it’s a long way down

“Down slow!” came out of my my mouth and I stepped backwards into the void with 800 feet of air underneath me. Since joining Mono SAR, I’d heard stories about Dana’s Third Pillar. It’s the name tossed around for one teammate to scare another.  The tallest climb in our county, it’s in rarified air as having exceedingly high consequences, requiring solid technical skills, and hosting weather that can change in minutes.

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That huge scary ass thing is Mt Dana’s Third Pillar.

Three hours before that, my phone rang. An automated voice recording came on going something like this:

Team, we have a callout. Report of an injured person on Third Pillar Dana. Please bring technical gear and Rescue 3. We’ll be staging at the airport for helicopter insertion.

In 21 minutes I went from sitting on my couch to being in a Ford F350 loaded with teammates and gear, barreling up the 395. Readiness and response times are critical: people call us when they’re hurt or otherwise in trouble. Getting the job done right means getting it done fast.

“Technical gear” means all the stuff for rigging. With it you should be able to lower someone, raise someone, lower yourself on a rope, ascend a rope, and create anchors. Not shown is 50′ of 8mm and 30′ of 6mm rope.

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My base technical equipment, aka my “RFR kit”, named after the Rigging for Rescue curriculum that we base our practices on.

We got to the airport and went through our briefing. How many people, who was hurt, the nature of the injuries, stuff like that. For these I always have a pencil and a pad handy because random tidbits of data fly out that you allow you to assemble a narrative, be it medical or perhaps trying to put yourself in a lost person’s mind. If they’re lost, what do we know about them and what are they inclined to do and not do?

If it’s medical, when did they get hurt? Did they report something on a 911 call that two hours later they don’t remember saying, perhaps indicating ACR or a more serious TBI? Stupid little things aren’t so stupid, and I’m not smarter than my pad and pencil so I write everything down.

3rdgoingup

My team leader ahead, we’re on Dana Plateau headed to the summit of Third Pillar.

We decided we could beat the chopper if we headed in on foot so we packed up and drove to the trailhead. The folks on my team move fast. No matter how fast you’ve ever seen me move, I have to use everything I’ve got to keep up with a few folks in particular. They kick my ass on the way up and can standing glissade on the way down.

3rdpillar

Me, going down. Someone was hurt about a 100′ below me. The boulders and snow are about 800′ down.

I balked at the idea of being litter attendant, which is the job shown above. You go over the edge, find the person, treat their injuries, attach them to our rescue system, and guide the whole thing back up again. I’m well trained on all of that, but the “going over the edge” for lack of a better term is just scary as hell.

On the walk up though I did the math. I had the most medical training, held the highest license, and had the most patient time. I had gone through five days of professional rescue rigging taught by the best of the best barely two months before. I practice this stuff. Two days before when camping with the kids we rigged a mechanical advantage system to pull a snag widowmaker down.

I stepped through every component of the rigging systems in my mind. What they should and would look like. I knew the people who’d be running them, and I have and would again trust them with my life.

I re-volunteered for attendant. I had a teammate who’ve I’ve done a lot with double check me. I double checked him. We do it in silence because solid systems setup correctly don’t need explanations.

The screaming in my head before I went over the edge was loud: neurons were ganging up like angry peasants with pitchforks and torches. Fortunately, all I had to eek out was, “Down slow” and my team lowered me where my own nerves probably wouldn’t. Once over the edge it was game time.

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My team on top of 3rd pillar, I’m over the edge coming up. Mono Lake and the 395 in the distance.

I’ve told my daughters that when things get hard you need to listen to that part of you that won’t quit, and tell all the other parts to shut up. The original line was “…the patient is the one with the disease…”.  In emergency medicine, you can say “The patient is the one with the emergency.” At that moment there’s someone hurt that needs help, I get to have my emergency later.

I stopped by Vons at midnight after I got back, bought a pack of frozen yogurt popsicles, drove home, and hopped back on my couch and ate the whole box. My PS4 game was still waiting for me where I left off.

a busy summer for mono rescue

This post contains graphic content. 

To quote Forrest Gump, Search and Rescue (SAR) is like a box of chocolates: you never know what you’re going to get. Like most first responders the bulk of SAR work is actually fairly mundane and uneventful. But 2018 has proven to be one for my record books. While last week’s volume has been high with nearly a call per day (and two in one day), they’ve also required some of our most advanced skills.

