Clinical year

Yup. The first post from PA school is on clinicals. Why? Because there was no time to post during the first two didactic semesters!

I was told that PA school would be an overwhelming amount of information, but somehow that didn't prepare me for the overwhelming amount of information covered. Here are a few tidbits about my didactic semesters:

      -33 other classmates

      -a disappointingly high amount of "bullshit" clinical experience

      -average of 40 hours of mandatory lecture every week

      -for the most part, I loved the information covered

      -I never want to do that again!

And, to hopefully cover some of the FAQ about physician assistants (PAs):

      -PAs practice under the supervision of a physician. This supervision varies dependent on practice setting. It may be that a PA works side by side with a physician who also sees all their patients, or the supervising physician may be miles away, and only meets with the PA periodically to do chart review. It all depends.

     -PAs can prescribe medications. They also do exams, take histories, make diagnoses, order imaging, etc, etc etc.

     -PAs and NPs, in Colorado, perform very similar job functions. An NP can operate independently in Colorado only in a primary care setting. Educationally, a PA receives about 3-4 times the amount of clinical hours.

Now that I've passed the first two semesters of school, I am out on clinical rotations. Half of school is spent in the classroom, and half is spent in different medical settings. The rotations are 1 month in length, and vary. I'll be in surgeries, emergency rooms, family practices, urgent care, internal medicine, and who knows what else. In addition to being on rotation, I will be completing an online masters in medical science at the same time, so I will still be quite busy.

I just finished the first week of my first rotation, and am trying to recover some of my mental energy. My rotation right now is at a state prison. I never thought I'd be practicing medicine in a correctional setting. It has been interesting. Here are a few bits:

-The clinic where I work is full of good-hearted people stymied by a difficult system. Providers are compassionate about their patients, but often lack the resources in order to provide the best care.

-Government moves sllooooooooooowwwwllllly. Between filling out the correct forms, and going through the chain of command, it might take weeks to get a patient to a specialist.

-As a provider, you aren't supposed to know what crimes the inmate committed. I think this helps to maintain unbiased care.

-I can't bring anything useful in with me! Most of my notes and resources are electronic--but no electronics allowed. No reflex hammers. And no fork for my lunch! 

-Compared to some private practices, the patient load is very reasonable--7 to 10 patients per day.

-I've seen stuff that is "cool" to me now that would have been boring as a paramedic. Some examples from this week: uncontrolled asthma, uncontrolled type two diabetes, hand laceration, and new onset CHF.

-I have so much to learn. Crap. Perhaps my biggest daily lesson is that it is the practice of medicine. 

That's all my thoughts for now. Hopefully more clinical updates soon.

Paramedic to PA

After years of prerequisite classes, and non-stop second-guessing myself, I am headed to physician assistant school. As I have hinted before, I have a great interest in medicine, and have contemplated which path forward would best suit me.

I weighed the pros and cons of a PA, an NP, a physician and an RN. It became analysis by paralysis. Now, with that decision made, the title of this post has been an often used search term. Who else has done this? Have they blogged about it? The internets fell woefully short of expectations on this one. Perhaps I am that "paramedic to PA" blogger. I'll give it a shot. 

The past six weeks have been a whirlwind of....well, nothing. I took an official leave of absence from my job as a firefighter/paramedic, and have spent the last month and a half experimenting with "retired life." I've camped, fished, hiked, hung out with dear friends--it's been fantastic. It's winding to a close now, with the first day of school this Friday. I'm thankful for the time off I've had.

Let's chat a little about that. I felt some time off was important in this career transition, partially so I could "get my head right" for school. Perspective will continue to come, I imagine. I have some initial thoughts. At the fire department, I was a field instructor on a busy, busy, busy ambulance. In retrospect, I was definitely burnt out and chronically sleep deprived. We worked 48 hours on, with 96 hours off. That first 24-36 hours off I was a recovering zombie. The gremlins that plague EMS plagued me. Compassion fatigue? Definitely. Lack of support from administration? Yes. Affected my home life? Yup. I didn't realize how short tempered I was to deal with--and thankful my wife is so loving and patient. The lynchpin holding the whole show together was my crew, and consequently the part of the job I miss the most. I don't think I'll ever get a chance to work with a better group of fellas. 

It is the rare paramedic that can be placed on a busy ambulance (the fellas said they did 32 calls in 48 hours last set) and have happy longevity in that position. It is reflected in our department, where the average medic stays perhaps five years on the "meat wagon." After that, many want nothing to do with EMS. They move to a slow station, a rescue house, or promote. It is, unfortunately, representative of EMS as a whole in this country. 

I don't miss being woken up in the middle of the night. I don't miss the constant stream of degenerates. I don't miss the frustrations of trying to do right for a patient without my organization's support. I do miss the fellas. Miss the station life. Miss the chances to actually save a life. They're few and far between. EMS is a drug, and I was that junkie who seemed to go longer and longer between highs....requiring a bigger high to tide me over. 

I'm looking forward to medicine where I don't have to ride from high to high--I can help a willing patient population consistently. There is advice about PA school to write down why you want to be a PA--the idea being that the experience is intense, and you will question your motivations. Well....

