppression, apparatus operation, efficient communication, emergency medical care, vehicle extrication; the list goes on and on. One thing that I think should be placed higher on that list is pedagogy. If you're really great at vehicle extrication, you can make a difference when you're on the scene; if you're really great at TEACHING OTHER FIREFIGHTERS about vehicle extrication, then you make a difference every time one of the firefighters who learned something from you is cutting up a vehicle. The effects of a good teacher are like ripples that carry throughout a department as those who learn from the instructor teach others the way that they learned.

Let me give an example where we see three teaching styles on the same subject, and maybe it will be clear why this is such an important topic.

SCENE 1
Instructor: "don't forget this, it's important: when you are going to have the apparatus parked in one place for a while, engage the 'High Idle'".

Student: "Why is that? What does it do? Is it really important?"

Instructor: "What did I just say?"

Student: "When the apparatus is staying put for a while, engage the High Idle"

Instructor: "So what do you do when you're parking and you're going to leave the engine on?"

Student: "Engage the High Idle"

SCENE 2

Instructor: "don't forget this, it's important: when you are going to have the apparatus parked in one place for a while, engage the 'High Idle'".

Student: "Why is that? What does it do? Is it really important?"

Instructor: "That let's the engine generate more electricity so it's able to handle more things being on at once like warning equipment and panel lights, etc."

SCENE 3

Instructor: "don't forget this, it's important: when you are going to have the apparatus parked in one place for a while, engage the 'High Idle'".

Student: "Why is that? What does it do? Is it really important?"

Instructor: "well, what does your car do when it's idling?"

Student: "It's just running at a low speed"

Instructor: "And what does the term high-idle suggest?"

Student: "That it's running at a slightly higher than low speed?"

Instructor: "Good, that's right. Now, why would that be helpful?"

Student: "I don't know, I guess it's using more gas, that's actually BAD. Maybe it's maintenance related, do long periods of low idle damage the engine or something?"

Instructor: "Interesting thought, but no, you're thinking to specifically to the engine. What about all those blinking things on the apparatus?"

Student: "Warning lights?"

Instructor: "And what do they need in order to keep blinking?"

Student: "Electricity. I guess the high idle probably generates more electricity."

Instructor: "Right. All those lights take a toll on the battery, and if you leave it in low idle the load manager will eventually start switching lights off to conserve energy, which is a big deal if you're on a highway or something where you need all your warning equipment going."

Now let me give you a scenario: The student is now pumping the apparatus at a large vehicle fire, and the lights start to shut off one by one. High idle can't be engaged because it doesn't work when the apparatus is pumping. What will the student do about his quickly diminishing warning equipment? If he's been taught by the instructor in scene 1, probably nothing, as he won't even know there's a connection. This kind of teacher just bugs the hell out of me. Anytime someone answers a question with "Because I said so", they're doing the student a disservice. You can't think adaptively without having the necessary information to synthesize into a solution. If the student was taught by the instructor in scene 2, he'd probably suspect that he should be engaging high-idle, but he's been told he can't do that when pumping, so what should he do? After thinking about it, he'd probably have to resort to choosing which lights he needs least and manually shutting them down. He's been told what he needs to know, and he's doing the most he can with the information he has. But the student who learned from the instructor in scene 3 knows the mechanics of his truck. By having a long dialog on the subject, he's been forced to think it through and knows what the players in this equation are. He knows that the high-idle works by increasing the engine speed, thus generating more electricity. He also knows that pumping the apparatus involves using the engine to power the pump. Putting this information together, he'd probably figure out that all he has to do is gate down the water he's flowing out of the truck and throttle up the pump, causing the engine to work harder, and generating the extra electricity he needs.

Good firefighters aren't born, they're made. Let's recognize the great makers, and realize that within a department great teaching means better everything else.