Paramedic Notes From The Inside
introduction to an evolving series
Emergency medicine is extended periods of intense boredom, interrupted by occasional moments of sheer terror, joyful exuberance, heart wrenching pain, and transcendent humanity.
Writing creative nonfiction, by both definition and mandate, requires a truthful accounting. What that truthful accounting looks like, is heavily dependent on the skill of the writer and the leap the reader is willing to take. If you’re a writer and you’re good at your craft, there are certain ways to tell a tale that may, in a semantic sense, be factually accurate, yet at the same time emotionally dishonest; absent many of the deeper truths that define the experience one is imparting. For me, writing in a way that lays my vulnerabilities bare through what I know to be emotionally honest, even when it may portray me in a less than favorable light, has never before been particularly difficult. I say “never before”, as writing this series has been something I’ve found incredibly difficult, and there have been more than a few stops and starts along the way.
To put this in context, I left full time work as a paramedic in 2006. Since then I’ve maintained my certification by the attending the required number of continuing education shifts mandated by my licensing body, but have not been employed either full or part time since 2009. In my time away, I’ve written many drafts detailing my experiences, I’ve written a couple things here and there that have even been published. However, I’ve never taken that serious deep dive into the twelve years I spent working in emergency medicine, and really explored it in any great detail. Why? For the simple reason that I wasn’t ready. Ready to deal with the 12 years of memories; good, bad, exuberant, rage inducing, hilarious, and terrifying. I especially wasn’t ready for some of those memories or people, ones that 11 years later I can still see a face, or recall every detail of an event, or describe with exacting accuracy the words said to me by someone I couldn’t save. Those things still haunt me. To be completely truthful, I don’t know if I’m ready. But what I do know for certain, is that I have to at least try to unpack some of that baggage.
Paramedic Notes From The Inside, is how I’m intending to do that. I’m keeping it flexible enough to exist in many forms, but for now it is going to be a weekly look back at some of the experiences and memories that, despite time and distance, have stayed with me after I left a 12 year career that, at it’s core, was about trying to save a life. Stories will run the gamete from an urban, inner city based ambulance service, to a provincial critical care helicopter, to a remote medical clinic in a Central Asian mountain range. They will be diverse and many, and will at times be chronicles of humorous, non medically serious anecdotes, through to detailed accounts of life threatening emergencies. And everything that exists in the large space between. Some stories will not be pretty, many were hard to write, and others will be sad, senseless, and tragic. There will be those that offer an uplifting and needed validation, with a potential to remind one of the things that are truly important. Some will defy categorization. But what I promise, and this is to myself as much as it is the reader, is a sincere assurance ensure that the stories I tell and the memories I describe will be just as emotionally honest, as they will be factually accurate.
A Paramedic Glossary Of Sorts
One thing I found while writing these memories was that if you didn’t have an understanding of what, exactly, a paramedic is, and what it is that we do, you’d be missing a prohibitive amount of the story. The level of knowledge the average person has, regarding what a paramedic actually does is extremely wide ranging. I’ve seen it all. From questions such as “why does an ambulance driver work in the helicopter”, right on through to the other assumption that says “you guys are just like doctors right?”
The option here is to explain as I go, but that just doesn’t fit with the immediacy of the moment vibe I am hoping to impart. Thus, I came up with the idea of a glossary of sorts. Quick, specific details that are required info to appreciate the story. So, to start off, consider this the Cole’s Notes guide to the education, various levels, and scope of practice of those of us tasked with the somewhat heavy responsibility of showing up and attempting to save a life.
Education and Levels
Are there different levels of paramedics? We no longer have the designation of EMT (in Canada), as the education requirements for an entry level position (what is now commonly called a Primary Care Paramedic) is two years of full time study resulting in a community college diploma, or four years of an undergraduate ending with a degree in Paramedicine. What is different from the older designation of EMT? Besides the amount and length of training, paramedics are assigned the responsibility of what are called delegated medical acts. These are procedures and treatments that are normally only provided by a physician. Obviously, in emergency care, adaptability is key, so current EMS systems has developed so as to allow non physicians that are certified to perform these procedures. Thus, paramedics.
I’m guessing the most common idea that the general public has when it comes to paramedics, is similar to what we classify as an Advanced Care Paramedic. These are your Third Watch people. Individuals that have gone back to school after their initial two or four years, through either an affiliated community college or university, and have taken another one to two year program of study in advanced life support, human physiology, pharmacology, psychology, crisis intervention and counseling, and advanced trauma management. In most regions of North America these are the highest trained paramedics, and are often able to deliver a wealth of emergency drugs and treatment, cardiac defibrillation, advanced airway management etc. Most often without the tight, sexy uniform.
Critical Care EMS
In the last fifteen years in both Canada and the US, there has been a new, third level of paramedics completing training. Critical Care Paramedics. Though the numbers are still fairly small, they are usually based in high volume urban centers, or remote, isolated environments that are often lacking a high level of emergency care. The actual name varies by region, but in my case, because my training was in California at UCLA I needed to complete the US national registry exams, to be certified in both Canada and the US. The specific title being Critical Care Paramedic (F) The F in the bracket indicates I was certified to work in flight environments. Essentially, the CCP’s role is to literally bring the ICU or critical care environment to the patient. Patients that are almost always critically ill, usually unconscious, and are often mechanically ventilated. Virtually all of the calls I have performed as a critical care flight paramedic have been life threatening, or if not life threatening, patients have had otherwise extremely serious conditions that mandated intensive treatment, performed in a narrow window of time.