The Sheriff’s Office has clarified its policy on posting pictures so I feel a little more comfortable sharing some of the work we’ve done, hence this post.

chopperout

January 1, 2018: the year started with me getting hoisted out of a CHP helicopter. This would be the least exciting thing I did all year.

On the first day of January, 2018, we responded to a fallen climber. I’ve written about it previously so I won’t belabor things. Eight months later though I’m amazed that something so mind-blowing at the time (getting lowered out of a chopper to treat a heavy trauma patient) wouldn’t rank amongst the more trying moments of my SAR career.

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Me, training, in the yellow gloves. Rigging for Rescue. Horseshoe Piles, Mammoth Lakes.

The amount of training I’ve been through in the last year has been nothing short of incredible. There is of course all the team specific training we put on ourselves. We build mechanical advantage systems and haul heavy loads across parking lots. I rappel off almost everything to learn the different friction feels of various ropes through various descent control devices coupled with different friction hitches.

But then there’s the formal training. Weeks in Alaska getting my Wilderness EMT. The five day Rigging for Rescue basic series. Stop the Bleed. It’s just a non-stop battering ram of advancement in technique, repetition, and locking it in with your teammates.

training

Hauling trucks around the parking lot, practicing mechanical advantage systems.

Most of us have been through training that we’ll never use. It’s rare that you learn something, get good at it, and then 24 hours later you’re using it in the field to save lives. But this year that’s exactly what happened.

mainfield

Mechanical advantage systems in the field, saving actual lives instead of moving trucks around parking lots. Less than one week after our most recent training on the same topic.

On July 29th, our team was dispatched to “a call from help” coming from the Conness Glacier. Trapped underneath roughly two tons of granite, a man was pinned with crush injuries. The same mechanical advantage skills we had been practicing all summer, skills designed to lift patients and rescuers up through vertical space, quickly transformed into a technique to precisely move thousands of pounds of granite.

connessrock

I debated about including this picture. But it’s hard to capture the real anguish for the patient and the urgency of our team in words alone.

glacierview

A small chunk of the Conness Glacier in the background, our team working at the base of Mt Conness. Many of those boulders are loose, including some that are the size of passenger cars, weighing several tons.

conness

Those mechanical advantage rope systems deployed again. I’ve got the blue gloves on, the patient draped over me.

Moving boulders off trapped climbers is not a skill practiced by most rescue teams, let alone something they’ll ever do in the field. Crush syndrome is one of those topics you learn in EMT school that is glanced over: it’s common enough in urban settings because of motor vehicle accidents but in that urban world a hospital is generally not far away. Having a crushed patient in your care for hours, no one needs to tell you that field amputation is a real possibility if your team can’t get the job done. Even if you can extract, the rhab-d clock has been ticking from the start with no mercy.

guardian

Extracted, our patient leaves the Conness Glacier onboard Guardian 2-3.

The call up on Conness in late July scrambled me a bit. It’s hard watching someone in pain, and harder still when the math is not in your favor. My teammate told me later that the rock is what hurt him, we saved his life. Intellectually I know that but the trauma, pain, and adrenaline of the whole operation (nevermind the part where we had to climb onto and off of a glacier ourselves) was a lot to process. The next day our team met up at lunch and disinfected our equipment.

subway

My teammate (and others) after a late night call last week. Laying on the asphalt, eating Subway sandwiches: heaven.

The next night I found myself in an elderly woman’s tent, 7 miles in, an IV bag hung ingeniously by a stethoscope (good work, H40 crew). Treating her, I was happy: she was not actively dying in front of me. My blue nitrile gloves were more of a formality than anything really protecting me from gushing blood or CSF. There was urgency and we needed to do our jobs, but compared to the last few calls this was downright pleasant.

The calm didn’t last.

ducklook

Me in helmet and goggles, looking at the helicopter hoist wire out of frame. NE of Duck Lake.

24 hours later our team would again be dealing with crush trauma, a call remarkably similar to the one from only a few days prior. Perched on rocky mountain top, an operation that most rescue teams will never perform played out with spooky deja vu.

alexcrush

Normally I cannot show a picture like this, but the patient has allowed it to be public.

Another aspect of SAR is that we’re all volunteers. Our day jobs sort-of care about our SAR responsibilities, but it gets old for them fast. In California we’re protected by the Labor Code, but you can tell it grinds on people when you leave in the middle of meetings or your coworkers need to pick up your slack. The first time or two it’s exciting, but eventually I’m pretty sure it gets old for them.

