If you guys play your cards right, you will soon get a new episode.  But until then, this will be the last of the archives being moved to Gomerville.  Thanks for listening.

But I question whether or not it is sustainable.  The business model simply does not seem sound.  But before I get too terribly into any sort of industry analysis, let me outline how I watch TV.

This was done on the cheap.  We were paying about $70 for our cable which included a rented DVR and a few movie channels.  One of the things that has always irked me is that even though I was paying for cable, I still had to watch commercials.  So my goal with the new system was to eliminate commercials completely.  I have been about 90% successful with this.

Our house is small, and we find ourselves watching TV in only two places.  The vast majority of TV is watched in the living room, and the wife and I occasionally watch TV in our bedroom.  The bedroom was very simple.  We have a computer in there with a 20 inch screen that is easily visible from the bed.  We simply watch TV on that.  The computer was originally designed to take a cable signal and function as a DVR so it even has a remote control that we can use.

The living room was a bit more of an ordeal.  We do not have an HDTV.  Yes, you heard that right.  We watch internet TV on a conventional TV screen.  Truth be told, that TV is about eight years old.  It has an S-Video cable and we never have had much trouble hooking various computers up to it.  I used to have a dedicated computer hooked up to the TV in the living room with a wired LAN connection, but it failed not long after it was put into service.  It was an old Pentium 4 that I had frankensteined together from the body parts of other computers.  The motherboard decided it was time to die, and I was never able to fix it.  Luckily I had a laptop that also had an s-video connection.  We simply booted up the laptop, configured the show we wanted to watch, attached it to the TV configuring it as screen 2, and watched our show.  Recently, the Wii finally came out with software allowing us to watch Netflix through that system.  This has made things quite a bit easier.

How do we get content?  Mostly we just watch Netflix.  It amazes me how many people pay for Netflix every month and are still not aware of the ‘watch it instantly’ feature.  We were paying for Netflix long before we cut the cord with the cable company.  So there was no added expense when we cancelled cable.  Netflix has sort of become our favorite TV channel, with a few differences from normal cable viewing.  Almost every month they provide new content for their ‘watch instantly’ service.  We are usually interested in 5 to 10 of the movies, and two or three of the TV shows that are made available.  This isn’t counting the content in which my daughter is interested.  This month Netflix put up the entire ‘Backyardigans’ collection so she will be good until she is goes to college.  This selection satisfies about 90% of our needs.  Whenever the wife and I get to a point where we have time to sit down and watch a show the conversation turns to the new shows available on Netflix.  Our tastes are very similar so a consensus is reached fairly quickly, and we bring it up and watch it.

The best way to describe this to someone who is still tied to cable is to tell them that this is very similar to something like ‘HBO on Demand.’  However, our selection is bigger and all the content is on demand.  We still get DVDs in the mail, but we feel a bit guilty about this.  We pay about $16.99 a month to Netflix, and this allows us to have three DVDs in rotation.  To be honest, these DVDs languish on top of our TV, sometimes ignored for weeks at a time.  It is not uncommon to mail them back unwatched out of guilt thinking that someone else is waiting for that title to become available.  Netflix has a cheaper plan at $8.99 that lets you have only one DVD at a time.  We considered downgrading our plan, but we never have done it out of guilt.  We enjoy the service so much that it seemed insane to actually lower our monthly payment just when we started to use the service more than ever.  So, to support a company we like so much we actually pay more than we have to.  Being honest hurts sometimes.

So what happens the other 10% of the time that we aren’t watching Netflix?  Well, the internet is a wide open space full of interesting things to watch.  Hulu is a good service with a lot of free content.  Every major network has a website that has several full episodes of many of their shows.  Currently you can go to NBC.com and watch everything from new episodes of ‘30 Rock’ to old episodes of ‘Magnum P.I.’  They used to have the complete ‘Star Trek TOS’ catalog available, but I see that they have taken it down.  I have also found a couple of shady places on the internet where you can view brand new BBC content without commercials only hours after it is originally broadcast in the U.K.  So I can get my Dr. Who fix without having to wait for it to come out on DVD.

In other words, there is always something to watch, and I will never pay for cable again.  Many people argue with me and say, “I couldn’t ever do without show X.”  When they tell me this I can usually go to Google and find a way to watch it online within two or three minutes of searching.  Full disclosure here though: I am not a sports fan and I never will be.  If I was though, I might be tempted to keep cable.  I haven’t found a good way to watch live sports on the internet.  Although to be honest, I have never tried.  But I hear it is pretty much impossible.

What about quality?  Online content is not DVD quality, but it is just fine for the casual watcher.  If I wanted to spend the money I could get a better TV and increase the resolution, but the reader should remember that I make my living as a paramedic.  This will not happen soon.

The result of this break with the norm is that I watch what I want to watch when I want to watch it for very little money.  And my daughter has grown up commercial free which has implications that go far beyond the boundaries of this small blog post.

But I do worry about the sustainability of this.  Take the entry level Netflix plan at $8.99.  Think of it, unlimited streaming and DVD’s mailed to your house for $8.99.  If you watched a movie every 3 or 4 days, you could easily burn up $8.99 in postage over the course of a month.  Ignoring that though, let’s say you just watched streaming almost daily for a month.  That kind of bandwidth and hard drive space could easily eat up the price of admission.  And if there was anything left, perhaps a dollar or two, is this enough to sustain the authors and distributors of this content?  Let’s say that I watch a mixture of ‘Dr. Who’ and ‘Buffy the Vampire Slayer’ for 30 days.  Does the BBC and FOX get to split the dollar or two left from my monthly fee?  It is important to remember that Netflix has no commercials.  At least Hulu has that going for it.  But can Netflix really take less than $9 from me, mail stuff to my house, provide me with gigabytes worth of bandwidth, pay the licensing fees to content providers, and still make a profit?

Of course not.  They most likely went into the red on the postage and the bandwidth alone.  Now you may understand why we haven’t lowered our plan from the original $16.99 a month.  We just couldn’t do it in good conscience.  But what is their plan?  This is obviously one of those Web 2.0 ventures in which a company with a good idea has unlimited backing from hopeful investors while they try and build an audience while losing money.  I have always wondered how the Twitters, Youtubes, and Netfix of the world kept their doors open.

From this perspective, there are only two ways out.  Either the rent will be raised or commercials will be introduced.  Make no mistake.  This will happen at some point.  Netflix will continue to offer this service at a loss until their customers are addicted to it like crack.  At which point they will make a move to make some money.  Will it be successful?  Or will it fail?  Hulu and Youtube have already made their moves to monetize their operations.

I have a secret though.  I am not sure Netflix needs to know this, but I am going to say it anyway because the way I consume media is at stake here.  Hulu made a mistake because they have commercials.  Youtube made a mistake because they have commercials and that stupid annoying bar at the bottom of the screen.  Netflix is the only major service left standing that is commercial free, and that is why I have thrown my lot in with them.  So, I will say this only once.  And Netflix, I suggest you listen closely because I won’t say it again.  Psssst…Netflix…if you raised my rent to $40 a month and all I got was commercial free streaming I would pay it.  There.  I said it.

But it has to be commercial free.  I am tried of people trying to sell me something.  I am tired of trying to explain to my daughter that she doesn’t need some unimaginative plastic piece of crap.  I am tired of one forth of my precious free time being used up suffering through tasteless pitches for useless crap that I don’t want.  Have I made it clear that I don’t want commercials?  If it is not clear than I will be happy to tell you again.  I DON’T WANT COMMERCIALS.

So, here is my proposal.  Netflix, go ahead and charge me more money.  I will pay it.  Try and keep your costs down, and name the percentage profits that you want to make.  After that there should be some amount of money left.  This should be split between the content authors and distributors.  If I watched half Star Trek and half Dr. Who, then half of the money left over would go to Paramount, and the other half would go to the BBC.  This may be a simplified version of the reimbursement of these companies, but you should get the general idea.

Is it a pipe dream?  I don’t know.  But what I do know is that there is no way I can keep watching as much TV as I want for $8.99 a month.  (Or $16.99 in my guilt crazed loyalty to this company.  But that should drive the point home.  So much do I hate commercials, that out of the goodness of my heart will I pay more than I have to.  Netflix should consider this like a tip.)

