I wondered - actually agonized over – what gift could I possibly give to my reader(s) this Holiday Season. Something from the heart and universally meaningful (and unexpected, of course!) for whatever reason he/she/they might tune in. Happy to say, I figured it out…

…a short Blog!

Blessings to all and wishing for all of you to have time for everyone you love!

Russ,

a firetender

The ER lobby was empty. A sign said “Fill out form, drop in box, wait until you’re called”.  To the question “Why have you come to the ER” I wrote “Rule Out MI.”

To my relief, it only took a minute before I was ushered up to the Intake desk and then quickly into a curtained cubicle. My heart was pounding in my throat and I could hear my irregular beats throbbing in my ears. I’ve gone to a Doctor once since 1993 (see The EMS OUTSIDE AGITATOR goes to the Dockta! Part I), and believe me, I did not want to be there!

It wouldn’t have been a terribly bad week except I had decided to quit my 16 oz. a day habit of triple, home-brewed, muddy high-octane coffee. I also had decided to significantly cut down my food intake. I decided, now that I’m sixty, hell, I oughta do something for my good health for a change. Who would ever have guessed the rebound effects of seeking it!

Arising at 4:45 a.m. I coasted down my favorite volcano (no kidding, I do get to coast a good ten miles!) to work, and picked up my Luxury Limo E-250 High Top Ford Van. There, I found out I had been last-minute scheduled to drop off a jacket to a hotel that had been left on board the van the day before by a client. That would put me behind about ten minutes. Then to the local Minit-Mart to pick up hot coffee for my passengers. Coffee not done so I had to wait for it to be brewed. Then to the Caterer to pick up a couple of plastic “hot boxes” filled with a Gourmet Lunch for eight. That wasn’t ready either so I ended up a good half-hour behind.

I was scheduled to be at the Ritz Carleton in Kapalua — 40 miles away — by 7 a.m. to pick up my first of four couples at four different pick up locations scheduled to go to Hana with me (see Once a Hack for a view of what I do). I managed to shave off about five minutes by creative driving but it hardly mattered, my well-heeled passengers were irate with my tardiness, even though they had been notified of my delay.

To make this part of the story bearable, I’ll just say that I was saddled with four different couples from four different hotels who, because of the configuration of the 8 passenger van (Driver and Shotgun in the front row, two rows of two seats side by side and three seats at the rear — all plush leather Captain’s Chairs!) could not all sit next to their respective spouses. I may as well have been asking a fifty kid kindergarden class to wait their turn to get into a four-stall bathroom!

Nobody was happy. Through most of the day they ignored my sharing of the history, geology, ecology and mythology of the island (Maui) as they shared their bile toward me and the company with each other. If it weren’t such a pain in the ass it would have been laughable, but let’s put it this way; imagine yourself doing a ten-hour stand-up comedy gig, sitting down, with a room of hemmorhoid sufferers!

My problem is I’m good at what I do because I strive to reach people where they’re at and I strove and I strove and I strove to no avail. I have never in five years had such a bunch of sourpusses! All this, mind you while driving the curviest paved road in the US; 1,234 curves and 108 one-lane bridges! Throughout the day I felt my chest palpitating and worked very hard to maintain denial that the beats were way more irregular than I’d ever heard my heart produce. Two of the couples completely stiffed me on a tip, the other two granted me a pittance.

By the time I got home, it was 8:00 p.m. and I had to be in bed by nine to be ready for another shift. I climbed up the ladder to the bed in my loft, and curious, took out my stethoscope and BP cuff. My BP was about 160/90, and then I decided to listen to my heart. No chest pain, no diaphoresis, not even shortness of breath, but those beats! My resting pulse is typically 48 and I was doing about 100. I could hear double LUB’s and then a DUB. Great! Atrial what-the-fuck’s-it-called again? But then came the LUB-DUB – excruciating silence – DUB and I knew I was throwing PVC’s, about six a minute during the worst part!

In my head, I knew damn well that all those years as a paramedic in the 1970′s and 1980′s were wasted pushing all that Lidocaine into distressed patients in the belief that I was saving their lives by preventing the nefarious and fatal R on T phenomenon, or was that P…maybe Q. But in my heart, well, I was wondering “I guess everything goes blank and that’s it!” I’ve had a decent life, I thought but Jesus, it’ll take a while before some paramedic saps get called here to find they have to drag my dead, shit-splattered ass out of the loft. Now THAT would be embarrassing!

But, still, out of respect for all the Evidence Based medicine that Rogue taught me I figured, don’t get crazy here, Russ, lay back, breathe slow, focus on your karma, calm yourself down, you can mobilize your own defenses! After an hour or so of this I remembered how they took away your Lidocaine and gave you aspirin instead, so I popped an aspirin under my tongue and tried get to sleep. Then the aspirin kicked in and my heart began to calm down.

Naturally, that scared the living shit out of me because if the aspirin worked then it had to mean I was fucked! I came to the conclusion that this may be one noisy Silent Heart Attack and maybe I shouldn’t screw around! In the between-time, of course, I meditated and prayed to every known and unknown Sacred entity, including extra-terrestrials.

But do you think I’d call me an ambulance? I could walk, I could talk and my buddy living next door knows CPR (old-kine!) and has a van. I know how much those damn rides cost and I probably wouldn’t let a paramedic touch me unless my hands were amputated and I was bleeding out!

So I woke him and had him drive me the 15 miles down the volcano to the only hospital on the island; my only instructions being, “If I pass out, pull the van off the Haleakala Highway, call 9-1-1, check for a pulse, if none ,drag me out into the grass and start the ABC’s but skip “A” and “B”, got it?!! (If you mug me, I’ll kill you!). Oh, and you may as well give me a hearty thump on the chest, you never know, it always worked on Grey’s Anatomy!”