This isn’t getting into the impact it has to our families or friends, all of which end up being “SAR widows”. The phone rings, the world stops, and I’m out the door. I might be back in 10 minutes, 10 hours, or in rare cases 10 days. Emergencies are quite inconsiderate like that and while we have other good medical providers and riggers on the team, we’re a small team. In the second picture above, counting the guy taking the picture, there were five of us.

Five people to handle three mechanical advantage systems, extricate a patient, communicate with our base and the overhead choppers, and provide medical care, all at the same time.

The next day I went camping with my kids, happy to take a break from SAR and spend some time with two little people in the prime of their lives that weren’t suffering from massive trauma or medical illness.

While walking around Devil’s Postpile, my phone rang. SAR call: Devil’s Postpile, right less than a mile from where I was standing. A deputy that I work with walked the girls over to the ranger station and got them into the Junior Ranger program while I rigged a raise and lower system for the litter team, extracting a patient.

deputy

My kids wondering exactly where dad is going.

At the same time, an 8 year old boy was reporting missing in a remote part of the county, our team responded. The next day (yesterday), a patient was airlifted for medical reasons.

We were notified that our team will be covering a large portion of Tuolumne county because wildfire has shut down critical highways in their area, blocking their team from access.

Today is a new day and I don’t know where it will lead. I do know that my harness has my technical gear. My medical bag is restocked. The battery on my team radio is charged. The fuel tanks are full on our rescue trucks. Three gross Cliff bars that don’t melt in the summer are zipped back into my pack.

And I know I’m lucky enough to work with a team of professionals that I would and do trust my life with more often than I can count.

 

my sar medical bag

I was having a discussion with some folks about this topic so I thought “hey Eric, you should sit on your ass and write about it, bro.”

I really think buying medical equipment that you’ve never trained on is a bit silly: it’s akin to buying random tools at the home improvement store thinking “well you never know, I might just need this rivet gun one day.” Everything I carry is something I’ve used in the field or at home, and was part of my training from either basic first aid, my WFR, or my WEMT. When some dude is bleeding in front of you is not the time to stare at the piece of gear you got from Amazon and try to figure it out: take a class.

Also, our sar team has its own medical bags which I often use instead. We have a “first out” bag which carries basic airway, bleeding, and assessment gear. We have O2 tanks we can bring in, litters, vacuum splints, etc. But there’s only a couple of bags and if we’re on a search or otherwise not in a simple “the single injured person is at coordinates xxx.yyy, sss.tttt”, I don’t like running around in the field with my own personal wimpy backpacking first aid kit (my team’s minimum for me personally). Also, I use this for my family and keep it in my truck for whatever randomness the world provides.

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I have allergies so I use unscented deodorant. TheMoreYouKnow.jpg

For starters, you can see it’s pretty small. The bag itself is sort of a piece of crap but it works and if something breaks on it I won’t be sad.

medopen

It’s not the size that counts. -_-

I put the stethoscope on top because I didn’t like how it was getting bent inside the pack. If I’m going to use it I’ll throw it down my shirt while I get other stuff ready so I’m not freezing someone to death with a 0 degree piece of plastic on their skin.

medlayedout

Not bad for a little bag, right?

So here’s my list of what’s in there, trying to group things:

Assessment, since you can’t fix problems you don’t know about and handing off patients to paramedics/hospitals with a “I dunno” response makes you rightfully look like an idiot.

  • BP cuff. I keep a pediatric at home and if I needed I can toss this on a kid’s thigh and get X/palp with a pedal artery.
  • Pulse oximeter. Handy not only at altitude up here, but also gives you a pulse nice and easy so you can move a bit quicker.
  • Thermometer. Temple and forehead, I won’t lie: this is mainly for home use with sick kids. It also doesn’t work under 50 degrees F.
  • Stethoscope. Getting good lung sounds is pretty important for diagnosing HAPE, pneumothoraces, etc.  Plus you can say “auscultate” which is pretty tight.
  • Pupil light. More often than not I use it to read something or stare down a patient’s throat.
  • Emergency Spanish for Fire/EMS. Small booklet, but good luck doing anything if you can’t talk to someone.

Bleeding. For the most part, by the time a sar team gets to you a massive arterial hemorrhage isn’t going to be treatable. Most sar responses are well outside the golden hour, but that doesn’t mean all hope is lost. Also, I have this kit with me in my truck and have been to enough motor vehicle accidents to know that I can actually be there fast enough sometimes, even if just in a good samaritan role.

