# riding off into the sunset



## Veneficus (Aug 14, 2010)

It occured to me as I was teaching class on Thursday that I have 3 days left as an EMS educator.

I got into it because I was angry with what I saw coming out of the classroom.

I started teaching lab skills, and will finish it out with a lecture. (on neonates of all things)

But time has caught up with me. 89 weeks of finishing out my hospital clinicals, board exams, figuring out where I am going to apply for post grad training, and pursuing more of my medical interests will be receiving top priority.

Since I also want to spend at least a few hours a week with my family, something has got to give. So it will be EMS. 

As I look back, it appears to have been a great effort that ultimately hasn't succeeded with the goals I had hoped for.

I had hoped impart some perspective on how EMS providers see themselves and their future. 99% just see it as a requirement to take a fire test.

I have tried to enable the students to be better providers. To know more and make better decisions. But their decisions and proficency are still limited by unfounded traditions, outdated practices, and ancient protocols. Many more agencies are embracing a culture of cookbooks; of just wanting react instead of think. I watched the fire service subjugate EMS like it was a task or skill set like technical rescue or hazmat despite my best efforts.  

I had hoped to help train EMS professionals. Now I watch great strides backward in education level and the embrace of vocational labor over an educated professional.

Since there is a new curriculum which will be presented by people, most of whom do not have any exposure to basic science, fewer who have some mastery of it, and without mandatory increased class time. I forsee the education being diluted to a few bullet points on each topic written at an 8th grade level instead of comprehensive understanding. It will make any effort in EMS education a complete waste of time.

We face the same problems and have the same arguments as when I was the new EMT-B back in 89. I have watched it play out in many stations, EMS forums, and teaching institutions. for all of our gas, we are all talk, and talk is cheap. 

Like others before me, I have realized it is time to move on. That the time and energy is better spent on endevors in medicine that can be a success, with people who will push the envelope, that focus on what could be instead of the mindnumbing ideals of perfecting what is not sustainable and that has not been working.

There is no grande passing of the torch, just leaving it for somebody else to happen along and pick it up.

I still plan to hang out on the forum here though unless I find time again demanding more.


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## CAOX3 (Aug 14, 2010)

You attempted as many have to change it from within maybe the best way would be to change it from the top.

Maybe a medical control/director is in your future. 

Good luck.


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## MrBrown (Aug 14, 2010)

I am going to be keeping an eye out for a House Officer or Surgical Reg wearing a ninja outfit and carrying a sword.

Give it a few years and be sure to take note of any Anaes Reg's rolling around in a bright orange jumpsuit.

You have done well my friend.  

Now, care for a protege at all?


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## firetender (Aug 14, 2010)

*Another show of good sense!*

Vene, you are a Crusader and a prime role model for medics to show what it looks like to expand their understanding of themselves beyond being just temporary, fancy technicians!

Luckily, you're leaving a legacy of your past posts, which are bound to get and keep a lot of people thinking, and also provide lots of nourishment to them for a long time to come.

And your choice to leave EMS is a good choice. EMS truly was something in your life you were reluctant to let go. I think you had to give it a try to see if you could carry it and your family into the future together. Thanks for giving it a go, and really, spend every minute you'd spend in EMS with them now, and more!

Blessings, my Brother, and Thanks for the great contributions! Great Work!


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## EmtTravis (Aug 14, 2010)

And again we lose a great medic because of things that could be changed if everyone would try.  I am new in the field of EMS but I do know that I want to go far in it.  I have learned alot from the posts that you have had on here and I thank you for sharing your knowledge and wisdom with those of us who are new.  I wish you well in everything you do from here on out and truely hope you achieve the goals you have set.