All the time I’m thinking it would be better I died because if I lived to tell you this story, I’d have to cop to being the ditziest patient I ever encountered in my life — especially since I was a Paramedic with a Capital “P”! And if I got through it clean — which I did – I’d have to cop to being just one more of the litany of patients you find in the ER for no damn reason!

As a Community Leader at EMTLife.com, my “job” is to read as many posts as I can. I’m supposed to be looking for Rule Violations but what I’m really doing is learning about you, me and us as a reflection of Man/Womankind’s drive to beat death. What incredibly meaty stuff! I’m fascinated not so much by the technology of the whole mess but by all the human stuff that goes on underneath it all. To that extent, I do a lot of reading between-the-lines.

But sometimes I don’t have to. A thread will show up where someone airs his/her very human concerns and they have nothing and everything to do with EMS. In this thread, The Grand Life Do-Over, the OP asks:

 

If you could go back in time and choose a different path would you? what would you change. I’m 21, my biggest regret is…

Interestingly enough, the responses to the thread focused on regrets. And even more wild was that the majority of the ones chiming in were under thirty years of age and they were full of them! It was quite a thought-provoking thread so I studied it and really took the time to reflect.

Blogs are cool, but they’re limited to dealing with a topic, a bit of banter by a select few, and then, on to the next blog. In the Forums however, we get a much more broad representation of the people and get to look at things from multiple angles. If the subject is not compelling, the thread dies. In most cases, they run to about 20 responses and by then have run their course. But some get revived as Newbies come in, search, find a subject that moves them and then respond, reviving the thread. I bet the thread there will be commented on for a good long time because it’s key to the experience of being a human being; that’s the stuff that lasts!

Paradoxically enough, I started responding to the thread on the site, realized it was more in-depth, and then moved it over to my blog where few will see it, let alone respond; go figure! So now, here’s my take:

Some of the richest times of my life have been periods that others were sure I’d regret for the rest of my life!

They were wrong.

To me, the problem with the whole concept of regret is that it negates the person who you are right this moment. And that is what you have to live with!

If you want to get down to the nitty-gritty, let’s take EMS. Just the fact that you’re involved may very well mean someone will die because of a few moments of your incompetence. Does that mean you will regret ever getting into the fray?

I hold myself responsible for a couple deaths, yes. Do I regret the losses and the ripples emanating from them? Of course.

Do I regret what I did? How can I? I did what I did. Those moments have passed. I did, however learn there are natural consequences to doing things the ways I did them.

Now if I lived in those regrets, I would have quit the biz if not slit my own throat. That would have been regretful because it would mean a lot of people might have died a lot sooner than they would have without me being part of their lives — past incompetence and all!

So how to avoid regrets? Learn from the actions you took.

Use that knowledge to assure that what you’re doing in this moment causes less and less damage to others and especially yourself. It’s all about the learning-curve, and let’s face it, if you’re going to learn a lot through life experiences chances are you will make a lot of mistakes, some of which turn out to be extremely costly.

So if you have to, get Zen about it. All there is is the present moment. That is what you have to build with and whether you like it or not, this moment stands on the shoulders of all the ones that came before it, good, bad or indifferent.

Those moments that passed are what fills your current tool box; Use every one of them and there will be nothing to regret!

Oh, by the way, I’m sixty years old. I come to you as a person who graduated from Grade School with an average of 73 — passing was 75! I am college drop-out, was drummed out of nursing school for selling pot on campus, a felon with jail time under my belt, a divorcee, the Black Sheep of the family, fired as a paramedic for Union organizing, living just above the poverty level today, and let’s just say without success (society’s dominant values and definition; spelled m-o-n-e-y) in any of the creative endeavors I’ve spent my whole life pursuing.

Although I have to say, I did get a book out of my EMS experience which I really think you’d enjoy!

Oddly enough, were success to come to me, I’d pass on it if it meant I had to compromise the joy of living moment-to-moment in the lifestyle I live today.

I am a recalcitrant Hope Fiend of the highest order and still live in the illusion that the accolades of the world just haven’t quite caught up to me. All I know is, if I can live long enough, they will!

And if that doesn’t happen, who cares? I’m not going to miss this moment with you because of regrets for anything!

Rogue Medic’s response to my response to his post regarding Excited Delirium (I think it went that way) got me wondering. Seeking a “lay person’s” explanation, I came across this article from NPR Death by Excited Delirium; Diagnosis or Cover-up?

You may not have heard of it, but police departments and medical examiners are using a new term to explain why some people suddenly die in police custody. It’s a controversial diagnosis called excited delirium. But the question for many civil liberties groups is, does it really exist?

It speaks to the very topic at hand; the use of force to control a person whose behavior patterns correspond with the diagnosis of Excited Delirium. The article deserves review because you, my medic friends, are the ones caught smack in the middle. When you walk in on a scene like either of the videos we are referring to in these blogs, YOU are the one who has to take what is given you (courtesy of the Officers in charge) and make good of it. Part of that duty involves protecting the patient.

I wish I had firm conclusions on treatment planning to draw from the article, but I don’t. This is one of those scenarios that you just have to educate yourself about. Considering aspects other than the obvious could work to the benefit of your patient, but all that happens at the time of the incident. What I DO know, however, is that there’s danger in accepting Excited Delirium as a diagnosis at all; especially if that means initiating Cookbook protocols!

My quibble began with two videos that Rogue featured; Our favorite Rogue worked off my last post HERE  , offered his take on this video (Video #1) and then added one of his own (Video #2) that could only be described as HORRID!