The training for this level usually begins in a University based hospital program, and progresses to a university medical school. For example, my paramedic education involved the optional completion of a masters degree in in community health. Something that was not necessarily related to my work as in critical care, however, the additional study provided the background required in other allied roles or as expanded scope paramedics in non traditional environments, such as when I worked overseas in remote clinic environments and international medical aid missions.
Scope Of Practice
The scope of practice for the various levels of paramedics can vary widely, and it is usually left up to what the physician responsible for the program (state or provincial EMS director) feels his / her medics can handle and are sufficiently trained in. Paramedics at the primary and advanced levels usually carry anywhere from 15 to 50 different types of medications. In my case, at the time I left full time critical care work, we had an open ended scope of practice. Meaning, any medication or medical therapy the patient may have required, we were authorized to administer, provided it was one we were familiar with and trained in. At last count our medical bags contained three hundred and sixty various emergency and critical care drugs. Yes, it can be a hell of lot to stay on top of.
In terms of procedures, we were certified to provide some of the most challenging, as well as some of the most potentially complication inducing medical acts. Procedures which are performed infrequently, but have a high degree of acuity. Meaning, we would often see an immediate and dramatic return to health from time sensitive, critical emergencies. Surgical cricothyrotomy (tracheotomy in layman terms), insertion of chest tubes, pericardial centesis, the management and maintenance of intra-aortic balloon pumps, and wound suturing, to name a few.
Getting Personal
Obviously, being a paramedic can be an exciting, rewarding, though high stress career. It’s one that requires a significant commitment, both in initial education, keeping current with a rapidly changing knowledge base and skill set, and maintaining an above average level of fitness to carry out what can often be exhausting work. The most difficult aspect, however, can be the significant toll, both mentally and emotionally, that the job inevitably takes.
Today, in 2017, there are a record number of paramedics, emergency nurses, and emergency physicians experiencing a PTSD diagnosis. For myself, while I enjoyed my time in EMS immensely, twelve years was enough. When I began to notice the warning signs that were suggestive of not coping well with the jobs inevitable emotional baggage, it was a huge ego blow. I thought “I was different”. I believed myself to be more mature, more self actualized, and emotionally stronger than many of my co-workers. Whether that was true or not, in the end was really irrelevant. Everyone has a boiling point. Everyone. It’s not only foolish to think you don’t, it’s also supremely arrogant.
What it took for me to finally make that realization and admit I needed a change, is something I’ll never forget. It was the first call of the day on a Christmas morning. A Delta level call (the most serious), we were being dispatched to an infant in cardiac arrest. CPR was being performed by the parents, on what was their first born child. By the time we got there the baby was cold, blue, and it was clear the child had been dead for several hours, a likely SIDS case. It was one of those moments that the obvious futility in continuing CPR is definitely a judgement call. Some parents will want to know everything possible was done to save their child. This mother, however, clearly knew. Looking at me with red, wet eyes, she softly asked me what I knew to be true.
“He’s gone, isn’t he?”
As both our priority and patient shifted, we began functioning in what are largely unknown roles. Offering an embrace, making tea, helping grieving parents find their address books to make those dreaded calls. Since, after a pronouncement of death had been made, our only role was to simply be with the parents in their grief. Even that, however, was something we were unable to do for long, as our call was cut short for another emergency.
Exactly 17 minutes later, and 5 km from the home of those grieving parents, my partner and I would deliver a healthy set of twins on the side of a six lane highway in the middle of a Christmas snowstorm. When we finally were able to clear the second call and leave the hospital, our dashboard clock had yet to read 9am.
Having to manage the dynamics of those two in-every-way-light-years-apart scenarios is a special kind of skill, one that I realized had a limited and finite shelf life. It was an experience that finally allowed me to admit that I just didn’t have the emotional range to effectively treat and manage those types of calls anymore, and at the same time take care of my own mental health. Admitting that was both a freeing and incredibly humbling experience, allowing me to take inventory of my life, my future, and the things I truly wanted. It was reflection that ultimately lead to the difficult decision to get out.
Thankfully, it was the correct decision for me, allowing in a somewhat serendipitous fashion, my pursuit of a long put on the back burner dream of becoming a writer. The heavily touted excuse of a well respected, highly paid and secure career was gone. I now had literally no reason not to apply to a local universities MFA program, something I had been toying with doing for years. And even though more than a few family members and friends thought I was certifiably insane, I bit the bullet and sent in my application. Two and a half years later, in the spring of 2008, I graduated with my MFA in literary nonfiction.
At times, yes, I do miss the excitement of EMS, but I don’t have regrets over my decision to leave, nor any doubts that I did so at exactly the right time.
Starting next week, you will find a new chapter of Paramedic Notes From The Inside, on the Nonfiction page of Crossin(G)enres each Sunday morning.
In the fall of 2006, Allan Rae left a career as a flight paramedic to obtain his MFA in creative nonfiction. Today he is a freelance writer and qualitative public health researcher exploring intersections of HIV, PTSD, and stigma using a narrative focused model of inquiry. Starbucks, satire, and stray dogs do not displease him.