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## Veneficus (Aug 14, 2010)

*res ipsa loquitur*

this is a comment posted by an apparently highly educated guy whos icon is a firefighter. Why am I not surprised?

http://lifeunderthelights.com/2010/08/thanks-rogue-medic-what-are-emss-fad-diagnoses/


"the Happy Medic  1 day ago in reply to Matt Wright 

It can be done, just not tastefully. I agree with Matt on SIDS, it was a name assigned to help parents cope with the fact that their child is just dead. I heard on a news show years ago SIDS was on the decline since less parents were smoking in the home, but found that difficult to believe. It is indeed just a gathering point for "We don't know why your seemingly healthy child died suddenly."
My favorite fad diagnosis is erectile dysfunction. No, really. A bunch of middle aged guys who are used to watching 18 year old girls on the internet do things their less than healthy wives would never consider suddenly have trouble becoming aroused? And we're surprised? "ED" is a simple way to say "Watching too much porn? We can help make your reproductive organs work without your involvement while at home with the wife."
What a joke."

I guess it escaped his notice that SIDS is a common term for a group of pathologies or that ED is caused by by both nervous and vascular diseases as well as psychological.

Now I know who all those 8th grade texts are marketed to.


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## MrBrown (Aug 15, 2010)

way to make Brown feel bad for reading a high school chemistry book bro


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## jjesusfreak01 (Aug 15, 2010)

Myocardial infarction, pleural effusion, pulmonary embolism...all just the latin translation of the english words that anyone would be able to understand. My favorite is rhabdomyolysis...literally the breakdown of skeletal muscle tissue. Doctors translate everything into latin so they can charge for the diagnosis. 

Well, the tests show that your husband is suffering from ARDS (another one of those acronyms that loosely translates to "we have no idea whats wrong, but that isn't going to stop us from billing you")


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## Veneficus (Aug 15, 2010)

MrBrown said:


> way to make Brown feel bad for reading a high school chemistry book bro



8th grde isn't high school. It is still primary school here. 

Not to worry Brown, you are still on my list of people to adopt.


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## MrBrown (Aug 15, 2010)

Veneficus said:


> Not to worry Brown, you are still on my list of people to adopt.



Do you know any single white females between the ages of 18 and 25? 

Oh, and since when do Doctors really know what's going on considering most of the body remains a mystery and mechanisims of action are, to use a phrase that medicine itself touts, "poorly understood".


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## Veneficus (Aug 15, 2010)

jjesusfreak01 said:


> Myocardial infarction, pleural effusion, pulmonary embolism...all just the latin translation of the english words that anyone would be able to understand. My favorite is rhabdomyolysis...literally the breakdown of skeletal muscle tissue. Doctors translate everything into latin so they can charge for the diagnosis.



Silly me, I thought it was so that there would be absolutely no mistake about what we mean when talking to each other. A precise language common to all doctors around the world. You know so we don't accidentally mix up things like Kwashiorkor with marasmus when we talk about "protein difficency."



jjesusfreak01 said:


> Well, the tests show that your husband is suffering from ARDS (another one of those acronyms that loosely translates to "we have no idea whats wrong, but that isn't going to stop us from billing you")



Acute respiratory distress syndrome and we have no idea what is wrong? Let me give it a go:

It is a syndrome that is a common clinical course from diffuse alveolar capilary damage. (specifically relating to the endothelium) 

the pathways involve the imbalance of pro and anti inflammatory mediators causing activation of the inflammatory cascade. 

The initial cascade is set off by different receptors depending on the initial insult but leading to the transcription of NF-kB.

The cellular debrs causes the release of IL8 primarily (and a few other cytokines IL1 and TNF) from pulmonary tissue macrophages which leads to neutrophil attraction and sequestering. 

The products of neutrophil activation, reactive oxygen species, proteases, PAF, and leukotrines cause tissue damage to the alveolar septum and capilary beds. 

Of course this becomes a vicious circle because as the tissues are damaged by the bodies own immune response, the macrophages become more activated. 

Mophologically, hyaline membranes (edematous fluid rich in fibrin)  line the alveolar walls mixed with cytoplasmic and lipid remanants of endothelial cells.

the end result is usually organization of fibrin resulting in intra alveolar fibrosis, (scarring) which thickens the alveolar septa, from subsequent collagen deposition in the ECM which prevents gas exchange by creating a physical barrier that inhibits difussion of gas. 

