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Greetings from the uncivilized part of the country. It was another one of those killer shifts. Three crews of 1 EMT and 1 medic each ran 37 calls in the first 24 of our 48. I finally got 5 hours of sleep at 9:30 the following morning when a supervisor called in a crew from the substation to get each of us some down time on the second day. The second half of the 48 was almost as bad. We went through 4 rotations after midnight. The angel of death rode with us this shift. I personally had 2 die on me, and one (details to follow) lived despite our efforts to kill him. This is the one that bothers me this morning, a full three days later, so as is my wont, I am writing to expunge it and appreciate comments from all. I had just returned from a call to the state prison, where a 25 year old inmate had shot himself up with a lot of heroin. CPR had been in progress. Long transport time, but this one is going to live. We get toned out for a gunshot wound in BF nowhere. This location is 40 minutes from our station down I-40, locale for desert rats and lean-tos. In this area, I have seen garbage piles that pass for residences, ran on patients with maggots infesting open wounds and 14 year olds beating up their grandmothers. Dispatch states “gunshot wound to the neck - the weapon has been secured.” That’s it - that’s all I get. We go enroute and I launch a rotor. 15 minutes into the run, I get an update from the BLS volunteer squad on the scene. There are a couple of new EMTs out there, which is a positive development because at least they still remember what they need to do, and are green enough to want to do it. I get “he’s got no nose, no tongue, and we can’t stop the bleeding.” I co-ordinate with DPS and BLS for landing the chopper, and it gets on scene about 10 minutes before I do. My EMT partner is tearing up the dirt road, he turns to me and says “I’m only doing this for you.” He knows I want to get there, and he is driving faster than he normally does. The dust from these dirt roads is infiltrating every nook and cranny in the cab and the patient compartment, and he is going to have hours of work to clean this thing up, if we ever get enough downtime to eat, let alone decon a rig. (Our “management”, 60 miles away, is based at a station that never runs on anything but pavement with half our call volume and 1 more rig, and writes us up when we turn over dirty rigs.) I get on scene. The flight crew has moved the patient on a gurney into the BLS rig. The patient is a 77 year old man. He is in tripod on the gurney. I see accessory muscle use, and labored breathing. There is a seeping clot where half his face used to be. I immediately flash to that infamous picture in the Brady Paramedic text of the patient with a shotgun blast to the face and whom my esteemed instructor referred to as the walrus. I also immediately recall his first rule of wing walking: “Never let go of one thing before getting a hold of something else.” This patient cannot be bagged because it’s pretty hard to get a seal on hamburger. I also figure that if I see no identifiable external landmarks, my odds of identifying internal landmarks are pretty slim. If it was my scene, I would hit the guy with some Versed and crice him. The flight crew is getting their RSI drugs ready. The flight crews around here are infamous for knocking down patients and then not being able to get tubes. I also note that there are no ACLS drugs in the rig (recall that it‘s a BLS rig). I turn around, go to my rig and get my drug box. On my way back, I note the patient’s son and granddaughter standing outside the rig. When I get back to the patient, they have given up on the tube and are cricing him. They get the tube in through a very nice hole in his throat and begin ventilations. The patient arrests. He is in a brady PEA. CPR begins and the flight RN is yelling at someone to get her ACLS drugs from the chopper. I draw up epi and pass it to her. As she is pushing that, I draw up the atropine. I hand that to her and she pushes it. I take over chest compressions. I get about 50 in and ask her to verify that she is getting a pulse with the compressions. She is. After about 2 minutes, we do a rhythm check. Patient has a pulse of 135 (um.. That would be the atropine) and a BP of 220/140 - um, that would be the epi. The Hs and Ts folks - when you cause hypoxia in a patient, if you correct that, you actually have a chance for ROSC from a brady PEA. I take over ventilations (and custody of the tube) from the flight medic. He is pumped because he just got his first field cric. My supervisor is on the scene. (He had come out in the supe vehicle) and he secures the tube. Does a fine job of it too. Patient is now stable. The EMTs and the flight medic begin organizing the move onto a spine board (why he wasn’t on it when they put him on the gurney is anybody’s guess). My supervisor grabs the yankauer and begins to suction the hole in the guys face. “leave that alone” I tell him - “it’s the clot”. He grins sheepishly and stops. A few minutes later, the RN picks up the suction and heads for the hole in the guy’s face. “leave that alone” I tell her - “it’s the clot”. Bottom line, the patient is loaded onto the chopper and off they go. They had debated taking him into Kingman and I chime in with “no - get him into definitive care in Vegas. That’s where he will need to be anyway”. They contact med control and get the OK to take the patient to Vegas. I am left on scene with my rig covered inside and out with dust, the BLS rig knee deep in trash and gore, and the patient’s family staring at me and my blood covered gloves, jacket and uniform. I remove the gloves and the jacket and go over to the family. “Is he gonna be OK?” I tell him the patient has done a lot of damage to himself. He wont’ be able to talk (no tongue), and I prepare them for the fact that he may lose one of his eyes and he has no nose. The son says “I wish I had known - if only… “ I stop him and say “It’s not your fault - there is nothing you could have done or not done.” The son collapses weeping into my arms. OK - so that’s the story. Now I’m going to tell you what had me up this morning thinking about it. This patient has shit for a life. He got to the point where he put a .38 under his chin and pulled the trigger. If he makes it, and I’m pretty sure he will, now he’s got shit for a life and no face. Tell me again why we do what we do. Thank you for listening.

I agree exactly with what Vent is saying (hmm, I note that is a common occurrence....) as legally you are not working within your scope of practice nor utilising your EMT card i.e. you are not working under standing orders as defined by your medical director. To that end, it's worthless and has no point. You need to go by what the school is saying here.

Just had this discussion again on another forum. Forget the freaking EMT thing. If you are working as an educator or teacher in a school system, as educated individuals responsible for children several hours a day 5 days a week, you have a greater responsibility than someone with a 110 hour first aid certificate. You do what your job description calls for as an educator or teacher. Leave the stupid very limiting EMT cert at home if it is not mentioned anywhere in your job description as a teacher in the school system. Teachers have no less than a 4 year degree with most likely a Masters or Ph.D. They are mature individuals who understand the responsibility trusted to them and they understand children as well as having some idea of what the disease is they are treating which is more than one can say for either the U.S. EMT or Paramedic since pediatrics is lacking in the curriculm. Imagine if all the certified Paramedics working as McDonalds while waiting for their shot at the FD thought they were hired for their ALS skills and not the ability to flip burgers. They have to do the job they were hired for.

WOW, I am so sorry to hear about your trials and tribulations. I wish you the best of luck through it all, and know that you are in my thoughts.