I want to be a physician assistant. It will allow me to have mobility with my career. It will allow me variation in my career. It will let me swim into the deep end of the pool of medical knowledge. It will challenge me intellectually. I will be able to care for patients on a deeper level. I will acquire the knowledge and skill set to make me an asset on international medical trips. It will offer (and require) me  to be a lifelong learner, avoiding stagnation. The eduction, combined with my background, will make me an asset for positions I desire in rural, international and austere locations. 

I hope to blog my experiences during school. I'll also put up some retroactive stories from my experiences at the fire department. Enjoy.

Introspection

Words I should try to live by:

So live your life that the fear of death can never enter your heart.
Trouble no one about their religion;
respect others in their view, and demand that they respect yours.
Love your life, perfect your life, beautify all things in your life.

Seek to make your life long and its purpose in the service of your people.
Prepare a noble death song for the day when you go over the great divide.
Always give a word or a sign of salute when meeting or passing a friend,
even a stranger, when in a lonely place.
Show respect to all people and grovel to none.

When you arise in the morning give thanks for the food and for the joy of living.
If you see no reason for giving thanks, the fault lies only in yourself.

Abuse no one and no thing, for abuse turns the wise ones to fools
and robs the spirit of its vision.

When it comes your time to die, be not like those whose hearts are filled
with the fear of death, so that when their time comes they weep
and pray for a little more time to live their lives over again in a different way.
Sing your death song and die like a hero going home.

(Often attributed to Tecumseh)

I understand this as a more eloquent reminder to live your life with no regrets, and grasp each day to its fullest. A simple idea in the grand scheme of things, yet more of a challenge in the day-to-day grind. 

Big news: I'm going to PA school! I will start this fall, and it is a big accomplishment to be accepted. I'm excited to move my healthcare career forward. I will miss the camaraderie of my current workplace, but look forward to new and different challenges. 

I believe I can better attain the way of life I desire in this new career path, while maintaining my commitment to service. As much as I enjoy my leisure and outdoor pursuits, I know that at my core, service is something I can't stray from. Perhaps this is why that passage sticks with me--"seek to make your life long and its purpose in the service of your people."

Calls that stick with you

Dear Lewis-

You are often in my thoughts. One of those cliché patients that sit on a healthcare provider’s shoulder as a constant reminder of events past.

We always move quickly at my station, when a call comes in. There are a few things that make everyone snap-to a little quicker, and a child gunshot wound is one of those things. So please know, we came as fast as humanly possible.

Usually when guns are involved, we wait until the cops have cleared the area before we enter. This time, we came in on the cops’ heels, knowing it was you. I’m not saying this was a smart idea, or that I recommend it to others, but we wanted to give you the best chance possible.

It was so quiet when we got to your apartment, Lewis. Quiet like no apartment full of children should be. I wish I could have known you earlier–I definitely liked your superhero pajamas. You were a superhero that day, very brave.

I want you to know you had a great pre-hospital crew take care of you. My partner and the firefighter we brought with us are some of the best paramedics I know. The silence in your apartment followed us in the ambulance though, each of us pulling silently for you. We were quick, with our scene time. We were quick to help you breathe, to give you fluids, and then to give CPR. We were quick to the trauma center.

Unfortunately, some things are beyond our control. Some traumas damage the human body beyond our control.

My heart aches with sorrow that you’ve moved on, but I’m trying to fill that with warmth that you may be in a safer and happier place. Five years old is too young for the things you’ve experienced. May you find peace.

One for Ten

As is not unusual for me, it's been quite a while between posts. I've wanted to write, and even have a couple of ideas for posts stashed up....but ultimately what drives me to write is emotional release, positive and negative. Lately it's been a lot of negative energy. I've been frustrated with conditions at my employer, as well as the state of EMS in general. That being said, I thought I'd write a post about what keeps those of us in EMS going. 

A friend I went to paramedic school with recently had this status update:

Gotta love the EMS shift with no death, drunks, or drama....just a healthy newborn baby girl! Best job on the world!

That, friends, is in a nutshell what keeps us going. Depending on who you talk to, statistics in EMS range from 10-20% of the calls we run being the "serious" calls. That is, calls for help from people that are in that true life or death scenario. So, for every twenty calls I run, it's a pretty sure bet that 16 to 18 of those are going to be (to use a technical term) bullshit. 

.....47 year old female panicking because she "doesn't know what to eat when her stomach is upset..."

.....chronic drunk we are called to because he was sleeping in public and someone called in a "man down..."

.....same drunk calling because it's cold and he knows the ER is warm...

.....person calling FROM THE ER because the "wait is too long".....

In addition to the bullshit, there are the serious calls that take a little from your soul. It's the loved one that arrests in front of their family, that's too far gone for us to save. Chronically ill kids. Teens in a car wreck from drinking and driving.

The list goes on and on. It can grind one down as well, especially in a busier system. My medic unit averages 18-20 calls per 48 hours (closer to 30 this last rack). That's a lot of calls to wade through to hold out for that one.....