(which seems like we know exactly what is going on to me) 

infact one of the experimental treatments for the condition to stop the cascade is to use exogenous IL10 to supress the inflammation.

There is also a comprehensive list of conditions that will lead to ARDS that I am too lazy to type out in its entirety, but the top 4 are: sepsis, diffuse pulmonary infection, gastric aspiration, and mechanical trauma (including lobectomy) but scanning over the list there is more than 20 known causes. (basically anything that can possibly set off a disseminated inflammatory response)

Now granted not all doctors are equal, and we don't always tell the patients or family that level of detail, but it is not from lack of scientific knowledge. 

yes, when the family demands heroic measures under circumstances we know are futile, we absolutely bill for it. In fact we bill more for it, because when somebody wants extrordinary effort (regardless of the result), it takes extrardinary skills, knowledge, and materials that comes at a premium.


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## MrBrown (Aug 15, 2010)

At least I recognise most of the words you typed and even know what some mean ... now you see why Brown can pass for a Doctor at the bar


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## JPINFV (Aug 15, 2010)

Veneficus said:


> Silly me, I thought it was so that there would be absolutely no mistake about what we mean when talking to each other. A precise language common to all doctors around the world. You know so we don't accidentally mix up things like Kwashiorkor with marasmus when we talk about "protein difficency."



There's also issues about different diseases occurring just at different points in a person's life span. Fundamentally, there's no difference between acromegaly and gigantism, as both are caused by the exact same thing. Namely, too much hGH. The only difference that matters is whether the growth plates have closed or not before developing the disorder. 


Vene, enjoy the last part of a long road and remember, you can make a bigger difference in EMS as a physician than as a medic.


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## firetender (Aug 15, 2010)

Not sure if this is Riding Off Into the Sunset or the Campfire Scene in Blazing Saddles!


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## DaniGrrl (Aug 15, 2010)

I wish you success in all your future endeavors. I've certainly enjoyed reading your posts here.


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## Veneficus (Aug 15, 2010)

I think there is a little confusion over my position. Just to clarify.

I don't plan to stop hanging out with my friends here on the forum. 

I do plan to not teach EMS formally in the classroom for money anymore. 

I do not plan to engage in what EMS should do to improve itself, everyone already knows.

I am not followng the disaster that is the new EMS curriculum.

I am not going to EMS conferences.

I am not substitute teaching, or riding on an ambulance anymore.

I am not teaching homogenous classes of EMS providers stuff like PALS, CLS, etc. Come to the hospital and learn with everyone else. (I will maintain my AHA TC faculty position) 

I don't care if you have a union or not.

I don't care what agency is driving the ambulance. 

I don't want to follow all the newest "gear" and crap EMS has.

I don't plan to care anytime a helicopter falls from the sky or somebody crashes a truck. EMS entities and providers have chosen against safety, they reap what they sew. 

I will be more than happy to help people with question, engage in medical debate or conversation, or offer information or knowledege. But if I have to chose between spending time with the family, pending time with my future career goals, instead of the past, well then, something must be sacrificed.


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## Sassafras (Aug 16, 2010)

MrBrown said:


> At least I recognise most of the words you typed and even know what some mean ... now you see why Brown can pass for a Doctor at the bar



I kind of felt proud of me for understanding most of those words too (though some of the abbreviations threw me).  I can not, however, pass for a doctor at the bar...I have had people call me a medic often though and I wonder if I should correct them. ^_^


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## 46Young (Aug 16, 2010)

Veneficus said:


> I think there is a little confusion over my position. Just to clarify.
> 
> I don't plan to stop hanging out with my friends here on the forum.
> 
> ...



I understand your position. Trying to improve EMS seems to be an exercise in futility with the current status quo, and eventually causes you to lose interest through frustration. It seems that EMS generally attracts those looking to make some quick, easy (no college) bucks, or as a requirement for a cushy fire job. 