  • Tourniquet. Spooky and dangerous, these are actually back in vogue and for my training was the preferred mechanism of stopping an uncontrolled bleed. Refer to your training for usage and ischemia management.
  • Gauze. One roll because if you need more than one roll you need like a million, or a tourniquet.
  • Triangle bandages (x3). So these can double-duty as crummy gauze.
  • Bandaids. Sometimes it’s just that easy.
  • Povidone iodine pads. In my WFR training (where you may not have sterilized water) these little bastards can be squeezed into a water bottle killing off germs and making a diluted wound irrigation fluid that won’t harm skin.
  • Medical tape. Good for taping gauze/stuff down on wounds. Also good for deadlifting days to put on your shins so the bar doesn’t cut you up when lifting heavy. #SubtleBrag

Airway. This is actually fairly legit (in my opinion) to carry because for sar you tend to have long carry outs and if homeslice loses consciousness things can go bad quick.

  • I used to carry a whole mini-fleet of OPAs but a single NPA with a lube pack is way lighter, smaller, and more versatile. Yanking an NPA out takes a second and if someone is U on AVPU I’d rather have an NPA in than an OPA. Pulmonary aspiration of vomitus is a big deal with scary high death rates.
  • Valve mask. More applicable to motor vehicle accidents and random urban life than sar.

Medications. This is all about your protocols, your prescriptions, your scope of practice, and how much liability you want to handle. Again, some of this stuff is for me and my family’s use: do your own math and consult your training.

  • Aspirin, chewable 81mg. If a patient is having a heart attack you might just save their life or add a decade (or more) to their clock.
  • Diphenhydramine. Allergic reactions are common and life threatening ones aren’t the rare rainbow-unicorns from twenty years ago.
  • Electrolyte tabs. It’s pretty normal to find people exhausted and cramped up. An hour’s rest, some electrolytes, and fluids can make the difference between walking someone out and carrying them.
  • 500 MG amoxicillin (x6). Not for sar, but if on an extended trip into the boonies this buys me two days of bacterial combat to get them (or me) handed off to higher care.
  • Prednisone. Again nor for sar, but I’ve had my own life saved by this stuff so I keep it on me.

Doo-dads. Rounding out the edges, things that are handy.

  • My protocols, written down, staring at me in the face. It’s so easy to get carried away in the moment.
  • Pencil, rite-in-the-rain EMS vitals sheet. Use some of that medical tape to secure your notes to an unresponsive patient’s leg.
  • Gloves, cloth mask. BSI, PPE, scene safe! I put gloves everywhere so there’s no excuse not to wear them. Open the top pouch: gloves. Open the waist belt pouches on my frame pack: gloves. What’s up my butt? Gloves! Gloves everywhere, baby. Combined with a sharpie you can make cool balloon animals for kids with gloves too.
  • Tweezers.
  • Trauma shears. Nothing says “I care” like cutting someone’s $300 GoreTex pants off of them.
  • Vet-wrap for stability. The colorful stuff that you see on a horse’s ankle is called “vet wrap“. Dirt cheap, multicolored, and self-adhesive. You won’t be sad if you never get it back.
  • Triangle bandages. They come with safety pins and can double duty as gauze or making slings/wraps.
  • Burn gel. I’m not into most goofy creams and ointments but burn gel really does work and people really do burn themselves.
  • Antibiotic ointment (speaking of goofy creams). I know most hospitals like to work on non-gooey wounds so this isn’t really a sar thing. But if you’ve got a dirty environment and a couple of days until definitive care I can’t see this as a bad idea.

So there you go, that’s what I keep with me most of the time. Starting back at the top I recommend that you go out and get your training: WFA, WFR, EMT, RN, MD, DO, witchdoctor, alternative Eastern healer, whatever. Just learn how to treat others and yourself and equip yourself with tools for jobs you know how to do. Otherwise you’re that dude with an inch of dust on your rivet gun and no idea when or how to use it.

Oh, and a word about batteries. For my sar radio I have a six AAA spare battery pack in my pack, made up of lithium batteries which are really your only option in the cold. My pulse ox has two lithiums in it at, put the thermometer is so limited I keep the batteries out and just pop them in if I’ll use them, which is normally at home with a sick kid.

i still hate heights

Any official operation we do as members of search and rescue is run by the Sheriff up here, and as such I can’t really talk about specifics. Also when I’m touching a patient both out of HIPAA and general decency I can’t talk about the person(s) involved very much. You can read up on the official story  with officially release details, and the Sheriff released this video for public consumption. I’m down there on the bottom.