But we do. We all do. We tell war stories around the kitchen table of our "good" calls and take every complaint of chest pain from every drunk seriously, on guard for our 10%. 

When it comes, it is our junky high. Whether it is the sick respiratory patient (not being able to breath has to be one of the scariest things ever) that you can bring back from the edge of respiratory arrest, or the *rare* childbirth (nice job, Billy!), it is a call that stays with you. The "wins" buoy us through the storm, in the dark and frustrating moments that inevitably follow. There is nothing better than knowing that you have made a positive difference in a patient's life. That intimate moment and connection is unlike any other I have experienced.

Lately I have been feeling particularly run down. I rarely see that 10% any more. Coming back to the blog, to some introspection, I again come back to this quote. It helps give me some perspective.

To know even one life has breathed easier because you have lived.
This is to have succeeded.

Until next time....

Put me to work

It came to my attention recently that there are several people actually reading this. Thank you! I am humbled, as I mostly write off my ramblings as cheap therapy.

Anyway, I've been in a state of flux recently and to be honest haven't had anything too positive to write about. I feel that in some ways I have been boxed in by my system, and have reached a "stay or go"point.

The frustration is, I'm ready to work! I'm ready to be challenged as a paramedic, to provide excellent care to my patients. I want to receive more education, to participate in research and to have a voice in how our system evolves. However....I have no voice, budgets are reserved for "fire training," and I have about as much voice as an Army private in boot camp.

I don't think I am alone in this predicament. I'd like to see prehospital medicine (or paramedicine, as you may call it) flourish or even become established as a legitimate career in the US. I believe that EMS can be a part of building a stronger healthcare system. The days of a high speed taxi and low education should be gone. We are healthcare providers, not technicians that can follow an algorithm. I'd love to see EMS evolve to treat more in the field, for better patient outcomes and to ease the load on emergency departments. To the chagrin of many, I see this possible through increased primary care training. As my fellow practitioners know, many of our calls aren't for true "emergencies," but rather for primary health care issues from citizens who don't have access to the system.

Unfortunately....the current system is far from this utopia. Private EMS pays on par with what you might make flipping burgers at a fast food joint. Third service EMS constantly struggles for funding. Fire-based EMS....is often the butt of jokes in the world of EMS, and sometimes rightly so. It doesn't make sense to "force" a firefighter to become a paramedic, and doesn't lead to good patient care. It doesn't make sense to devote a majority of budget and personnel to training firefighters when fires make up less than 5% of all calls.

I'm making a call to those fire departments running their own EMS. Step up to the plate, and become part of the system. Take your medicine seriously, through your budgeting and training. Participate in the national discussion on EMS, and how it is changing. Participate in research. Now is a critical time for our field, and the fire-EMS system is the most well funded to facilitate change. The ambulance is not the bastard child of the fire department, the piece of apparatus to shy away from. Take pride in prehospital medicine, and take pride in your prehospital providers.

love,
MedicMuse.

Ah, Fall.

Apparently nothing worth blogging about happened over the summer. I can't say that with any certainty, but I don't (though I should) force myself to blog. It happens when it happens.

The newest news as of late is that I am dipping my toe into the educational and mentoring portion of paramedicine. Recently our rig has had two paramedic students, the most recent staying with us until mid-December. It has been very interesting being in a teaching position in the field, especially when many times I feel like I am still learning the ropes myself. The idea of teaching has always appealed to me. I've been told I'm good at explaining things and that "I'd make a great teacher."

That is not, however, how I feel.

I realized (not surprisingly) that I have high standards for street performance. I want people I work with to be at that standard right away, and it is a bit of a shock to see a student below that (duh, they're a student) and wondering how I'm going to get them from where they are to where I want them to be. Fortunately, my partner on the ambulance is an experienced field instructor and I've been able to pick up some good tips from him. As he put it, mentoring a student is a fine art of putting them on the line between uncomfortable and dangerous to practice. Apparently this zone is the best place to learn. 

Unavoidably, I've also compared both our paramedic students. I've come to the same conclusion I always have--this is a job field built largely on field experience. Most of our job, at the basic or advanced level, centers around being able to talk to people. If you can go up to a stranger and establish a rapport with them, as well as extract pertinent information in a concise and timely manner, you'll make a great pre-hospital provider. This comes to some naturally, while in the rest of us it takes many repetitions. I'm covering all this because I'm unhappy with the way paramedic education seems to be going in my state. Now, paramedic school started out as a two year deal. With the advent of fire-based EMS, programs were pressured to shorten their academies to accomodate agencies that needed more advanced providers in the field quickly. As a result, paramedic schools everywhere are cranking out paramedics in as little as six months. 

Experience also used to be a prerequisite to a paramedic program. EMTs with a couple years street experience on an ALS rig were considered the minimum when applying to a program. Now, however, there are too many "zero to hero" programs, where someone can become an EMT and then paramedic all in the same program with no street experience in between! Even worse, many fire departments (including my own), send inexperienced EMTs to school, EMTs who got their certification only so they could apply to the fire department. Does this product sound like someone you want treating your family?

Ah, I can see I've rambled again. Anyway. I'm sort-of precepting now and it's interesting.