I identified the subject in Video #1 as someone who was on a psychedelic trip and questioned the validity of the Police Officer on-scene making the diagnosis of Excited Delirium. Rogue denies the Officer made such a diagnosis. He called it an “assessment”.

Well, if we go to Miriam-Webster, here’s what we find:

The difficulty surrounding the clinical identification of ExDS is that the spectrum of behaviors and signs overlap with many clinical disease processes. ExDS is not intended to include these diseases, except insofar as they might meet the definition of ExDS.

ExDS doesn’t include these diseases, unless, of course, the disease includes ExDS. How’s that for circular reasoning that leads nowhere?

At present, physicians and other medical and non-medical personnel involved in personal interactions with these patients do not have a definitive diagnostic “test” for ExDS. It must be identified by its clinical features. This also makes it is very difficult to ascertain the true incidence of ExDS.

Once again, the Officer was making a diagnosis based upon what he observed as “clinical features”. Naturally, he was well trained in such things.

It is impossible at present to know how many patients receive a therapeutic intervention that stops the terminal progression of this syndrome.

One reason for that is, as the first article described, the diagnosis is most often applied to a dead person after the fact of forcible restraint by LEOs.

There is only one reference before 1985 known to mention the exact term “Excited Delirium.” In this reference, the words “excited” and “delirium” were combined to describe the condition of a patient just prior to death following a hemorrhoid operation by an accomplished surgeon. At the time, it was felt that the operation somehow damaged the patient’s nervous system, and lead to acute psychiatric de-compensation and death.

(I just thought that was kind of cute and speaks to the specificity of the term!)

The typical course of a published ExDS patient involves acute drug intoxication, often a history of mental illness (especially those conditions involving paranoia), a struggle with law enforcement, physical or noxious chemical control measures or electrical control device (ECD) application, sudden and unex-pected death, and an autopsy which fails to reveal a definite cause of death from trauma or natural disease.

…there has been continued debate about the validity of the term “excited delirium.” This debate continues today. There are those who believe it to be a convenient term used to excuse and exonerate authorities when someone dies while in their custody. It is articulated by some that ExDS is a term or concept that has been “manufactured” as a law enforcement conspiracy or cover-up for brutality.

That certainly validates a few points in the NPR article.

The exact incidence of ExDS is impossible to determine as there is no current standardized case definition to identify ExDS. In addition, since ExDS is mainly discussed in the forensic literature and is a diagnosis of exclusion established on autopsy, there is little documentation about survivors of the syndrome.

… pathophysiology of ExDS is complex and poorly understood.

… majority of lethal ExDS patients die shortly after a violent struggle.

… it must be noted that a similar syndrome, termed capture myopathy, has been reported in the veterinary literature. Clinically, it is characterized by prolonged neuromuscular activity, acidosis, and rhabdomyolysis.

I don’t know how more clear this White Paper can get; The diagnosis of Excited Delirium is NOT derived from Evidence-Based Medicine. In that respect, I’d imagine Rogue would have to agree with me; DO NOT ACCEPT ExDS AS A VALID DIAGNOSIS!

It is important for LEOs to recognize that ExDS subjects are persons with an acute, potentially life-threatening medical condition…

Here we are, in a Alice in Wonderland world where the ACEP makes very clear you really CAN’T diagnose ExDS and then goes on to warn LEOs that it’s a life-threatening medical condition. But then, it goes on to validate their taking down someone who they think might be diagnosed as such:

It is not feasible for them to wait for the ExDS subject to calm down, as this may take hours in a potentially medically unstable situation fraught with scene safety concerns.

So why then must the ACEP be driven to state, just one more time, that you really DON’T know?

There is no current gold standard test for the diagnosis of ExDS.

… combination of delirium, psychomotor agitation, and physiologic excitation differentiates ExDS from other processes that induce delirium only.

…Similarly, subjects who are agitated or violent but who do not also demonstrate features of delirium simply do not meet the definition of ExDS.

There are an awful lot of big words in the above statement that I don’t think are covered very well in Cop School. In the video in question, it’s clear the Officer ran through a check-list of other possible diagnoses. Isn’t it?

When death occurs, it occurs suddenly, typically following physical control measures (physical, noxious chemical, or electrical), and there is no clear anatomic cause of death at autopsy.

Basically, they’re saying that there doesn’t appear to be a “cause and effect” between use of restraint or chemical/electrical controls and death. But, really, how can they say that when the only cases of death through so-called ExDS are precisely on the heels of the application of force?

Is it fair for me to ask this question one more time: If a patient diagnosed in the throes of ExDS were given NOTHING to resist, would that help assure survivability?

Once again, the ACEP reiterates its stance that no one is in a good position to make the call on ExDS.

The general public, law enforcement, EMS, and even highly trained medical personnel may not be able to readily discern the cause of an acute behavioral disturbance, or differentiate a specific organic disease from ExDS.

…and now, here’s something important that I hope Rogue doesn’t miss…

Sedative or dissociative agents such as benzodiazepines, major tranquilizers, and ketamine are suggested but there is no evidence yet to prove that these will result in a lower morbidity or mortality.

There’s one for you, Rogue, what was it you said? oh, Yeah! something about Sedate, Sedate, Sedate!

Without including suspected cases and survivors, no meaningful conclusions can be reached that would allow the development of case definitions, etiologies, and treatments.

… Finally, research is needed to establish field protocols and techniques that allow police, EMS and hospital personnel to interact with these agitated, aggressive patients in a manner safe both for the patients and the providers.

The risk of death is likely increased with physiologic stress. Attempts to minimize such stress are needed in the management of these patients.

Now THAT is something to work with, isn’t it? But that needs to start with the LEO’s and then MAINTAINED by the Medics.