So this story really isn’t about the rescue as much as it’s about what it’s like for this particular guy to get a call on my phone and find myself in a world that I’m still coming to grips with.

For starters, the part you don’t see in the video is where my buddy and I got lowered out of that helicopter, by a little wire, with all our packs and gear, onto those rocks, a half hour before that.

So let’s backup a bit to the point where I found myself at a lonely municipal airport, geared up: harness, mountaineering boots, helmet, goggles, radio, full pack. The helicopter crews start to rip the gear off slowly but surely: all the excess weight must go. Seats, spares, everything. Hauling my teammate and I up into the mountains takes a lot of power and to carry us the rest must go.

I’m surrounded by paramedics, the CHP flight team, other SAR members, and law enforcement. Radios crackle with updates, and I’m noticing that this all seems totally normal to them.

A little voice gets into my head:

It’s time you come clean and tell these people that you have no business here.

I try to shake it off, just figuring it’s the jitters. The pilot does his last fuel calculation and we load in. Sitting on bare metal, clipped to a bolt on the flooring, and holding onto the back of the pilot’s seat (the only seat left), the blades start slowly whirring.

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My buddy and I in the back, red helmets, taking off.

The voice comes back, trying to bargain with me:

You’re on the team and technically you’re trained for this but this is the real deal. The is the stuff you see on Youtube. You’re not that guy. You’ve managed to get here, but you’re not supposed to be. You better tell them they have the wrong guy.

A classic case of imposter syndrome, I was feeling it in earnest. Putting myself on the couch, was it actually imposter syndrome or was it my deathly fear of heights scrambling for leverage? I even got worried that my feet would fall asleep being crunched up on the chopper floor. Wouldn’t that be hilarious: rescuer tumbles out of helicopter because his foot fell asleep.

I first decided to get into search and rescue, bluntly, because my daughter’s life was saved by a team like that. Maybe knowing that I’ll never be in the incredible PJ squad has me always feeling like I’ll never really be “enough”, and that it’s a cast of heroes that do the real work and my place is more centered around getting them coffee than being on the the pointy edge of the spear.

laurelhill

This was the first fire truck I ever ran a call on. Laurel Hill, Norwich, CT.

The first time I ever responded to a 911 call I was 18 years old running code 3 to a motor vehicle accident (“mva, car vs motorcycle” in dispatch parlance). I distinctly remember the feeling of “Oh shit, there’s no one else coming, it’s just us.”

I think for the average Joe Citizen when you call 911 you imagine this Hollywood-esque crew of Dwayne Johnsons rushing towards you, equipped with everything and flawless. But when you’re the one getting the 911 call it’s a very different story. You’re aware of your shortcomings. You’re trying to remember everything from your training. You’re trying to be aware of the things that won’t let you stay focused. You’re trying not to get hurt yourself but really you know you took this job because you wanted to help people and a bit of risk is part of the package.

LeeViningFall

My team and I, doing our thing, in the middle of nowhere.

The voice kept talking to me, but I went back to that realization I had as a teenager: this is your job and people are relying on you. If you don’t want to do this, quit later, but for now do your f’n job kid. You trained, you have a solid team that will back you up. They’re relying on you. The patient is relying on you. He’s hurt, he needs your help.

The crew chief hooked me onto the hoist wire and unclipped my tether. The spitwadded toilet paper in my ears did its best to muffle the rotor noise. I don’t remember going over the edge, but I do remember looking up at the underside of the AStar helicopter, dangling from its hoist wire: RESCUE was written in large, bold letters underneath it.

Touching down on the ground, I unhooked the wire. Meeting up with my other teammates we got started on our jobs. I don’t know if I’ll ever feel like I belong in this work, serving with these amazing people. But I sure as hell will try to keep up with them, not let them down, and take care of my patients. The voice in my head can quiet down and take a number.

 

death

A few days I had my first patients that I couldn’t save.

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Imagine a few of these crumpled up next to each other.

On Monday I was driving home from San Diego on Highway 72 and traffic came to a stop in a place it normally doesn’t. I was behind a big rig but couldn’t see much, so I grabbed my phone and checked my messages. After a few moments I heard someone say “accident”. I peered out, didn’t see any flashing lights, and got that EMS feeling.