So what’s the take home here?  If you hate commercials too, take a stand.  All of the major video game consoles will let you watch Netflix on your TV.  (X-Box, Playstation, and the Wii will let you stream Netflix through the console.)  If you don’t have a video game console you can purchase a Roku box or simply hook up a computer to your TV.  Then call up your cable company and tell them to take a flying leap.  Then start consuming commercial free TV for $8.99 a month.  But be prepared to have your rent raised some day.  Nothing is for free.  Fight consumerism by paying for what you really want.

Unfotunately, I don’t think any paramedics will be affording this anytime soon.

“My fellow Americans.  This country has a bunch of brave men and women fighting overseas.  And by and large I think they do a good job.  But it has come to my attention that many of them may be there for the wrong reasons.  A certain percentage of them constantly use racial slurs like raghead and sand-nigger to describe not only the enemy, but the people we wish to protect.  This would be unfortunate in any circumstance, but when we are engaged in the task of nation building this sort of hatred and racism undermines our goal.  Why is this happening?  Our military is made up of many people who are earnest in their desire to protect this country at all costs, including their very lives.  But our military is also populated by some very young adults who were not very successful in life and so they went to see a military recruiter out of desperation.  Our military recruiters have been under great pressure to recruit enough people so that we can avoid a draft, and to be quite honest, we have had to resort to enlisting people that by almost anyone’s standards are undesirable.  Due to this, a certain percentage of our military are extremely intolerant, angry people who are probably not suited to be on the front line of a humanitarian effort.  So I am calling for us to change our policies…”

Okay, I want everyone to stop for a moment.  Did the above paragraph piss you off?  If it did, ask yourself why.  I have great respect for our military.  When I owned my own educational company I went out of my way to support troops coming home.  I turned some of them into paramedics.  I became personal friends with a few of them.  You can listen to this podcast I recorded in order to document the story of one of them.  My own brother is a career military person.  But you know what?  My brother was a complete jerk when was in college.  He failed out of his classes, and was sent home with no job and no prospects.  My mother, exasperated with him, sat down one day and told him that he was a failure and his only chance to support himself and get by would be to join the military.  A few weeks later he was in the army.  And come to think of it, to this day he is a racist, intolerant jackass.

If you talk to anyone in the military in private, they will tell you that many grunts in the military are young people who are consumed with defending our country or with bettering themselves with the GI Bill.  I think this is fantastic.  But this same person will also tell you that the military contains many of the great unwashed.  Because of this, everything has to be dumbed down to the point of ridiculousness because all army training is focused on the lowest common denominator.  This isn’t just me talking here.  They right books about it.  They perform plays about it.  They sing songs about it.  Watch M*A*S*H for crying out loud.  I’m not the only one making this claim.  Don’t get me wrong though.  The great unwashed does not make up the bulk of the military.  It is also filled with a bunch of very interesting and very smart people who do fine things and risk their lives for our country.  I respect them.  I admire them.  And I thank them.

But does anyone think that our entire military is a very intelligent, humanitarian, well spoken, altruistic group of homogenous do-gooders who are selfless and pure?  Of course not.  The brigs are full of soldiers who are guilty of assault, rape, theft, and all sorts of fantastic behaviors.  This has always been true.  But in recent years they have really had to scrape the bottom of the barrel to find applicants so that a draft would not be necessary.  And frankly sometimes it shows.  The current missions we are engaged in are sensitive, and some of these people are probably not the best choice for that mission.

But Obama can’t say that on TV.  Why?  Because some things are just not to be discussed in public.  Back in the 60’s and 70’s people used to talk openly about this.  But the veterans from Vietnam and other wars had finally had enough.  They made it a political hot button.  People who paid high prices serving their country didn’t want to be insulted.  And politicians are all about not offending people, so the whole ‘support the troops’ thing became ubiquitous.  And that is great.  I think everyone did support the troops to a certain degree.

But all the sudden criticism was taken off the table.  And that has effects.

All of the sudden, saying anything disparaging about our troops became taboo.  Any politician who even got close to saying anything critical about our military was instantly blacklisted.  And in just a few years we start to learn of all the hideous torture and atrocities that have gone unchecked.  Many of them have been brought to light, but we still can’t say anything about the nature of the men and women who serve our country.  Even though I have recently read an account of a giant corn fed boy from the Midwest who took it upon himself to sodomize muslim males in order to humiliate them (yes, he basically ass raped several men without any direct orders to do so, but claims he did this in the name of freedom and Democracy) we can’t go out in public and say anything like, “Hey, what the hell is wrong with the military?”  How does anything get better if we are not allowed to criticize?  I’m sorry, but I would like to be able to make a statement in public to the effect of, “I don’t think soldiers should be ass raping prisoners,” without my patriotism being called into question.

The same can be said about EMS volunteer services.  (You were wondering when I was going to get around to EMS, weren’t you?)  The idea of volunteers is a good one.  When a member of the general public hears of someone in their community who volunteers to take people to the hospital and put out fires, that person is usually deeply impressed.  Who wouldn’t be?  I mean, on paper it looks great.  How could you say anything disparaging about someone who helps people out of the goodness of their heart?

But that’s the problem that I would like to discuss.  I would like to take the time to criticize and tell you exactly what is wrong with the volunteer services, and why it is so difficult to run a good organization.

Let me first say, that I don’t think there is anything wrong with volunteering.  As a matter of fact, I am volunteering right now.  Yes, typing on this keyboard is my own way of volunteering.  Take a good look around Gomerville.  Do you see any ads?  Do you see a ‘donate’ button anywhere?  No.  You don’t.  I spend a lot of time doing this.  I pay hard earned money to maintain my hosting account.  I continue doing this knowing that I am never going to make one thin dime off of my work.

But there are other rewards.  I would like to think that some of my writings may call attention to some of the problems in EMS that others who have a higher stake in things would not feel free to say.  Perhaps this will make someone think about what is going on in their service and a change will be made for the better.  Perhaps someone who was thinking about getting into the business will read this blog and find out that this is really not for them.  Perhaps another will read it and find that EMS would be the perfect profession.  Perhaps a manager who is far removed from his or her employees will hear this voice and think a little harder about the policies that they implement.  I also get to interact with many of you.  I get new readers all the time.  Thousands of you.  So something I am saying is striking a chord.  And that’s enough.  That’s my payment.

So believe it or not, I get the whole volunteer thing.  I get it because I am doing it right now.

And many volunteers do have the right idea.  They are selfless people who have found out that hard work has rewards other than money.  I respect them.  I admire them.  I appreciate their efforts.

But just as I have discussed with the military, does anyone really think that all volunteers are selfless, well trained, well spoken, altruistic do-gooders who are on a 24 hours a day, 7 days a week mission to help their fellow man?

Of course not.

So, if not all volunteers are good, then who is bad?  And why do they come?  What’s the motivation for them to give up their time like that?  What is the reward for a bad volunteer?

There are several reasons for this that I will cover.  The first is what I would like to call the ‘zero to hero’ phenomena.  Is everyone who applies for a job suited for that job?  Is every employee who works for a company a good employee?  Of course not.  And as you might have guessed, not every volunteer who applies to a department is going to make a good volunteer.  Some of them are people who are down on their luck because they are not very intelligent and not very well organized.  The world is filled with people who just haven’t done well for themselves.  They are lonely and desperate to belong to something and  feel important.  And then they drive by the station house and see that sign…

I hired a Medical Director for my EMS academy.  I paid him money for his services.  Some of my colleagues thought this was crazy because there are a few physicians out there who will offer their services for free to EMS education projects.  And I had worked with some of those people before.  They were sometimes hard to reach on the phone.  They often cancelled things at a moment’s notice.  I once spent almost a month trying to track an ER physician down trying to get a signature on one piece of paper.

Money makes people accountable.  Money makes people honest.  Money gets people’s attention.

Now I am not claiming that you will be happy with everyone you pay to do work for you.  Quite the contrary.  But you have a leash on those people.  You have a way to make them accountable.  And if things don’t work out you can fire them.  Not so for the volunteers.

And thinking back, the most successful volunteer programs I can think of were programs that offered an alternate form of payment.  For instance, many suburban fire districts in my area are paid departments that have volunteer programs.  Every so often a paid spot will come open, and where do you think they look to fill that spot?  Consequently, many of the volunteers are giving their free time in the hopes of getting paid.  So a perceived monetary reward is at the end of their efforts.  Some of these departments also have what is known as ‘live ins.’  These are volunteers that are allowed to live in a dorm room in the station.  They live rent free.  This obviously has a monetary value to the volunteer.  If you combine those things together, what you really have is not a volunteer, but a person who is being paid indirectly.  Consequently, these people are more accountable.  And the department gets to ‘try before they buy.’  All things considered, many of these programs work pretty well.