Maybe THAT should be our starting point when we ask each other how to really deal with a patient in an extreme agitated state. That sounds more like a description than a diagnosis; vague enough to be accurately applied to a broad spectrum of conditions. Unfortunately, the DIAGNOSIS of Excited Delirium is more likely to lead to death than open a doorway to recovery. But how will we ever know? To date, it’s an after-the-fact thing.

But this conversation has been primarily about the poor slob in Video #1 who was just tripping a bit hard. Check out Video #2 (HORRID! ) once again — if you can stomach it! Then I ask you this, Rogue: If it kills your patient to get him to you so you can sedate him, is that protecting the patient from further harm?

I only ask, Rogue, because you made your recommendation clear:

ROGUE MEDIC: The treatment is sedation. Unfortunately, restraints generally need to be used to get the patient in a position where it is safe to give medication. A Taser is another way to stop the patient for long enough to get a lot of sedative into the patient.  

My read of the White Paper you refer to says otherwise.

Our favorite Rogue worked off my last post HERE  , offered his take on this video (Video #1) and then added one of his own (Video #2) that could only be described as HORRID! These videos and the points that myself and Rogue are bringing up about them are really worth (I can’t beleive I’m saying this!) studying!

So what is good medicine, anyway?

It becomes more and more clear to me that Rogue and I stand for two completely different points of view that are in service to the very same thing; excellent patient care. Whenever I try to beat Rogue at his own game, I fail. I can’t call into question anything that Rogue commented on in his blog that has to do with appropriate medications. so I have to take this conversation to a different level which builds off of both of our earlier themes.

The subject started with Excited Delirium, which, if you study these videos you’ll see is nothing more than a dangerous catch-all phrase.

Watch the 1st video, what is the patient going through?

I’m going to let my Freak Flag fly here, my friends.

(Full Disclosure; Yes! to whatever you’re thinking and we can subtract from there.)

That hapless Bastard was tripping his balls off!

At the very moment that Rogue is giving the Officer a high-five for his diagnosis of Excited Delirium, what is happening?

It is 23:47 (according to the original Police video time code) and the guy is on his feet and yelling.

At 23:48., the room is silent, the cop is on the phone and making the diagnosis.

(Let me say that again: Making a diagnosis!)

At 23:52, however, we see the guy lying on his back; completely placid. He’s looking up into space as he has conversations aloud to he only knows whom and is also noting hallucinations (the hand) as they pass. Watch as his eyes follow something and notice how that alternates into a very, very distant stare. In my last blog I was questioning if the guy was under something other than or in-addition to psychedelics, but after reviewing the video a few more times I’m absolutely convinced we are witnessing a man coming to the “peak” of his psychedelic experience and this is absolutely, positively NOT Excited Delirium. It’s a good, old, American Psychedelic Voyage!

One of the characteristics of psychedelic experience is that the perceptual shifts and mood swings come in WAVES. Here, they are not waves of Agitation and Recovery (spelled C-R-A-S-H) which is typical of speed or crystal-meth related episodes. In this case they are waves of Agitation and something akin to Bliss; at the very least, literally he’s in another land and undisturbed by it for the moment! I would be extremely hesitant to diagnose someone as Excited Delirium when it is not a persistent state wrapped around tension.

[RANT] After seeing this, I would never apply the diagnosis to my patient, were I in the field again. As you can see in both cases, once that happens there’s a very set PROTOCOL to follow which leads to the administration of drugs, no variation.  That eliminates taking the time to see if there might be a better way to go FIRST!  And maybe that’s my core rant here. Sometimes taking the time to do nothing is the best thing you can do to “do no further harm” and adequately TREAT an emergency. EMS didn’t have that component in my time, it doesn’t in yours and unless y’all can begin to understand its importance, future generations will be handling psychiatric emergencies just this incompetently. And, yeah, if you have a lot of people tripping on your beat, then maybe you should learn a bit more about it. [/RANT]

But EVERYTHING SHIFTS WHEN? The second the Police move in to restrain him!

He Violently snaps into this world in response to an interruption. There are better ways to get a non-violent person’s attention. What did the Cop lead off with? Oh, Yeah…”Calm down now!” something like that. He wasn’t even moving! While restrained in the gurney, he went right back into his trip exhibiting waves of (prompted) agitation and something far more peaceful. Can you see the disconnect?

I’ll say it again, this was a trip gone worse because of forcible intervention. But shit like this goes bad all the time.

Now, if you want to see a TRUE case of Excited Delirium watch Video #2 that Rogue so graciously supplied.

Would someone please tell me what the patient care was that was being rendered here?

What do you mean “patient care” you crazy, Hippie firetender, that was a Cop Action!

Didn’t we already establish that Cops Can Diagnose?

What would be the very first treatment of choice here, friends? Really, what’s the first thing you do?

Protect your own ass, right? What’s next? Protect the patient. That, my friends was not an example of Protect and serve.

What that guy needed more than anything was a Cop-ectomy, first, and a perimeter established around him that would allow him some movement, protect bystanders and leave-him-the-fuck-alone until a trained medic could APPROACH him, or a life-threatening shift occured. What protocol suggests pouncing?

Now I want you to carefully compare the human beings in distress in Video #1 and Video #2.

Would it be fair to say that, yes, the man in Video #2 WAS a potential threat to himself or others? How about the guy in Video #1 in comparison?

But, you see, none of that means anything because first and foremost both the Police AND EMS’s first resonsibility is to REMOVE THE PATIENT FROM THE SCENE! Right? None of this, “Let’s try non-invasive first.” Find me something more invasive than what the cops did!

Did you ever wonder why non-invasive went the way of using hearses as ambulances? Because we’re too well trained to have the time to do things appropriate for the situation. If you don’t think doing NOTHING in this case would have worked, then given what was done and its result, don’t you think a non-invasion approach like I suggested could have at least been tried?