Most of the time, things aren’t an emergency. Even “emergencies” usually unfold slowly and you have a minutes if not hours to correct things. Actual no-kidding emergencies where the stuff hits the fan are, fortunately, rare. The EMS feeling is my stomach dropping an inch or two, thinking “oh shit, is this for real?”

I pulled off to the side and saw multiple vehicles ahead. Some on the shoulders, some flipped over on their backs, some so smashed to pieces I couldn’t tell what they were or in what position.

9ypcd5c

Try to determine if it’s “safe” to touch someone in the white truck. Broken glass, sharp metal, and blood.

Someone started yelling at me to stay back. Instantly my training kicked in: scene size up. Is it safe for me? How many patients? How many rescuers? I looked at the guy yelling at me to not go in: he was a civilian, there were no red and blue lights anywhere, and if there was anyone in there that I could help, fuck you, I’m rolling in.

Is it safe for me? Hard to tell. I had my exam gloves which offers me razor thin protection, but it was a debris field of gasoline and gear old, car parts, walking wounded mulling about like zombies from a horror flick. How the hell do you determine what “safe” is in something like that? One step at a time, I told myself.

How many rescuers? One, counting me.

How many patients? Again, hard to tell. If they’re walking, I’m not interested in them at the moment. Take me to the worst and most terrible: I was pointed towards two vehicles that looked like soda cans crushed for recycling.

I didn’t even know how to access them. In one vehicle, if I crouched down, I could see a body part hanging down with bones sticking out. The “safe” part kicked in and I realized that I wasn’t a firefighter anymore with extrication tools, a team, and turnout gear. I pounded on the vehicle and listened: nothing.

I moved to the second vehicle. Air bags had been deployed: lots of them. Curtain air bags, steering wheel air bag, side air bags, the works. The un-moving person was in their seat belt.

I yelled that I was here to help. No response. I reached into the mangled metal cage and squeezed tight for a carotid pulse. Did I feel one, or was that my own adrenaline? For a moment I felt the faintest movement, deep inside the neck. I probed around more. I check a lot of pulses and the carotid is by far the easiest and most pronounced: even on a baby you can find it within a second.

As a I kept probing all I felt was warm soft skin.

A few minutes later, I couldn’t really tell you how many, a CHP car raced in. I explained who I was, my level of training, and what I was up to. He nodded and thanked me for stopping and asked me to keep working the scene. There wasn’t much to do as all signs pointed towards death. The kind of death you don’t come back from. The physics required to bend metal and send cars flying airborne is simply more than ample to cause massive hemorrhaging in nearly every part of the human body. Brain and heart, in particular.

Ten minutes after the police arrived a fire rescue team rolled in. I gave my assessment and findings, and got out of their way. I read the news this morning and saw that both drivers were pronounced dead at the scene.

I spent the rest of my drive home calling my wife, and then two of my friends: one cop and one fellow sar. The next day I went snowboarding by myself for a while. I’m still not “okay” with seeing and feeling so much death and carnage. But everyone, including you and me, will die. If you’re an EMT you’ll see it more often than a librarian.

Be good to each other out there. Leave lots of follow distance when driving. If you care about someone let them know. And don’t think the safety features in your car have made Newtonian physics obsolete.

The location and date have been changed.

 

follow up q&a to my wemt/emt+w post

A friend of mine asked me some questions about my last post (finished my WEMT) and I thought the answers might be helpful for others out there.

What was your favourite part of the course?

Having people in it who had some serious experience. Two guys were heli-ski operators, one guy was a mine rescue technician, several were guides, one guy got shot in the chest point blank, and the instructor is a paramedic who has patients she can’t transport for up to 48 hours because of weather and general Alaskan-remoteness.

In a normal world I’m the most outdoorsy-medical guy around, so it was really humbling and level setting to be around others who experience near daily horror stories and handle them with grace.

What was your least favourite?

I think from an annoyance prospective it was dealing with state and local protocols which are basically always a little out of date with current research. You learn and get tested on some things that aren’t in the best interest of your patients because it takes years for medicine to change (great example: back boards and traction splints, medieval torture devices that are still on most rescue inventories).

At a personal level it was going through scenarios that I had never considered. Like a pediatric with multiple gunshot wounds or a woman who just had a miscarriage, sitting on a toilet, and you being the person who’s going to manage that scene and bring calm. I think everyone has situations that hit them hard in the emotional department, and you never really know what they’ll be until you’re in it or perhaps after the fact.

What surprised you the most?