Many come to realize that EMS is more of a catch-all instead of a legitimate medical profession, as it stands at the moment in the U.S. That's where we get all our cute sayings: EMS - Every Minute Sucks, EMeSis, Cabulance, Boo-Boo Buggy, you call we haul, Ghetto Sled, MediTaxi, All-State-itis, etc.


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## 46Young (Aug 16, 2010)

Me personally, every day I realize how little of a difference we make in pt outcomes, how few of our calls are really worthy of a 911 response. I thought that I was going to save the world when I started, but now I'm keeping my medic cert for the money and career development opportunities within the FD. Don't get me wrong, I enjoy EMS, I like the pt care and comfort aspects to the job. My pts are treated really well, and I generally enjoy the work. 

The thing is, even I'm getting tired of getting the BS calls. A good number of medics in my dept eventually look to promote to a position where they can drop their cert, or go "status B' where they aren't utilzed as medics at all, unless they choose to ride as a medic for OT. I guess that some get tired of running nonsense, missing PT, missing drills, missing dinner, and getting up multiple times at night while the suppression crews are back in quaters in 20-30 mins. I don't plan on getting off the box, but I'm tired of running all day for pts that don't really need 911, nonetheless. They say that EMT's burn out in 7-10 years, and I'm sitting at 8 at the moment.

You may say that those that drop their medic certs didn't want to do EMS in the first place, but that's not the case for many initially. It's the same factors that force many out of EMS. It's just that in a fire dept you don't have to quit, only that you go suppression exclusivelly, with MFR or EMT only.

Whether you quit EMS or drop the P-card in the FD, it's essentially the same thing, caused by burnout.


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## the Happy Medic (Aug 22, 2010)

*Context*



Veneficus said:


> this is a comment posted by an apparently highly educated guy whos icon is a firefighter. Why am I not surprised?
> 
> http://lifeunderthelights.com/2010/08/thanks-rogue-medic-what-are-emss-fad-diagnoses/
> 
> ...



Veneficus,
Clearly I have offended.  My comment you quoted was posted to a website in response to a post about "fad" diagnosis in EMS.  The author and I are close friends.  He asked if any readers had their own "favorite fad diagnosis" to which I responded with the quote you posted.

Please understand I do know that SIDS is a collection of pathologies, but I still think calling a death "SIDS" instead of by that particular pathology is a "fad diagnosis."
And my feelings on ED are fueled by numerous commercials telling me I'm not less of a man, just suffering from "Low-T" or missing a chance to be with my someone special.  Indeed the inability to take part in sexual activity can be caused by a number of different issues, but does it need to be marketed with a trendy abbreviation on daytime TV?
That was the point of my comment.

As far as your clear distaste for my current position in the Fire Department, I don't know you so won't pass judgment about your background, education, experience, drive, desire or abilities.

Have you been to my blog? I think a quick look around there, seeing my involvement with the Chronicles of EMS, EMS 2.0 and the movement to make EMS a Profession rather than a trade, your opinion may change.

Or, because I chose to use a fireman to represent my being a fireman, perhaps you are set in your opinions.

I welcome your comments and thoughts at thehappymedic.com and wish you well in your future endeavors.

Justin Schorr


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## Veneficus (Aug 22, 2010)

the Happy Medic said:


> Veneficus,
> Clearly I have offended.  My comment you quoted was posted to a website in response to a post about "fad" diagnosis in EMS.  The author and I are close friends.  He asked if any readers had their own "favorite fad diagnosis" to which I responded with the quote you posted.
> 
> Please understand I do know that SIDS is a collection of pathologies, but I still think calling a death "SIDS" instead of by that particular pathology is a "fad diagnosis."



DIC is in the same category, but we do not waste the time nor money, nor mutilate a corpse to have pathology figure out the exact pathology of the cause of DIC in most cases. The same with SIDS. 

I agree that pharm companies go a little overboard in their advertizing of certain medications, but the way you comments are worded made it look like the whole medical profession is involved and nothing could be further from the truth.