If our resolute Officer who made the diagnosis in Video #1 actually knew what he was diagnosing he would know that provoking further agitation could produce death. Well, maybe he wouldn’t know because he didn’t get to see Video #2! But once he took a good look at that, he’d KNOW wouldn’t he!

I’m going to end this entry with one question. I want you to look at that video again and again. First of all, you get to watch a man progress from distressed health into DEATH! Yeah, there it is, right in front of you Hurry! Hurry! HURRY! and watch…

…because what really happened? The man in Video #2 lost his life because he was given something — many things — to resist.

That exascerbated his physiological “off the charts!” and do you have any doubt it robbed him of ANY chance to stabilize naturally until skilled medics could get on scene and approach him and THEN get the proper drugs on board?

In order for what happened to happen, a few individuals entrusted with the duty to protect and serve did the medical equivalent of shooting up a hyper-stressed person with Epinephrine.

How impractical to do otherwise, you say? Well, I guess you’re right because then you’d have to just stand around and do nothing but secure a perimeter around the guy. I saw no good reason to move either of these distressed people except for the convenience of getting them out of the sight of others and placed into an institution.

Oh, I almost forgot…my Question:

If the guy in Video #2 was NOT given anything to resist, might he be alive today?

Here’s a video of a (questionably) hallucinogenic trip gone bad. You can watch and laugh or watch and learn, it’s your choice. It dawned on me that this is something most of you have little experience in, so let me offer some perspective. You can find a thread on this video at EMTlife.com HERE.

http://www.youtube.com/embed/b4PfW41bX-4

I didn’t see evidence of the guy being violent against anyone, including himself. I saw him resisting restraint with attendant bursts against his forced confinement. I also heard it was great fun for the guys who were commenting on the video! Hopefully, they aren’t medics, though to be completely up front, I certainly got my chuckles from it!

This appears to be a case of “removal” of a disoriented person under the influence of drugs; a matter of convenience rather than true patient care.

“He can’t do this here”, it says, “we better get him there” and “there” is an institution. Once he’s in the hospital  it usually becomes all about management through the administration of even more drugs, upsetting his physiological balance for days or weeks rather than the time it would take to help him to get through a temporary crisis and attain mental/emotional homeostasis on-scene. If you consider the time to be lost and the financial impact on the guy through ambulance-ER-hospitalization the cure is far worse than the disease.

As an aside, I find it a bit hard to believe that this is a Shroom-induced OD. My money is on it being a combo, a speed or God Knows What-dipped concoction that they call LSD these days. I do, however, see psychoactive properties consistent with a psychedelic experience through his reference to knowing he can never die. At the “peak” of the experience there is a sensation of loss of self and absorption into the great Everything — essentially a dissolution of Ego, which, in an unfavorable setting can send someone into what appear to be psychotic episodes, usually coming and going in waves as you witnessed. At the same time, his extreme tension is more consistent with chemical stimulation than a psychedelic experience. Still, you can see a trip working.

What you witnessed was most likely someone at the “peak” of his trip; the most intense part of the voyage. Now that you know what it looks like, I hope you’ll remember.

There was a time when such reactions happened and someone(s) in the guy’s social circle would sequester (NOT restrain) the guy and spend the hour or so it takes to get him through the crisis. It’s called “talking someone down”. There is a flow to the “trip” and it has a time-limited pattern having to do with absorption and excretion of the drug. To get more technical, psychedelics like LSD essentially “trigger” the release of chemicals that already exist inside the brain. It’s a sort of “burst”, but it doesn’t last.

It has been explained to me in this way: The normal functioning of our brain is dependent upon our innate ability to heavily “filter out” stimulation. Every cell of our body sends to and receives information from our brains. This info is both from the external environment and the cell’s internal environment. The brain parses and orders that information, only letting an extremely miniscule proportion of that info to come into our consciousness or be experienced viscerally.

It is believed that LSD strips away a limited number of these filters. It essentially brings into our consciousness things that live in the unconscious realm, or even allows a crossing of senses where someone believes they can hear colors or taste sound. Strychnine (rat-poison), for example, is like LSD Gone Wild! Its mechanism of action is that it completely strips away those filters, the “subject” is inundated with information, and the whole body, overstimulated to the Max, convulses and the subject dies.

But, as stated earlier, this is a time-and-volume limited experience with most all of our street psychedelics, whether they are organic or bath-tub concoctions. In cases like you just witnessed; a little bit of patience will prevent the affected person from being further traumatized. Surprisingly, the only one on-scene exhibiting a little patience and sensitivity was a Cop!

But let’s get real folks; what you see here is a Grand Example of our simply not having the time to deal with what is and choosing to find somewhere to “place” a human being in distress. Sure, you could say it’s a self-inflicted wound that we just want to get out of the way, but in our culture – since drug abuse of all kinds and shapes is part of our societal experience — what really is happening is the guy screwed up, got in over his head and, God forbid! needs HELP!

But we don’t intervene with people in this kind of situation, do we? We control them. We do not have the time to attend to the real problem. We can only Buff and Turf and drug up more.  This is handled as a case for the professionals; that’s cops and you. So how would I handle this you might ask?

Today, probably the same way as the guys did here because, after all, what’s most important is that the ambulance stays in service as much as possible and in this job market, I wouldn’t want my ass canned!  Way back when, however, I, at times did use my influence if not out and out weasel my way and put my unit out of service to handle psychological interventions taking an hour or more! I can’t honestly recall ever having done so specifically with a Bad Trip, though.