But the more a system relies on the altruism of the participants, the more suspicious I get.  EMS is a pretty thankless job.  Anyone who has done it for any length of time will tell you that most of the calls aren’t bad.  But if you work for any length of time you will encounter violence, drunkenness, disease exposure, verbal abuse, personal injury, sleepless nights, and all manner of unpleasantness.  And in this day and age, less and less people find themselves able to easily leave work.

There are a certain percentage of volunteers who put up with all the drawbacks of EMS service for free because they are simply desperate to belong to something.  As I said, volunteering looks good on paper.  If you ask a member of the general public what they think of when they think ‘EMS volunteer’ they will probably conjure images of a chiseled man wearing a helmet and speaking into a portable radio.  Now that’s sexy.  But some of the people who volunteer for EMS are people who really don’t have a lot going on mentally, but they are dying to wear that badge.  They desperately want people to think of them as that chiseled guy with one leg up on a bumper, talking into a handheld at the scene of some mayhem.  Yeah, that’s sexy.  It’s the same reason so many garage bands are started in high school.

But it’s not a good reason to become a public servant.

Oh, and I could tell you stories.  And to be honest, I probably will.  Now that I have laid the ground work here I would love to tell some tales of volunteers showing up drunk, or with faulty equipment.  The stories are outlandish, and I am going to save them.  I am not going to try to tackle all of those at once.  Some of those stories need to be savored individually.  But I also have to be very careful.  My story about the one volunteer who was caught masterbating in the radio room really upset some readers and I need to be careful.  This really seems to be a hot button.  Telling stories like this leaves you open to accusations of being unpatriotic.

But with this post I would like to point out the characteristics of a good volunteer service as well as the characteristics of a bad one.  Please keep in mind that these are observations.  I refuse to offer them as absolutes.  I am sure that a volunteer organization exists somewhere that will contain every bad characteristic I am about to detail and still manages to be a fine service.  Inversely, I am sure there is another service somewhere in this country that contains every good characteristic, and manages to perform horribly on all levels.  These should be considered markers, and warnings rather than absolutes.

Characteristics of a Good Volunteer Organization

1. Some sort of monetary compensation should be in place.  Some services pay per run.  Some pay with free rent in a dorm room.  Some pay indirectly with a chance at a paid position.  The trick is to pay with something, because pay can be removed when standards are not met.  As I said, money keeps everyone honest.
2. The level of training should be consistent with that of paid staff.  If there is no paid staff, it should be consistent and equal to other services in the area.  Too many times I have heard the excuse of ‘Hey, we are volunteers, we don’t have to train as much.’  I would counter that argument by saying that your patients are just as sick.  The car wrecks are just as horrific.  The diseases are just as contagious.  The heart attacks are just as deadly.  Your training needs to be just as intensive.
3. There should be a schedule that allows volunteers to have days where they are not available for runs.  Do you want to be available 24/7?  Neither does anyone else.  As a matter of fact, no one should be.  Family is important.  Friends are important.  Careers are important.  And some things in life should just not be interrupted.  Volunteers should take the time to have a day off, sleep late, and have a drink or two.  Rest and relax with the pager off.
4. If there are paid units as well as volunteer units, the volunteer units should look identical and the equipment list should be the same.  An ambulance in service is an ambulance in service.  The patients do not know the difference between a volunteer and a paid ambulance.  No one else should be able to tell the difference either.
5. A good volunteer organization is always recruiting.  The more experienced personnel are always training the newcomers how to improve performance.  No reasonable person wants to spend every day on call.  The answer to this is more staff.  A new influx of people is always a good thing.  ‘Training your replacement’ is not a bad thing.  It is something that everyone in any position of responsibility should be doing.

Characteristics of a Volunteer Program That Has Potential Problems

As you might have guessed, it looks almost directly the opposite of what I have described above.

1. Volunteers receive no compensation, yet they are inappropriately possessive of their place in the organization.  Again, motives play into this.  I know of a volunteer who was let go from an EMS organization.  He then went and retained a lawyer to defend himself.  Frankly, this is bizarre.  This person was never paid money, so what purpose would a lawsuit serve?  Did he want the judge to order the service to allow him to work for free?  I have also heard the “You can’t fire me because you don’t pay me,” argument.  All I can say is, “Motives, motives, motives.”  If someone is desperately clinging to a non-paid position there is usually some unpleasant undercurrent there.  This can be avoided by paying something, even if it is miniscule, for the service.  It won’t fix everything, but it will help.
2. There is an obvious difference in training level and performance between volunteers and the paid staff.  If this volunteer is actively participating in training, this may be correctable.  But if you get the old song and dance of, “I’ve been doing it this way for 20 years and it was good enough back then…” then you may wish to reconsider what is taking place in your department.
3. The volunteer rig looks vastly different from the paid rig.  The signs are usually obvious if something is wrong.  Perhaps it hasn’t been washed in several years.  You may find bow hunting equipment instead of back boards when you open the side cabinet.  I will let your imagination guide you.
4. The volunteer staff has not changed in years.  That new guy who showed some interest a few months ago responded to three scenes and you never heard from him again.  Twenty-year veterans are starting to park the ambulance at their residence.  These are not signs of healthy organizations.
5. The volunteer staff has become an impenetrable clique.  Some camaraderie is to be expected, but if the membership of this clique has not changed in five years and that’s about how long it has been since you have had an applicant, it may be time to change things up a bit.  Also, having beer in the station vending machine is also probably a sign that socializing needs to be reigned in.

What are the telltale signs of volunteers that have gone too far?  At the risk of offending someone, I am going to describe a couple situations which may let you know that you may have a problem on your hands.  If the warning equipment on a volunteer’s vehicle is worth more than the vehicle itself, it may be time to reevaluate priorities.  This is going to sound snobbish, and I will probably take some heat for the statement.  But this should be good information for folks applying to paid jobs in EMS.  I have worked for two different services that would send someone out to look at an applicant’s car during the job interview.  If too much crap was installed on their personal vehicle, we would not hire them.  Be offended if you wish, but this is a good job application tip.

I once attended a fire school in the Louisville area.  A volunteer crew arrived to this training in an in service engine from 300 miles away.  They were all wearing metal badges pinned to fire department t-shirts.  That’s right.  Not class A’s, t-shirts.  And yes, as you might expect, the badges were swinging wildly and low, ripping the t-shirts that were straining to hold their load.  They all had portable radios and tone pagers that were turned on.  I asked if they could receive dispatches from 300 miles away and they just looked at me quizzically.  That’s one hell of a repeater.  I am going to jump out on a limb and suggest that this organization may need a bit of help.

I could go on, but I think I’ll stop before I get in trouble.

I’ll wrap this up with a few pieces of advice.  There are many healthy volunteer organizations out there.  If you find one, enjoy it and hold it up as an example for all to follow.  Thank the diligent people who run it, and find out their secrets.  If you should find yourself in the midst of a poisonous department, please remember that the world will not crumble around your district if you leave.  Fighting nepotism and ignorance will be one of the most frustrating things you will ever do in your career.  It might just sour you on the business completely.  Attaching yourself to such an organization for very long may also do irreparable damage to your local reputation.  Under such circumstances it may be preferable to starve rather than swallow poison.  Don’t ever damage future endeavors for a current one that is hopeless.

I would like to ask the reader the following question: “Do you think EMS as it stands is perfect?  Or are there any changes you would like to make?”

Not long ago I heard a statistic that the average paramedic will only last in EMS for about five years before leaving the field.  (Where did I hear that?  Last year I was doing research on this topic for a class and for the life of me I cannot find the quote or citation…sorry.)  That is pretty poor, especially with the hoops one has to jump through to obtain the certification now.  I cannot imagine spending two years to train for a position I will only have for five.