How quickly a talented person can burn through a primary assessment, establish an airway, stop major bleeds, and prep for transport. It’s like less than a minute (tops) if you’re good, complete with all the gore/mayhem/ppe/bsi/safety.

Going back to the last one, it was also the scenarios that I hadn’t considered. Using a plastic model to practice sticking your hands into a vagina to push a baby’s face off a prolapsed cord and keep the airway patent. Or how to deal with excited/agitated delirium. They’re not scenarios I really signed up to handle, but if you’re functioning as an EMT in an urban setting you can’t pick and choose your patients.

Also, how easy it is to get a bp via a pedal pulse and a cuff on the thigh on a neonate now that I know what I’m doing.

Have you done the NREMT yet, and was it different than what you learned in class?

I’m an Alaskan EMT-1, and have applied for my NREMT course but haven’t taken the test yet. If you’re taking a state’s written and practicals I would really focus on that (which is different than wilderness protocols, which is different than NREMT) because you need to pass it to move on and remembering multiple protocols is rough. It’s a bit dumb because I had to memorize Alaskan procedures I’ll never do in California, but conflicting and head-scratching protocols seem to be the name of the game with medicine in general. Most things are right, but some protocols are bad and just haven’t been fixed yet.

But in general Alaskan and NREMT protocols overlap probably 90%. Dyspnea is dyspnea, a biphasic AED is a biphasic AED, and COPD is COPD. The differences are more subtle like: emphysema patient with a 2LPM nasal cannula complaining of difficulty breathing. Do you crank up the flow a bit or swap her out for a NRM at 15LPM? Either way you’re increasing their O2 but  what’s the specific blow-by-blow protocol? Did you need to use pulse oximetry and if so how? Stuff like that.

My sample tests I’ve taken for NREMT are going well; there’s a few items that are new but nothing mindblowing.

Are you planning on working as an EMT, or did you just do the class for the knowledge?

I think like sailing you suck unless you do it so I’m going to try to work at the local hospital maybe 20 hours a month covering other people’s shifts. My neighbors are trauma surgeons at the local hospital so if I’m lucky I can work with them, or try to hang in the ER in general.

I studied vital sign ranges before the class but from taking literally over 100 blood pressures from various people I actually learned way more about the ranges and concreted in the numbers. Ages and sex matters it seems but I learned that a skinny 14 year old girl probably just has a really low BP and that for little pediatrics I’m high as a kite if I think I can get them to sit still. So the practical application seems to be part of the knowledge to me, if that makes sense.

Do you plan to register in California by county?

So after I get through NREMT I’m going to hit up the hospital in town and just say “Hey, I’m a NREMT EMT-B, what else should I do and what other training would be helpful?” I think there’s ancillary stuff they’ll want too like phlebotomy, probably some blood borne pathogen training, etc. It’s a super rural county so I’m expecting some hoops but probably not a million.

What extra study materials would you recommend?

I was based out of the “Brady Book”, it was the major text we used in conjunction with our wilderness stuff. I bought the workbook along with it and burned through those chapters doing the work before the class. It was probably 100 hours of my life I’ll never get back but the pathophysiology really helped and I liked learning why a pulse oximeter sucks for CO poisoning, as an example.

My learning style is that I need to understand the whole circle and then I can branch out so I felt like (for me) I really need to go ham on the textbook and know underlying health-nerd stuff that there just isn’t enough time in a lecture to cover.

Also, really knowing a lot of the abbreviations and medical terms help. Writing tx is way faster than treatment, ditto pt for patient, hx for history, etc. Sometimes people toss out things like npo and it sucks to have to stop and say, “Huh?”. Yeah, they should speak in normal English but around hospitals they don’t and it’s pretty available info.

In class I made flashcards of things I didn’t understand.

Are there any extra non-study materials you’d recommend?

I made good use of 3×5 flashcards (in addition to pre-made NREMT ones), highlighters, a notebook, and rite-in-the-rain for outdoor stuff. For field scenarios and on actual sar callouts I have WMA’s field guide. It’s 4″x6″ (same size as my rite-in-the-rain book), and both fit in my radio chest harness pocket. On real ops I thumb through it for whatever the suspected injury is to remind myself what the hell I’m doing. There’s also some dope stuff in the back on litter tie-ins, chopper stuff, and medical terms. For whatever field team I’m in I’ll read it out loud (before we get to the patient) and we can discuss what to look for, who’s doing what, what gear we’ll need, what complications we might see, etc.