The intervention called for here is to establish scene safety and trust, which does not involve tons of people or restraint, and separate the guy from stimulation. Find a quiet, private room, dim the lights, maybe put on some soft music, sit with him and reassure that this will pass. And it will. It may take about an hour, but it will. You’re essentially bringing the affected person back to the present moment and grounding him/her with your presence; one focal point. The problem with this, of course, is it takes personal involvement beyond the scope of restraining, starting an IV and pushing drugs. You actually have to “be with” a human being in distress for a whole hour!

Of course you’re saying this firetender must have personal experience in this territory. I do. Besides having gone to Woodstock (Yes, the Original one, before you were born and please, don’t get me started!), I spent much time on a Mobile Crisis Intervention Unit on the sands of Daytona Beach. It was a volunteer “patrol” driving a Winnebago all around the area to the scenes of such emergencies. We’d evaluate, intervene where practical, and call for support and transport when necessary. Spring Break in the 1970’s was hugely psychedelic! I was a paramedic at the time but my job there was to take the time with kids like him who got in over his head. I was also part of Santa Barbara County’s Psychiatric Emergency Team (P.E.T.) for a few years.

Maybe it’s time to mention that the purpose of both Units was to lessen the workload of the Emergency System. Appropriate patient care just happened to be the by-product.

And, before I forget (like I’m gonna forget? Who am I kidding!), my fellow blogger, Brandon Oto, in EMS Basics offers his impressions of my book.

Few of you know what I do for a living since I’m not exactly the center of attention here on EMSBlogs. I am entrusted with the lives of human beings in a high-stress environment. I make sure that the people who ride in my vehicle have no idea how much danger they are actually in. I must maintain hyper-vigilance at all times, be super-aware of my surroundings and the emotional/physical needs of the people in my care. Sometimes, beyond their physical safety, that includes their intellectual as well as spiritual needs.

Perhaps like many of you, I see myself as a healer; a practitioner of the healing arts, yet would never describe myself in that way to the people in my care. It doesn’t matter. I know what I’m doing and where the miracles come from.  All I do is prepare myself to be completely present in the moments that I’m doing my work with them and to become more and more proficient with the tools I’m given to work with.

The essence of my work today is all about communication and safety. The moments of my working days are spent juggling. I must dig into my knowledge banks, decide which is the most appropriate communication, to respond to their questioning, and sometimes engage in puzzle-solving, or stimulating them to come up with their own answers. And while doing all that I am transporting precious cargo.

All this stuff, of course, I learned how to do in the back of an ambulance. In fact, everything I’ve done in life since leaving the field has been a reflection of using the human skills I developed as a paramedic.

But, bottom line, I’m still just a hack.

The word “hack” as I use it is slang. In my life, which doesn’t focus on the computer world, it has had two major applications; driving and writing.

I got in to ambulance work in the 1970′s when “Ambulance Driver” was not a slur, but a bonafide job description. Unfortunately it wasn’t exactly a job that paid; it was all Volunteer in Queens, NY. as it was through most of the Eastern seaboard. The status associated with the job was the license to drive balls-to-the-wall to some sort of a disaster for someone and get them to a hospital. Getting them there in improved shape was not the goal, just getting them there was all that mattered.

So hack, from “hackney” a Taxi Cab, was what I was. That’s even what we called each other, and not with disrespect, either. We were, after all, part of a long tradition of people who made sure people could get from here to there in ease, comfort and safety. It is an honorable profession. But let’s face it, driving is a kick!  Add to it the adrenaline rush of high responsibility combined with challenging conditions and it’s, well…addictive.

The strongest reason I had to keep me working as a paramedic in times of doubt and despair was that I could tweak and trade shifts so that each year I could take at least a month off to tour around the U.S. on my motorcycle. Movement is in my blood I guess; put me on wheels and I’m happy. Okay, maybe a wheelchair won’t make me happy but it will help me get revenge!

Then, there’s the writing thing. Once applied to writers who prostituted themselves by writing formulaic pieces, short on invention and tall on commercial appeal or application, ”hack” also came to be a catchword for writers of comedy and then broadened to be all inclusive for anyone who writes for money and now, I’ll have to say it applies to those who write in hopes of actually getting paid for it someday. This, as was true with my paramedicing, has always been a have-to and not a want-to!

So in those respects I’m a hack all the way. Maybe even in more ways with more up-to-date applications. After all, I did hack my way into EMS again through this blog! Oh, yeah, you might want to read my BOOK  to see just what a hack I am!

So what is it this EMS Outside Agitator does for a living?

I’m a Tour Guide. I drive a Ford E-250 High-top Luxury Limo-Van with no more than eight passengers up and around Haleakala, the House of the Sun, on Maui, an active volcano (in a (hopefully!) inactive stage which means it’s overdue for an eruption! Most of my tours are on:

THE ROAD TO HANA click for a treat!

(If you look across the canyon you’ll see the road opposite, blasted into the volcano’s wall.)

I’m up at 5:00 a.m. Drive 15 miles to work, pick up my van and a catered lunch then go anywhere from 20 to 35 miles to pick up clients at hotels and resorts, drive back to the Hana Road and then cover 617 curves and 54 one-lane bridges, stopping at spots along the way, having lunch at Hana and then driving them back the 617 curves and 54 one-lane bridges to their hotels, etc. then back to base and then home by about 7 p.m.

When I’m not doing that I’m driving up to the summit of Haleakala to, literally, THE place most like the moon on the planet Earth. It’s 28,023 feet tall as measured from its base, the sea floor, making it 11 feet shorter than Mt. Everest whose base is the Tibeten plateau which is at sea level. It includes a stretch of 29 back-to-back 180 degree curves snaking up the mountainside. That’s only the steepest paved road in the U.S. and the only one in the world that goes to the summit of an active volcano. At 10,000 feet above sea level you’re dealing with about 10% less oxygen in the air and the rapid ascent (1 1/2 hours) belts you so on the way down, the biggest danger is falling asleep at the wheel while you’re hypnotized by the curves!

take a look…NOTE THE GUARDRAILS AND THE CLOUDS

On a real good day, I start the tour by going to the top of the volcano and THEN bringing them in to the rainforest a little more  more than haf-way, meaning to 10,000 feet then down into about 630 curves and 60 one-lane bridges; typically a 250 mile day on an island with a perimeter of 138 miles!