There have been a lot of studies recently that suggest that EMS needs to go back to the drawing board with many of our practices.  Intubation is one of the controversial subjects right now.  I find it interesting that every time this comes up in conversation, the medic I am talking to will find fault with almost every one of these studies.  Either the sample was too small, or there was some flaw with the method of data collection.  However, where there is smoke there is fire.  The last ten or twelve studies I have looked at involving pre-hospital intubation have turned up results that paramedics don’t want to hear.  I thought about listing some of them here, but it would be tedious to do so.  Stop by the EMS Garage or some of the other blogs.  They have been arguing about this for months.  One thing I would like is for someone to point towards a recent study where EMS intubation was shown in a positive light.  Can anyone point to one of these studies?  I would love to read it and showcase it here.  But whether or not you like my conclusions about his subject, you can bet that you are going to hear it from somewhere else.  Too much evidence is piling up to ignore it.

But as I have said, pointing out the problem is easy.  The hard part is the solution.  Over the past several years I have been educating EMT’s and paramedics.  During this time I have gotten a lot of feedback from students, hospitals, EMS services, and other educators about the competencies of skills, and the usefulness of them when applied in the field.  So, I would like to try and describe what I think would work.

If I had the opportunity to change the certification structure in EMS (and this is an opportunity, not a setback) I would take the six or seven certification levels that are out there and reduce them to two.  The two certifications that are left will not resemble our current EMTs and paramedics either.  The primary certification should be something between the skills set of the current EMT and the paramedic.  This will be the primary certification for 911 response so for the purposes of keeping this straight in the reader’s mind I will refer to this from now on as Emergency Responder.  The second certification I will propose is much higher and will be discussed later.

Why aim between an EMT and a paramedic?  Well, as I have stated before, paramedics have a lot of skills that go unused in the emergency setting.  And the training of an EMT is many times considered not enough for all cases.  No offence is meant to EMT’s here.  This is why we have paramedics in the first place.  But the different skills sets and roles of EMTs and paramedics have confused hospital staff for years.  It has created two of everything: two certifications, two methods of education, two types of billing, and about 20 types of EMS services from all BLS, to all ALS, to tiered, and everything in between.  So simplification would be good for all concerned.  Wouldn’t life be easier if every time there was a 911 call in the United States, two Emergency Responders of the same level of training got into the truck and responded?

What does the skills set and training of this Emergency Responder look like?  Let’s talk about what I would add before I start talking about taking away.  First of all, I would add a lot of patient assessment to the initial training.  As a matter of fact, my idea of an Emergency Responder may get more training in patient assessment than paramedics get now.  This knowledge would then be applied to get the patient to the right specialist in a timely fashion.  I have met many EMT’s who can do some pretty spectacular patient assessments by drawing upon their experience.  But I have known very few recent EMT graduates who can talk about local stroke teams, MI criteria, NICU’s, and other specialties with confidence.  The very reason we exist is to transport patients to definitive care.  But for some reason many EMS services have always considered themselves to be separate from the hospitals.  To do what is in the best interest of the patient, we have to jettison this attitude and think of ourselves as an extension of hospital triage.  Accurately assessing a patient’s illness and injury, and transporting that patient swiftly to the correct specialty with the best chance for a favorable outcome should be our absolute number one priority.  Sadly, many services do not even have a mechanism by which to track whether or not a patient was transported to the best facility or not.

I would also add a lot of training for infection control.  I have always thought that infection control was lacking in the basic EMT class, and I have often times been alarmed at how little some of my EMT partners have known about MRSA, VRE, and other types of infections which require various isolation techniques.  To be quite honest, the average nurse’s understanding of infection control is inadequate.  Trying to practice infection control in a moving vehicle presents challenges that complicate this already difficult subject, and initial training needs to reflect this.

So what would I take away?  You know I am going to say it, so let’s get it out of the way.  Yes, I would take intubation away.  The recent bad research is coming down on us like a hail storm.  But that isn’t the only problem.  Education and initial competency have proved almost impossible in recent years.  When I was a regular on the EMSEduCast I talked to many paramedic educators who had sad tales of not being able to reliably get students live intubations during their hospital clinicals.  It seems that more and more anesthesia groups do not want students to add further liability to their situation.  The recent popularity of the LMA has also decreased the amount of intubations available to a student.  Many of my students came back from surgery rotations complaining that out of almost a dozen surgeries that were occurring that day, not one of them was an intubation.  I also have a bit of a dirty secret.  When I graduated paramedic school in 1996, I had never once intubated a live subject.  I had gone to surgery clinicals, but was never allowed to do anything but watch.  The first time I ever did the procedure for real was when I was cleared and practicing in the field.  From talking to other providers I have found that my experience is not uncommon.  The current literature suggests that it takes 50 repetitions to become competent.  How about zero?  Is that appropriate?  There are also many services where the medic to intubation ratio is horribly skewed.  A few months ago a colleague told me of a fire based metropolitan EMS system that contained almost 1200 paramedics.  This system only had about 350 intubation opportunities per year.  You do the math on this.  Can anyone remain competent in a skill if they only practice it once every three years?  Recent technological advances have provided us with several alternatives to intubation.  It is high time that we started to re-evaluate this.

I would also seriously consider taking the monitor off the truck, and replacing it with an AED.  I have told my students time and time again to ignore the monitor when they suspect an MI.  I have told them that 20% of MIs show no changes on a monitor.  I have seen people in the back of my truck go straight into v-fib from a beautiful looking sinus rhythm.  I have also seen my 12-leads crumpled up and tossed into an ER trash can.  So I am starting to take the hint.  I don’t need a 12-lead to know when a patient needs aspirin and nitro, and many EMTs across the nation giving these drugs without ever seeing a monitor strip.  The time and money saved by removing monitors from the truck would be immense.

Would Emergency Responders start IVs?  Yes.  Fluid resuscitation is still useful and very easy to train.  The benefits outweigh the risks, and outcomes are affected.  However, the drug list for the Emergency Responder will not be as large as the paramedic, so IVs really will be for fluid resuscitation and dextrose administration only.

Now that I have mentioned the drug list we may as well explore that.  Most of the drugs in the Emergency Responder arsenal will consist of drugs available to current EMTs.  Aspirin, nitro, epi 1:1, oral glucose and the other usual suspects will be present.  However, I would like to add glucagon, dextrose and benadryl.  I have often thought that EMTs do not give enough drugs, and many paramedics only pull certain drugs out of their kits when they expire.  The one unknown here is pain control.  Pain control in the pre-hospital setting has been shown to be beneficial.  But it has also been heavily abused.  Is it worth the trouble?  To be honest, I simply don’t know.  I attempted to read up on this a bit before I made this post, but to be honest I think I am more undecided now than I was before.  I simply don’t know the answer to this one and I hope that more studies are done soon.

So, in the end the Emergency Responder would look a lot like an EMT as far as skill set.  What would be added would be IVs, and a little bit of expanded pharmacology.  What would be greatly expanded is patient assessment and knowledge of the hospital system.  This certification would be the entry level for EMS services, and the backbone of 911 and non-emergent transport.

But I did mention another certification didn’t I?  Actually, certification may be the wrong term for it.  I would like this provider to be a licensed and have a bachelor’s degree.  This licensure would look a lot like a critical care/community paramedic.  The education of this provider would allow him or her to make interfacility transfers with ventilators, ECGs, multiple drips, and chest tubes.  Sedation, and pain control would be possible.  And the ability to function independently as a ‘community paramedic’ would be part of the initial education as well.

In all my years in the field, I have often observed that transport medics longed for 911 jobs, thinking they would be a new challenge, only to be let down by the realities of that job.  In contrast, I have seen medics used to working for 911 systems attempt to get a part time job at a transport agency and become overwhelmed by that patient with five drips, two chest tubes, and a ventilator.  I have worked in both theaters, and enjoy either side when done correctly.  However, it has always confused me as to why more respect is perceived for one position over another.  Often the perception of difficulty, skill, or knowledge is quite wrong.  Believe me, I am fully aware that working for a transport agency can be less than glamorous.  But glamour is not a measure of difficulty.

The critical care/community paramedic would feel at home during serious ALS transports, critical care and flight operations, and the expanding field of community medicine.  And if a student is going to pursue something such as this I think that RN licensure is not too much to ask.  Now, before the hate mail begins to flood in, I am not suggesting that nurses be put on a truck.  I am suggesting that a four-year degreed medic should have more career opportunities available.  The college based medic programs in other countries lead to RN licensure, and I don’t think that is too much to ask, especially if these medics will be taking over the care of ICU patients.