There are actually several physician and medical student groups that put great effort into reducing the influence of pharm companies. It is very difficult to come up with accurate dx and treatment plans when patients say all the magic words that leads to the treatment they researched on webmd or saw on TV.

Some people are just not good parents, for a variety of reasons. Their inability sometimes leads to the death of their child. Something they have to live with for the rest of their lives. It serves nobody to determine the exact nature of the lethal insult and unequivically drive home the point it was the parents' fault. Particularly in parents that really were trying their best. (I know not all of them do) It also helps deflect overly zealous law enforcement and procecutors from making a name for themselves mercilessly pursuing criminal complaints and convictions on populations who are likely to confess guilt because they feel it was their "fault" or to not offer up a proper defense to demonstrate that ignorance, not malice led to the fatal event(s). That serves nobody.



the Happy Medic said:


> And my feelings on ED are fueled by numerous commercials telling me I'm not less of a man, just suffering from "Low-T" or missing a chance to be with my someone special.  Indeed the inability to take part in sexual activity can be caused by a number of different issues, but does it need to be marketed with a trendy abbreviation on daytime TV?
> That was the point of my comment.



In my opinion, treatments shouldn't be marketed to the public at all. But I have not yet discovered the balance between letting people know that there are treatments that can legitimately improve the quality of life and direct marketing.

Fad has a rather negative connotation to it, if such a commercial saved somebody's marriage and kept a family together would it be less distasteful? Sex is a part of a healthy life and healthy relationships. 



the Happy Medic said:


> As far as your clear distaste for my current position in the Fire Department, I don't know you so won't pass judgment about your background, education, experience, drive, desire or abilities..



From years of experience both in and outside of FDs, I have clearly stated my position that globally, fire service based EMS is a disservice. I recognize that there are areas where it is done well, but as stated in my original post on this subject, I have given considerably of my time and effort to demonstrate the importance of EMS only to see it become a set of skills that laborers need to be certified n in order to take a fire test to get on a department where the only purpose EMS serves is to pad the call volume and justify the budget. 



the Happy Medic said:


> Have you been to my blog? I think a quick look around there, seeing my involvement with the Chronicles of EMS, EMS 2.0 and the movement to make EMS a Profession rather than a trade, your opinion may change.



I have seen your blog prior to the post I quoted, I am sure many in the fire service rightly look up to you, but when you post oversimplified comments like this it really defeats the efforts of people (including yourself) who are trying to make changes. 

There is probably a host of people who didn't read or don't agree with EMS 2.0 who see comments like this and think of all the street cred you have and take the unqualified attitude that most of this vague medical crap is worthless to work with them.  



the Happy Medic said:


> Or, because I chose to use a fireman to represent my being a fireman, perhaps you are set in your opinions.



As I have admitted, I have a predisposition to seriously doubt the quality of EMS provided by the fire service in the US. Perhaps it is a character fault of mine. But as a very wise southern friend of mine likes to say: if it looks like a duck and quacks like a duck. It's a duck.

The picture of the fireman with the highly simplified comment looks the same to me as all the other fire service people with comments like: "We don't need all that useless medical education, I don't want to be a doctor, just tell me what to do!"


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## Jon (Aug 23, 2010)

Veneficus said:


> I think there is a little confusion over my position. Just to clarify.
> 
> I don't plan to stop hanging out with my friends here on the forum.
> 
> ...



I understand where you are coming from. I wish there was an easy solution... but I don't see any easy way out from the hole others have dug.

At least you have had the opportunity to teach in a EMS classroom setting. I was denied, because I'm "too intelligent and speak over the student's heads." I heard that from the director of our BLS EMS TI. The same person that prides herself on writing EMS Texts. 
It ends up being "NREMT-P < RN, M. Ed." and heaven forbid that I want to change the status quo.

I wish you the best of luck in the future - and hopefully you'll find your way back to EMS, in some form down the line. Maybe things will be different, and maybe you'll be able to move things forward then.

Jon


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