All the while I’m doing what could amount to a ten-hour sit-down comedy gig weaved into an information-full and sensorally stimulating journey from the current day, into the past and back out with glimpses into the future punctuated by segments on the history, ecology, geology, mythology, sociology and contemporary challenges of the Kanaka Maoli, the original people of Hawaii, of whom I am not. All this, of course, while I am aware of and respond to the needs, wants and proclivities of my clients.

Draw your own conclusions on how being a paramedic can prepare you for anything!

Don’t let burnout get in the way of your patient care

the perspective of a man who realized that his love for EMS would remain forever unrequited, and yet still found reasons to continue the relationship.

Captain Chair Confessions’ Oct. 12th blog, HERE got things stirring, so please allow this firetender the pleasure of turning up the heat! In just a few sentences, CCC pretty much defined the key components of burnout as it relates to our relationships, in his words:

I don’t like people

there are exceptions to the rule, but they are just that: exceptions

out of uniform, I don’t like them (colleagues)

I would much rather spend a day at home, alone, than with others

2 of my roughly 10 friends aren’t involved in public safety

I don’t see them often enough. But at the same time, I see them plenty enough.

“What’s wrong with not liking people?”

The last was his query to a Counselor. As can be expected and, I suppose hoped for and, especially much to his credit, he at least, through the blog, is beginning to face an aspect of his life that needs tending to.

But he’s at a choice point now. He can either go a little deeper at the risk of finding shit out about himself he never wanted to see, or he can write this off as an isolated “episode” that came when he was at a temporary bottom!

First of all I want to make it clear how thankful I am to CCC for this blog. You did a brave thing, mate, and I want you to know my intent is to build on the THEME you presented (and offer options for this EMS community), and it is not meant to focus on you in particular.

Yet, I must take off the kid gloves here and challenge you, and all of you:

What are the odds of this going further?

CCC already provided us with the answer:

Maybe it’s normal, and nobody else out there wants to admit it.

BINGO!

The culture of EMS — indeed the culture of Western Medicine as a whole — is to NOT talk about the personal things that rock us while we do the work. The last thing we talk about is the armor we CAN’T take off once we’re home and the damage it causes our loved ones or the isolation it brings to us. EMS has the highest rate of burnout in ALL of the medical professions and it’s not about on-the-job.

By now, I claim this as MY cliche: Burnout is the “Don’t ask, don’t tell!” of EMS.

Why do you think we’re NOT really a profession? Because we don’t keep a high enough volume of advocates in our ranks to effect REAL change. Yeah, this is my soapbox, and of course there are other factors but let me tell you this:

Until WE start taking each other seriously and talking to each other about this stuff and learning to be of more support to each other, we will always be bottom-feeders in the ranks of Vital Protection Agencies. My personal opinion is I ain’t the guy to do it, the Counselors ain’t the guys and our Higher-Ups aren’t either; it’s up to ALL OF US to create space for each other.

EMS has far more complex and different human, emotional challenges than either Fire, Police or Military. While all of them are expected to be warriors, only one is asked to be driven by compassion. We haven’t quite figured out how to make compassion work for ourselves!

Look, folks, I was there. I helped SHAPE the initial culture. Seven years down the line, I started to see how that twisted my life. I understand the crazy-making that this work creates. I had 25 years POST-Certification to face, examine and work through some of my own demons.

Oddly enough there’s one thing I’ve learned: EMS is one of the richest human experiences there can be and it doesn’t have to cripple any aspect of your life.

I suspect what most of us soon come to recognize a few years down the road is that we’re bound to lose some aspect of our humanity; it’s inevitable in this work. The thing is, you never know WHICH part or parts you’ll lose, and they are often long gone before you ever notice! And not everybody recovers, either! Really, of your colleagues, what percentage are burned out in your opinion? And how many of them don’t even see it?

I’m really happy to report, however, that that is starting to change. People’s eyes are beginning to open. But it’s not there yet. You need to fan the flames a little for yourselves. It may hurt a little at first, but you’ll see it gets some results for all of you.

I’ve been a participant in http://www.emtlife.com, the world’s largest EMS Forum since 2005. I joined to do some final research on my book. It not only brought me up to speed on the industry and technical/political/legal, etc. issues but I began to notice the occasional thread where someone would start talking about something that mattered to them about who they were becoming as humans while acting as medics.

To my delight, not only were there the typical, macho, “Tough it up!” comments and, sad to say, ridicule at times, but some people were picking up on the threads, sharing their own experiences and even lending support. Some folks even took the risk of initiating threads that spoke of things we NEVER talk about.

Just so it’s clear, my contributions were (almost; I’ve been known to get on soap-boxes wherever I’ve been in my life!) always geared toward chiming in and building on themes presented, sharing my experience and support as appropriate. If I had a bottom line it has been to encourage more participation, essentially helping to broaden the typical EMS discussions to INCLUDE issues of a more personal nature, from as many of those who were willing.

To be completely honest, I started on that site to “test”; to see if there was any interest in the kinds of things I liked  to talk about then AND now. I didn’t even have to bring stuff up; it was already going on. So I’m here to tell you there is stuff going on here, on-line, that may eventually lead to a change in how you talk with each other in person, but that’s not even the point. The point is there are places that are open to such discussion right now.