Anyway, I hope this explains my position a little more.  I have gotten a lot of mail in my inbox recently that has accused me of being burned out or hating EMS in general.  I assure you, nothing could be further from the truth.  Well…okay, maybe I’m a little burned out.  But its nothing more than usual.  Those people who thought I had completely given up on EMS may be surprised to hear that I think the minimum certification for someone in the field would be something beyond the scope of EMT.  They may also be surprised that I am calling for another certification higher than that needing a degree.  So this post is for you.

However, I think the controversy (and much of the misunderstanding) comes from my belief that the average 911 system could be well handled by someone with a bit less training than the current paramedic.  But so many services across the country have resorted to allowing BLS crews to take to the streets and transport without medics if one is not available.  Many rural systems have gone without medics for years and get by just fine.  I personally work for a system that went ALS in 2007.  The EMTs that work for this system are of a very high caliber.  I often find myself just standing back on scene and watching them work.  I seem to step in for a very narrow band of situations which I have tried to reflect in my description of the new Emergency Responder certification.  What I would really like to see happen in my district is a community medic program.  And although I think there is a real need for it where I work, I also think that we are several years away from considering it.

So to all those people who thought that I hated EMS, you were a little off in your assessment.  But now that I go back and read some of the stuff that I have written over the last few weeks, I know where some of that perception came from.  I was having a conversation with a colleague a few days ago about these posts, and where I thought EMS should go.  He told me, “No one can tell that from what you have written so far!”  And I am not sure why you all can’t read my mind, but I am disappointed in each and every one of you.  So here you go.  Maybe after this you will find a whole new set of reasons to be angry with me.  I don’t know.  But I’m sure I will find out.

As for the validity of my ideas, I don’t have much to tell you.  No one is going to read this blog and gut the EMS system as we know it.  Forget a blog post, this subject could fill a set of books.  Obviously, more studies will have to be done, and people smarter than me will be deciding what happens.  However, I will make this prediction: no matter what you think about intubation, it is about to be questioned by a bunch of physicians.  If you don’t agree with my assessment of the situation, that’s fine.  But those of you who wish to keep this skill in your bag of tricks better start preparing your arguments now.  Your medical director may be reading recent studies right now and reconsidering her opinion.  It happened to the London Ambulance Service and it could very well happen to you.

Fell free to add your own opinion in the comments section.  I enjoy discussion on this topic.  All seething anger can be directed towards hatemail@gomerville.com.

This seemed at odds with the political affiliations of the management staff. They were all very conservative, and voted Republican.  If you mentioned any sort of social programs to assist the poor they would instantly become of fountain of right wing rhetoric.  Many of them were even openly mean to beggars and homeless people.  A few of them would occasionally ask for a job application at McDonald’s or Burger King.  They would make a few copies of these and keep them in their cars.  When they encountered a beggar working a street corner with a cardboard sign, they would pull up and roll down their window as if they were going to give him some money.  Then they would hand him a job application and yell, “Get a job, motherfucker!”  They were bursting with pride over the stories they would tell about humiliating anyone asking for a handout.

Oddly enough, this outlook did not translate to people employed by the organization.  It seemed like the more shifts you missed, and the more in trouble you got, the more they were apt to try and give you a leg up.

Case in point: Jock Itch.

Jock Itch obtained his nickname one day when someone proclaimed that this employee was just like jock itch, he never goes away.  He had been fired and re-hired twice when he first acquired the name.  He would in fact survive a third termination before disappearing completely.  This is unfortunate, because I am convinced that if he had come back one more time, they would have promoted him to supervisor.

Jock Itch was an EMT straight out of school.  His job history before that was sketchy at best.  For the first few years of his life out of high school he had left a wake of abandoned restaurant and construction jobs.  This was the first time he had attempted anything of any permanence.

He was tall and slender.  Not bad looking really.  Some of the girls seemed to like his dark complexion and the way he was able to wear glasses but still look athletic.  But to be completely honest, he had this trashy streak.

He was prone to having violent conversations on the cell phone with a girlfriend who was living with him.  These conversations were histrionic.  One conversation would be all hearts and flowers.  The next had him pacing outside while yelling profanities into his cell phone.  His mood could be manic as well.  At first it was just chalked up to being young and inexperienced.  He was new and everyone tried to give him some space.

Then dispatch got a call late one night.  They played me the tape.

“______________ Ambulance, this is John speaking, do you have an emergency.”

“Hey John, it’s me man.  Hey I need an ambulance to come out here.  Ambulances are free to employees right?”

“Yes, that is correct.  What’s going on.”

“Well, my girlfriend and I…well…we got into it.  You know.  And now she’s not moving.  I’m really worried that I did something bad.”  Jock Itch started to cry for a second but seemed to regain his composure.

“Look man, we would really like to help you, but that sounds serious.  We don’t run 911 in that town and the closest unit is miles away.  If she isn’t moving I am going to roll this over to the local fire department and the authorities.”

“No, no, no!” yelled Jock Itch, “We gotta keep this quiet man!  No fire.  No cops.  Can you just come get her?  I’m begging you man!”

John kept him on the line while another dispatcher sent cops and fire to his apartment.  Later on during the call he said that he had “choked her a little” and that is when she passed out.

As you could imagine, this was termination number one.  But he bounced back.  A couple of weeks later he met with our director begging for forgiveness.  His girlfriend wasn’t pressing charges, and he had started attending anger management classes.

Would you have let him come back to work?  I don’t know about you, but for me the whole choking his girlfriend unconscious thing was leaving a bad taste in my mouth.  However, our director took pity on him and the next week he was back in uniform.  I even worked with him a couple of times.  Oddly enough, he was a pretty good partner.

Then he disappeared again.  Rumor had it that he was a relapsed alcoholic, and had become a raging, violent, snot slinging drunk in the space of one weekend.  But one of our supervisors came to his rescue.  Bobby-Don was one of my favorite supervisors, but he was part of the screw up support system.  He got Jock-Itch back into AA, and made sure he attended the meetings.  Bobby was also very religious, and Jock Itch apparently needed religion.  So when he sobered up he was allowed to come back to work.

The next few days were a bit on the creepy side.  And I am sketchy on the details as this was years ago.  But if I remember correctly, Jock Itch was already in a bit of hot water over the whole choking the girlfriend thing.  He apparently got into trouble over his drinking too.  It may have been public intoxication.  It may have been a DUI.  I will never know.  But something happened to his cert.  He wasn’t allowed to practice.  So did we get rid of him?  No.  We installed him on the wheelchair van.  Jock Itch was back, and in force.  He used to go to lunch with Bobby and they would have these little bible study sessions.  The whole thing was just weird and uncomfortable.

So now he was working completely unattended with the elderly, attempting to take them to doctor’s appointments and such.  Then disaster struck again.  Jock Itch wrecked the wheel chair van during a transport.  He called for an ambulance to help transport the injured patient.  I heard the tale through the grapevine.  As the story goes, he was transporting a woman with bilateral amputations.  The wheelchair was locked into the floor, but she was not fastened very well into the wheelchair.  When the wreck occurred she was launched out of the chair and smashed face first into the deck.  I could only imagine the scene of chaos and horror.  A legless woman with a bloodied face, pulling herself along on the floor of the wheel chair van while Jock Itch freaked out.

Many conversations were had.  There were meetings.  There was anger.  There was begging and pleading.  But in the end Jock Itch finally disappeared.  After beating his girlfriend unconscious and trying to get the company to help him cover it up, and then going on a bender and losing his cert, and then finally wrecking our only wheelchair van and injuring a helpless old lady with no legs, we finally decided to let him go.  I had suggested more than once that we probably should have called it quits after the choking incident.  I was accused of being intolerant.  I tried to defend myself against the intolerance charge by offering up as evidence that I didn’t taunt homeless people with fast food job applications.  But that didn’t go over well.  So I suggested that if we wanted to replace Jock Itch that we copy some of our own job applications and hand those out to random homeless people.  Perhaps one of them would be more sober and less violent.  Then I was accused of being an instigator.  I was also warned about my attitude and told to ‘get with the program’ or ‘suffer the consequences.’  I then asked what were the consequences of being really good at my job and not wanting to work with violent drunk people?  The consequences were that I was never promoted.

The volunteer service in Kentucky in both the fire and EMS sectors varies greatly in quality from region to region.  This is a nice way of saying that some of the volunteers are completely out of control.  This is not to say that Kentucky has not benefited from the wonderful contributions of many competent volunteers.  Some of these people started the services that now exist from the ground up, and they have been the backbone of what we have.  They are to be commended.