I just have the boring rite-in-the-rain 4″x6″ because I end up jotting down notes from witnesses, cops, other teams, etc. I’ll write a SOAP and try to format it well enough. In sar land I hand it off to the chopper/ambulance and ask them to give it to the receiving facility as well.

Anything else?

Just because I took so many damn blood pressures I’ll add that quickly being able to ballpark the systolic on a patient, rapidly getting there, then rapidly getting down to the diastolic then rapidly deflating completely is the difference between pro bp readings and torturing a patient by keeping what is essentially a tourniquet on their arm whilst futzing around trying to find their brachial artery for a minute solid.

 

three weeks later, i’m an emt

I’ve previously written up my views on WFR vs WEMT (aka EMT+W), and now I’ve got both of those cards tucked in my wallet.

For two weeks I lived, ate, and breathed emergency medicine up in Skagway, Alaska. I met some amazing people and as an aside I definitely want to write up an entire in-depth post/book/article about not so much the course but the trajectories of those involved. Think about it for a minute: who exactly are the cast of characters already armed with their WFR who are going to spend weeks of their lives up in Skagway learning a super persnickety version of medicine? But first, here are some pictures (some others on my Instagram account too).

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My class. Bent down in the middle is a former CHP trooper, and current paramedic in a fairly remote part of Alaska. When she spoke, everyone shut up and listened.

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On my one day off I hiked with a classmate up to some lakes near the far end of the Juneau Icefield

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The incredibly new and awesome fire department building, where I spent most of my waking hours for two weeks.

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Being in the “south east”, as Skagway is referred to we were actually in a temperate rain forest. As such it rained *constantly*. With the exception of pavement and well worn trails everything else was covered by copious amounts of plant life. The roofs of buildings had green moss, and I dare you to find a single square foot of raw dirt in the area.

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Skagway’s main business is the constant stream of cruise ships dropping off passengers. These folks buy ice cream cones, jewelry, t-shirts, and have a few beers. As such the majority of the town residents cater to these people. This shot was taken the day after “Last Ship Day”, and shows the ghost town that Skagway becomes after the final cruise ship of fall.

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Wilderness EMTs pass all the regular “in town” EMT training, but then we also have to perform the skills with less gear in jacked up environments and handle longer transport times plus coordinate our transport decisions. This photo was from a campfire after one of our nighttime simulation trainings, somewhere in the Alaskan woods.

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When not in the woods, we trained in the firehouse using the gear from Skagway’s ambulance, sar, and fire teams.

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My bunk and living space for a few weeks.

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The kitchen that myself and four others shared. Thanks to the dog sled gang from Alaskan Icefield Expeditions who let us use their bunkhouse while they were off somewhere else. I left you guys some fishsticks and 3/4 of a bottle of vodka.

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When not in the field or the engine bays, it was classroom land. I of course sat in the back because that’s where the cool kids go.

It was an awesome course: no way around it. Being up in Alaska, especially in such a small town, really focused the laser beam on what I needed to do. In the evenings we did assessments and simulations at the bunkhouse, otherwise we’d be out in town taking vitals on random strangers. I’ve probably taken the blood pressure of every child and barstool drunk in Skagway. I’ve auscultated the lungs of infants, found pedal pulses for systolic/palpation readings on neonates, and observed COPD sufferers. Protip: stay healthy, don’t get obese, and don’t smoke cigarettes.

We made jokes about putting a grim reaper sticker on your ambulance every time you screw up and someone suffers, and I watched one of the toughest people I know cry when he discussed a friend who slid in an avalanche and was attacked by a grizzly. The snowstorm cut their visibility down to near zero and as they moved his blood soaked trauma-ridden body out of the avalanche burial. He could still hear the grizzly somewhere close, howling in the hidden whiteout as he provided treatment.

The day after we finished our state practicals we found out about the Las Vegas mass shooting. As the eternal optimist, a silver lining to me was on a day of such madness and mayhem 18 more people walked back into society with the sole intention to help others in their hours of greatest need. It doesn’t cancel out horror or balance the ledger, but it buttressed me a bit to personally know such dedicated professionals that would have been those headed towards the danger.

If any of my classmates ever stumble across this blog entry, I can’t wait to work with you again in the future. Dangling from a chopper or a cliff, pushing the skinny pedal code 3 to a sick child, or just making someone feel better who’s having a bad day: I’d be proud to be there with you.

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Yes, as soon as I got home I popped that shit on my sar chest harness. I know I’m on the lowest end of medical professional but here’s me being proud.