EMTlife is not the only place stuff like this is going on, by the way. It just happens to be where I’ve been putting my energy. And to avoid giving a wrong impression, only a small percentage of the talk there is about more personal issues. Yet, what comes up is more universal for the group experiencing the cockamamie EMS world! So, here’s what I want to leave you with after six years bouncing around what YOU have created:

On-line EMS Forums, as long as you take each other seriously and are consciously building safe spaces for each other, CAN be places of mutual support on MORE THAN the usual nuts and bolts of the movement. Yeah, let’s just call this a “Movement” to professionalize EMS. Step One in my book? “Look out for each other.” And where does that start? With RESPECT.

You see, all CCC is grappling with is whether to face this alone or not. He can go to pharmaceuticals, but personally, I’d prefer he came to you.

As of this post I am a Community Leader of EMTlife but I am not here in an Official capacity; I have no stakes in the operation other than the traces of my heart I’ve left all over the place. It just became apparent to me it was time to offer you a new model to explore that happens to be spontaneously developing there. I’m sure you can apply what you learn from that to other sites that will help you and your peers to make each others’ lives worth living as you do the incredibly important work you do.

What a lovely running start our FNG, probietopractitioner got in the EMS Blogosphere! With 19 responses to probie’s third post, already she trounced my best! Check out the post I’m talking about HERE, it’s a Classic!

When I started to add my two cents I realized it was much meatier (no apologies to Vegetarians!) than I had realized. At first, I was tracking her complaints about seasoned Veterans who treat everyone in her generation like ignoramuses or worse as a very typical, generational thing, a typical Frikkin’ New Guy/Gal vs. Frikkin’ Old Guy/Gal thing.

But it goes a bit beyond that. In fact, I say it’s somewhat EMS specific. Because in EMS, the turnover rate is SO noticeably high, the odds of these squawking kids lasting long enough in the field to learn for themselves the answers to the stupid questions they ask of the FOG’s are really low.

So from the FOG’s point of view, they are getting asked the same questions and getting the same challenges over and over again by people who are not likely to pay their dues and stick around. Within that context there are all the age-related naiivities, and ignorances and just out and out lack of experience issues but I think the “edge” she is experiencing is more about impatience with relentless repetition of the same old crap rather than a judgment of her in particular or her generation in general.

The questions and mistakes and curiosities and outrages all stay the same but they come from an endless litany of new faces. About ten years in to the field it didn’t take me long to recognize when my FNG wouldn’t last very long. There are certain fatal flaws of personality that you just know don’t fit in the work we’re being called on to do. I’ll cop to questioning such flaws about my partner to myself and then putting him/her to the test. Often, it wasn’t pretty; but remember, our lives depend on each other and of the two of us, I’m the one who knows what that looks like.

The guys/gals who stick it out (FOG’s) are the walking wounded. They’ve survived beyond the typical five-year burnout period in EMS which, coincidentally is the highest rate in all of the medical professions! By the time they’ve reached that landmark, they’ve tasted most of the incredible variety of assaults on their professional, emotional, moral, psychic, and spiritual lives that the field has to offer.

That’s a lot to hold and sometimes it’s just a pain in the ass to force yourself to take the time to treat everyone as if they were going to, first, accept rather than resist your guidance, and then stick around long enough to understand why.

That sounds cold, I know, but I just want to put ONE aspect of the burdens of the job into the spotlight; EMS is NOT a profession for Tourists and unfortunately — and not necessarily due to their own faults — lots of FNG’s end up going no further. I still say the more quickly you can weed out the Looky-Lou’s the better. Where that lets us off is each FOG has to determine how much energy he or she is willing to invest in the newer generations. And not everyone can do it on an individual basis. Many wait and see who lasts.

It’s not unlike the cliche of the battle-seasoned Sergeant raking the new West Point trained NCO over the coals expecting that soon, like his predecessors, he’ll do what his books say and end up dead.

As our new blogger identified, much of the outrage of newbies is over how disgustingly burned out are the people who they are asked to answer to. Most seasoned medics have come to the realization that indeed, they ARE only one call from burnout themselves! There’s a big difference between hearing those echoes in your own head and being chastized by someone who doesn’t have a clue how that could actually happen! And what the new guys/gals do NOT see is how much of a struggle some of this stuff is.

Do you think for a hot second I’m going to talk about shit like that with YOU?

The longer you stay in EMS the more you see a steady stream of FNGs come and go. On their way out the door the Newbies offer much more criticism than understanding. Why? They haven’t been there…YET! And they haven’t put in the time of sacrifice necessary to get there.

Are the weathered Veterans guilty of rash judgments of the FNG’s? Yes, Ma’am! The first filter you have to get past is somehow making it CLEAR you’re willing to stick it out. Until then, honestly, don’t expect much coddling from FOG’s until you’ve cracked that elusive five-year barrier. The things you have yet to learn have little to do with what you picked up in the schools or your first couple years “delivering” the service.

What they will pounce on is whatever blindness you bring to your work. Let’s face it, in the beginning you don’t have a clue of what you don’t know. Whether it has to do with inexperience, immaturity, bad attitude, lack of knowledge or willingness to invest more, whether it involves your skills in communication, peer- or patient-relations, dealing with authority or even your housekeeping, count on being under a magnifying glass.

As a personal note to you, probietopractitioner, I’ll say you’re already showing a willingness to listen, HEAR whatever wisdom is offered you, LOOK at your position and MODIFY it accordingly. Not a bad start at all. Hope to see you around five years from now and learn what you’ve learned since you wrote your third blog!

In the meantime, keep throwing yourself into the fire. It’ll get you AND us to know and trust you that much better. Just so there’s no question in your mind, this is all about WELCOME!