However…

There is also inexplicable leeway given to many of them whose knowledge and skills are far below what is acceptable.  It is hard to explain to you how bad some of the things I have seen have been.  In fact, there is a problem with reporting them on this blog.  The things I have seen some volunteers do are so hideous, so ridiculous, so fantastically wrong and bizarre, that I think many people would think that I am lying.  The reader might be inclined to say, “There is just no way that this really happened, and Buckman is bringing shame to the volunteers by bringing this up.”

In a post that I have since taken down, I attempted to tell the story of a volunteer I once worked with.  As is my customary style, I simply told the story.  This person wasn’t diagnosed with any sort of developmental impairment, but it was obvious that his intelligence quotient was quite low.  He did some things that were very embarrassing to the department and to himself.  In the end he wound up being caught masterbating in the radio room and was let go from the department.

Yes…it was that bad.

One reader got really upset by this story.  And looking back on it, I can see how my usual gritty style of prose did not give this story the sensitivity it deserved.  That’s a nice way of saying that I screwed it up horribly.  When we discussed this in the firehouse we cursed.  I left that in the dialogue.  We got exasperated with him.  When he wasn’t around, we made fun of him.  This is all real, and I wrote it as such.  So I am not guilty of lying or exaggerating, but I am guilty of being insensitive.  Parts of the story were funny.  Parts were sad.  I really wasn’t trying to guide the reader in either direction.  The story was both funny and sad.

But it now becomes obvious that the plight of this poor person was the wrong subject for my abrasive style of prose.  When I wrote it, I wanted it to be shocking, because lets face it…it was.  But boy did it come off wrong.

So, here is the problem.  One of the missions of this blog is to let people know what happens in the emergency medical services and other sectors of public safety.  I have successfully tackled other subjects and have been praised for what I have done.  I truly believe that volunteers are not a sacred cow.  If there is something horrible going on there, I want to discuss it.  People with mental handicaps are not a sacred cow.  One of the points of the story was to call to the reader’s attention how ridiculous it was to put someone who was so mentally dysfunctional in a situation where someone’s life may hinge on his decision making capabilities.

It is an uncomfortable situation.  I want to talk about it.  But it has become embarrassingly clear that I am going to have to change my style of writing while I discuss it.  And this is a tall order.  I don’t want to clean it up.  I don’t want to sugar coat it.  One of our volunteers got let go for masterbating in public.  I once rode in a volunteer ambulance and tried to find something useful in the cabinets.  I found drugs that were expired over ten years ago, a turkey baster, and an old snake bite kit from the 80’s where you were expected to cut and suck the poison out of the patient.  I have seen volunteers show up to runs when they were so drunk they couldn’t walk.  I once read a year’s worth of paperwork from a volunteer unit and not once was a set of vital signs or an assessment written down.  The paperwork actually said ‘took vitals’ and ‘did assessment.’

I could go on and on.  I could also say some wonderful things about volunteers.  But I have to admit (and you can get angry at me for this if you want to) in recent years I have seen more harm than good.  This is my experience where I work in Kentucky.  Your experiences may be different.  I truly hope they are.  I am looking back over 15 years of service, straining my brain to come up with shining examples of how a volunteer EMS system has worked flawlessly.  I’m sorry.  I just can’t.  I will admit that I have known some large suburban fire departments that have had very successful volunteer programs.  And I commend them.  But almost every example of an EMS volunteer system that I know of has been horribly flawed.  Whatever successes they may have made were overshadowed by their inability to check the unprofessionalism that was occurring.  I have talked to other professional volunteers that were depressed by the state of things.  So the opinion is held by people on the inside as well.

So, just for the record.  I am deeply sorry if I offended anyone.  It is not my intention to shock or offend the reader.  Well, yes it is.  But not in a Bob Saget sort of way.  If you read one of my posts about how bad the EMS service in your area can be and you are shocked and offended by that, then good.  That was the intent.  It was not my intent to make fun of the mentally handicapped or sling mud on the whole of the volunteer services.

So here I find myself once again wanting to report something that is deeply troubling and deeply offensive without offending anyone.  This is a tall order.  All I can say is that I will attempt to do it with more style and grace than my previous attempt.  And, note to self, I must try in the future not to just rip off a quick blog post on such a hot topic in the middle of a 36 hour shift while I am so tired and cranky.

*Please note, the story is written in the first person as Danno would have told it.  Having Danno’s whole story in quotes, and then putting more quotes around the dialogue in the story just got confusing.

*          *          *

So we got called to this motel back in the seventies.  It was a dive.  We were there to pick up an unconscious girl, and when we got to the room we knew something was up.  The place smelled like shit, and it was nasty.  She was every bit of 500 lbs, and she was butt naked, and spread eagle on the bed.  There was a guy that was quite a bit older than her who was packing up some stuff like he was coming with us.  My partner and I went right to her and started working.  And I asked the old man a couple of questions.

“Sir, what relation are you to this woman?”

“That’s my old lady.  She’s been screwed up for a while.”

“How long has she been unconscious?” I asked.

“Two days,” said the old man.  His tone was matter of fact.

“Two days?  Really?  She’s been laying here unconscious for two days?”

“That’s what I said.”

She was breathing, but she was deeply unconscious.  Sternal rubs and other various means of checking consciousness turned up nothing.  She was dead to the world. My partner put some O’s on her.

“So, if you don’t mind me asking, why didn’t you call sooner?” I asked.

“Call sooner?  What the hell for, boy?”

He just wasn’t getting it, so I decided to let it go.  As we worked her some more we started to suspect drug usage.  Who wouldn’t in this case?  But my partner noticed something weird.  There was some blood and signs of infection down in her nether regions.  She was so obese that I missed it before, but when he pointed it out, it was pretty nasty.  I started looking around the room.  There were all sorts of weird things piled up everywhere.  They were just two junkies flopping in a motel and they had all their weird homeless shit with ‘em.  One of the things that struck me was that there were a couple of two-by-fours propped up in the corner.  When I looked back towards the patient, I noticed that there were a couple of splinters in her junk.  It sounds weird, but a couple of wood chips were actually caught in the fur if you know what I mean.

“Hey, old man.  What’s the story with those two-by-fours?  What’s going on here?”

“Oh that,” he didn’t miss a beat as he started to chuckle, “yeah, well you can see how damn fat she is.  And like I said, the bitch has been passed out for two days.  And well, I wanted to get me some, but her fat rolls was in the way, see?  So I been propping her shit out da way with those two-by-fours whenever I got the urge.”

Makes you have a deep faith in humanity, doesn’t it?

*          *          *

Danno was also a fountain of love advice.  He had been married for years, but his past was colorful.  He was fond of saying, “Some people try to call me a whore.  But that’s not accurate.  Whores charge.  I give it away so that makes me a slut.”

As I have said before, he was my first training officer.  In those very first days in EMS, he would often call out my name loudly and begin asking me medically related questions.  Some times they weren’t so medically related.  But he was always trying to impart his wisdom.

“Buckman!” he bellowed one afternoon.

“Yes, Danno,” I answered.

“Have you ever dated a psycho chic that you wanted to get rid of, but couldn’t?  You know, like she wouldn’t take the hint?”

“That hasn’t happened lately, girls have been getting rid of me.  But yes, that has occurred from time to time.”

“Okay, this is full proof.  This is what you do.  Go to her house and nail her senseless.  Just wreck her shit.”

“How’s that going to help?  Seems like that would kinda cause the opposite effect there, Danno.”

“Wait for it!  I’m not done.  After you get finished, walk over to the window and wipe it off on her curtains.  Then just get your stuff and leave.  I guarantee you, she’ll never call you back.  Mission accomplished.”

“Have you actually done this, Danno?”

“Hell yes!  Twice.  I don’t give advice I don’t follow myself.”

*          *          *

I truly feel blessed to have received such high caliber training so early in my career.  Although I was never able to try Danno’s ‘psycho chic solution’ I am sure that it is sound advice that every young man should know.  And I am proud to offer it here so that others may learn.

A short while ago I had occasion to work at a private ambulance company.  If you want to search this blog for angry rants about employers it will turn up other things I have written about this period in my life.  It was pretty bleak.

Anyway, one of my students worked as an EMT there.  I was just wrapping up his paramedic class when I started working there again to recoup some of the money that was flying out the window as a result of my academy failing.  We were talking outside one day and he started to spin a story for me.  He started to talk about how he took a chest pain in the other day.  That’s when I interrupted him.

“Hey, you are making it sound like you rode this chest pain into the hospital.  It was your partner, right?”

A lot of people around us starting laughing.  I was obviously out of the loop, so I asked what the hell was so funny.

“Haven’t you heard about my partner?”

“Well, yeah.  I mean I have seen her.  I know who she is.  She doesn’t say much, but she seems nice.  What’s up?”

More laughter.

“Dude, we switch out every call.  And when I say every call, I mean EVERY CALL.  We caught a chest pain at a nursing home and it was her turn to drive, so I rode it in.”

More snickering.

“So, let me get this straight.  You rode in the back with the patient?  And the complaint was chest pain?”

“Yep.  And shortness of breath.  And diaphoresis.  And nausea and vomiting.  The whole she-bang man.”

“She knows that you’re just a student, right?  She knows you don’t have your numbers?”  I was dumbfounded and other people just kept laughing harder.  “I mean, I think it would be appropriate for her to let you do some assessments at the bed side.  When you guys got to the back of the truck it would be cool for you to be doing 12-leads and making treatment decisions with her guidance.  But when it comes time to do ALS procedures and drive, you’re up front, right?”

Now the laughter was out of control.  It was obvious that the joke was on me.  But a few of them saw I was getting pissed and they assured me that they weren’t laughing at me.

“This is why we are telling you this, man.  Welcome to F&B Ambulance!  Let me spell it out for you.  There was no ALS care.  It was my turn, so we loaded the cot in the back and she drove.  I put a cannula on her, took a few blood pressures and did the paperwork.  We dropped her off at the hospital and went on about our business.  Get this, the next call was her turn.  It was a BLS patient.  She rode it in.  It’s fucking luck of the draw man!”

And that’s when it finally sunk in.  It was hard for me to fathom just how little this medic cared about what happened on her truck.  I kept assuming that this had to make sense or that someone would have stopped it, but all my assumptions were wrong.  This had apparently been allowed to continue for months.

“Have you complained about this?”

“Of course I have.  I used to make a lot of noise about it.  But no one gave a shit and no one around here does chart reviews.  As long as we get to bill ALS for so many runs, they could give a shit.  So I got crafty for a while.  I figured if money was all they gave a shit about, then maybe I should complain that she was making ALS-billable calls into BLS runs and we were losing money over it.”

“Oh yeah, how did that go?”

“They didn’t do anything.  I remember talking to the supervisor about it.  He looked bored.  When I got done he just asked me if there was anything else.  I said no and I left.  That was three months ago.”

“Well, you aren’t practicing outside your scope are you?”

“Nope.  I put a cannula on them and do the paper.  She drives.  We go to triage and put ‘em in a bed.”

“Okay, what about the facilities,” I was still having a hard time grasping this, “don’t they ask why you haven’t given nitro and aspirin to a patient like that.?”

“Man, that’s the killer thing.  The hospitals could care less.  They don’t know what our capabilities are.  I don’t think they care whether we are EMT’s or paramedics.  If they do they don’t act like it.  In all the months I have ridden with her I think one nurse has questioned our care, and my medic jumped in with this song and dance about how we were just around the corner and there was no time to do anything.”

“Was that true?”

“Fuck no,” he laughed, “we were all the way across town.”

He relayed another couple of incidents to me.  All of them were just as bad.  She never checked out the truck.  In four months he had seen her open the drug box once and that was because she had a headache.  He told me that he had checked into her previous career and found out that she had been fired or demoted at all the places where he asked about her.  But at F&B, she had the run of the place.  As long as she showed up on time, management loved her.

“So why are you still on the truck?” I asked.

“I can’t give up this schedule, man.  I have to go to your class so I can become a medic, get off this truck and do something besides put a cannula on people.  Although, I’m starting to think not much more is needed.”

“What do you mean?” I asked.

“Well, everyone gets to the hospital.  You name it.  Chest pains, strokes, hypoglycemia, abnormal lab values, GI bleeds…whatever.  We put ‘em on a cot and drive them to the hospital.  I’ve been doing this for four months, and everybody gets there.  It’s like chest pains, we take them to the hospital and the nurse probably thinks we are BLS or something.  Sometimes the triage nurse will give them aspirin and a shot of nitro while she is looking over the paperwork.  So the patient gets it then instead of twelve minutes ago while we were dicking around in the back of the truck at the nursing home.  It’s crazy.  I have been tolerating this bullshit for months so that I can have the schedule to go to your class and learn how to do what she is blatantly ignoring.  But at the end of the call I think I am just charging the patient more and getting no where.  I mean, I’m sure we’re living on borrowed time, but nothing has happened yet.  I’ll jump out on a limb and say we run at least 4 or 5 ALS calls a day.  They all get to the hospital.  Nothing bad happens.  It fucking hilarious.”

It wasn’t long before I quit.  I still know a few people who work there.  A few months later I asked about her and I was told that she was still doing it.  She just kept chugging along.  I was told that the only time it ever became an issue was on ventilator runs.  Someone told me that she didn’t know anything about vents and that she had racked up at least “one confirmed kill” but that management hadn’t noticed and neither did the accepting facility.  I mean, they obviously noticed that the patient was dead, but no blame was sent her way.  The patient was really sick and they figured the arrest had just occurred when they were pushing her into the room.  And perhaps it had.  I will never really know the details.  I can tell you from experience that all the medics there are woefully under trained on the ventilator and most of them have no business running calls like that.

As a matter of fact, when I had just started back working there, they had me go out on one vent run with another experienced medic.  When I got back they put me on my regular truck.  Two weeks later a certificate showed up in my inbox.  It was a certificate for four hours of ventilator training.  The medic’s name was on it, and so I went to ask him about it.

“I am tired of this shit man.  You remember that run we made together where I showed you the ropes on the vent.  They counted that as four hours of classroom training and put it in your file.  I have never seen this.  I would never sign it.  I never had a chance.  You were only with me for about an hour anyway.

But this is a whole other can of worms.  ALS transports and Community Medic ideas aside, nothing ever happened with initial responses.  (I am starting to formulate an opinion that the training for 911 responders should be one thing, and ALS transports and Community Medic should be a complete other set of training that looks much like a degree program.  This is way beyond the scope of this post though.  In the stratosphere actually.)  This medic responded to emergencies for months and it was a complete random chance whether or not the medic or the EMT saw the patient.  In that sense it was almost like a randomized study.  When the medic did ride in the back, there was still no ALS care given.  According to my student she would do an ECG if she felt like it and he had only seen her attempt one IV, which she missed.  And miraculously, everyone made it to the hospital unscathed.

Now am I advocating this?  Of course not.  Is this anecdotal incident conclusive proof of anything?  No.  But it was fascinating.  And just plain dumbfounding.  I still have trouble processing this.  But it is just one little piece in the puzzle that makes me question whether or not paramedics are needed in the first response setting with their current skills set.  And I offer up this wild tale for your consideration and inspection.  But please don’t get me wrong, or put words in my mouth.  Feel free to be outraged and disgusted.  It’s one of the reasons why I don’t work there anymore.  Truth be told one day I just had enough, parked the ambulance, and went home in the middle of a shift.  I haven’t been back.

But I would like the reader to ponder what would happen if tomorrow you decided to treat all of your patients like this for the next few months.  Would the outcome of any medical or trauma patients change?  From what I understand, that medic never encountered a respiratory or full arrest at that company in the first response setting.  But what if you treated that BLS as well?  Instead of a monitor you would use an AED.  Instead of intubating you would use a King Airway.  Instead of giving drugs you would simply do nothing.  Would it change the outcome of any of your patients?  And if it would, how many outcomes would be changed?

It’s just a thought.  Think of me as the little devil on your shoulder whispering in your ear.  Just ignore me and I will go away.  Or will I?

The crossing guard was sitting on the curb crying.  A frantic man was in the street not really knowing what to do.  I walked up to cross the street and he motioned for me to stop.

“What’s going on?” I asked.

“Just don’t move.  Don’t go anywhere.  Just stop.  Someone is getting help.”

*          *          *

I had just started work as an EMT.  I had just been hired by a private ambulance company in Dallas.  I was still in training and we were working as a three person crew.  I was really uncomfortable during my training.  I look back on that time in my life and wonder how I ever stuck with it.  I would ride around in the back of the truck as we responded to calls all day.  I was always left out of very hushed conversations between the two partners.  I felt like an unwanted fifth wheel.  When I held back I was told I was too timid.  When I stepped up and jumped in, I was told that I was doing the wrong thing.  I couldn’t find my stride.  I couldn’t find my balance.

“Unit 122, start for the city of Plano non-emergency. Signal 27 coming to your pager,” squawked the radio.

“Oh, hot damn!” yelled Danno. “Our trainee gets to play with a dead body!”

“What?” I asked, “What’s a Signal 27?”

“That’s the radio code for ‘dead guy.’  We have the body tote contract for Collin County.  So every time someone dies outside of a facility like a hospital or a nursing home, we have to go pick up the body and haul ‘em to the morgue.”

This really didn’t sound like fun.  So far, most of what I had done on the private ambulance were things that weren’t even mentioned in EMT school.  What I was trained to do and what I did were two very different things.  It was becoming harder and harder to reconcile the two things in my head.  And now I was going to pick up a dead body?

We arrived at the address to find a very nice house in a well-to-do suburb.  The patient was a man in his 70’s.  The house was packed with family, and from what I could gather from snippets of conversation the patient had a very volatile heart condition, but was not expected to die when he did.

We made our way through the crowd of family and paid our respects.  The coroner had already come and gone.  There was to be an autopsy and a police officer remained at the house to maintain the chain of custody over the body.  The policeman looked very uncomfortable and asked if he could leave now that we had arrived.  Danno saw no reason to keep him so he told him he could go.

A few of the family members wanted to view the body one last time.  Danno and his partner allowed this while we stood by in the room.  After they were satisfied, we walked them to the door and closed it behind them.  For the first time since we arrived, we were alone without family present.

“Goddamnit, I hate this shit,” Danno mouthed the words as if he was yelling, but his voice was only a whisper so that his words wouldn’t carry outside the room.

His partner Joe started laughing.  “Yeah, this is taking forever.  We’ve been on scene for what, 30 minutes already?”

The patient looked as if he had died peacefully in bed.  We pulled back the covers and found him in his pajamas.  His arms and legs were all over the place though.  He looked like one of those people who slept splayed out all over the bed.

“Well, at least he didn’t shit himself,” Danno said.

“Does that usually happen?” I asked.

“Oh yeah,” answered Joe, “It’s rare that it doesn’t happen.  If you are alive, you have control of your sphincters.  If you are dead, you don’t.  And when they relax, the poop and the pee will come out.  But don’t let this fool you.  We’re not out of the woods yet.  The second we move him, he could unleash the nasty on us.”

“What I am worried about right now,” Danno paused for a second to tug at one of his arms, “is the rigor.  Damnit, he is stiff as a freaking board.”

I wasn’t familiar with this so they filled me in.  As I have said, the patient died with his arms and legs splayed out.  Now the body had rigored.  The implications were lost on me until Danno looked at me like I was an idiot and asked, “How are we going to fit him on the cot and get him through the door?”

And as Danno predicted, this was pretty damn difficult.  What followed was a scene that could have come right out of a Three Stooges or Marx Bros. movie if the subject matter wasn’t so grim.  The poor guy simply wouldn’t fold his arms and legs in.  When we finally got him out of bed he looked like he died while doing jumping jacks and froze that way. 

“What do we do?” I asked.

“We gotta work him loose,” said Danno.

He proceeded to grab an arm and started working it back and forth.  He instructed me to do the same on the other side.  Back and forth.  Back and forth.  Back and forth.  It took a while but the limbs became a bit more pliable.  When we got them close to the torso he called for Joe to spring into action.

“Joe, quick!  Buckle him in!”

Joe fastened the stretcher strap around his chest and cinched it tight.  There was a tense moment when he let go and we all backed away from the stretcher.  We wondered if it would hold.  After a few seconds we all breathed in a sigh of relief and started to work on the legs.  This took a bit longer, but they too finally were secured.

“Okay, let’s cover him up and get the hell out of here.”

We took a sheet and carefully covered him up, taking pains to make the sheet nice and neat.  Little would the family know that if the button on the buckle was pushed the patient would explode like a jack in the box.  We opened the door and started to wheel him into the hall.

There was a tense moment as the wife wanted to pull down the cover and see him one more time.  Danno allowed it, but we were all sweating bullets.  She just gave him a little peck on the cheek and sent us on our way.  When it came time for transport I of course had to ride in the back.

“How in the hell do you do the paperwork for something like this?” I asked.

“We’ll let you figure that out rookie.  I’ll give you a hint though, you don’t have to take his blood pressure.”

*          *          *

I froze on my side of the street, unable to cross.  My second grade mind was scared.  I thought I had done something wrong.  The back of my neck was hot.  My palms were sweaty.  I wanted to cross and run into my classroom.  I wanted to do anything but stay here staring at the little girl under the coat not moving.

An ambulance finally pulled up.  It was the 70’s so not much was done.  They just scooped her limp body up and set it inside on the cot.  One of the EMT’s walked over to the frantic man and asked a couple of questions.  Then he got in the driver’s seat and they sped away.

I was scared.  The crossing guard was still crying.  I just wanted to leave.

*          *          *

We pulled into the coroner’s office and wheeled our patient into the bay.  The medical examiner was waiting for us and wanted to have a look at the body before we put him in the cooler.

“Hey Doc,” Danno seemed to be familiar with him, “here’s your guy.  Be careful though, we barely got him on the cot.  He rigored up in a hell of a position.  We liked to never got him out of the house.”

“Really?” he said chuckling a little bit, “Let’s see.”

“Okay,” said Joe, “you asked for it.”

Joe moved to the head of the stretcher.  He pulled the sheet off the cot and dropped it to the floor.  Then he carefully reached over the patients head and pushed the button on the upper strap with one finger.  The arms of the patient violently sprang out to the spread eagle position.  The doctor started laughing.  Softly at first, but then he completely lost it when Danno undid the legs from the other side.

“That’s priceless,” said the doctor, “you didn’t break anything squashing him in like that?”

“No, we did it slow.  We worked him into it.  It took a while though, and we were scared shitless he was going to come undone in front of the family.  You want him in the cooler?”

The medical examiner waved us on, still laughing.  We made our way to a dingy little room that was full of steel tables.  About half of them already had dead bodies on them.  We moved ours over to one of the empty tables.

“Hey,” I said, “this is the first time I have really seen a dead body.  It’s kind of fascinating.  Do you mind if I have a better look?”

“This is your first time?” Joe asked.  “Yeah sure, get it out of your system.  This won’t be the last though.  It is kinda interesting, isn’t it?”

“Yeah, but you know, I think I have seen a dead body before.  I was just a little kid and it was so long ago.  She was laying in the street when I was on my way to school.  It was creepy.  But I never really saw her.  Not like this.”

So Joe and Danno made it a training opportunity.  They showed me what dependant lividity was.  They talked about rigor mortis and how it can be ‘broken out’ like we had just done.  Joe pushed down on the belly to show how you can evacuate air from the stomach.  There was more to dead bodies than I had ever considered.

“See,” Joe said with a flourish, “nothing weird about this.  Death is a part of life, and a part of this job.”  He tapped a few times on the patient’s chest.

“But you can’t help but think some of them are just going to get up and wink at you,” said Danno.  He had been in the business for 20 years, but you could tell he was more uncomfortable with it than Joe.”

I walked over to the patient’s head.  “Do you like being dead?” I asked the patient.  Then I grabbed his cheeks and squeezed them to make the patient move his lips.  “No way!” said the dead patient.

Joe thought this was the funniest thing he had ever seen and was laughing uncontrollably.  Danno rolled his eyes and said something to the effect that rookies shouldn’t be playing with dead folks.  We turned off the lights and left.  As I was closing the door I noticed that the only light in the room was the soft blue glow of a bug zapper hanging from the ceiling.

*          *          *

When I was older I asked my parents about the little girl in the road.  They had never heard of the incident and questioned whether or not I was remembering it correctly.  To be honest I really don’t know.  It was so long ago that I can only remember flashes of it, a few seconds at a time.  It may have been a dream for all I know.  But I remember how I felt.  I felt queasy, hot, nervous, and jittery.  The memory is so obvious, so real, and so strong.

I finally got across the street and made it to class.  I hadn’t thought about it in years until I saw the eery blue glow of the bug zapper in the morgue as I closed the door.