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First Responders

  First Responders  
 

Simulations of common medical emergencies, intern Matthew Knowles and graduate Missy Boswell minister to a victim of trauma.

By David Geffner • Photography by Pete Bohler

The Paramedic Program in the David Geffen School of Medicine at UCLA is one of the toughest in the nation, and the instructors training the next generation of lifesavers wouldn’t have it any other way.

There’s a moment in his riveting memoir Lights & Sirens — The Education of a Paramedic (Berkley Books, 2015) when Kevin Grange, about to begin clinical rotations in a busy emergency room, wonders if he has what it takes to complete paramedic school. UCLA instructor Nanci Medina tells him everyone knows that “paramedic school goes from hard to harder to hardest.” A few pages later, Grange is challenged to insert his first IV line on a patient with HIV, perform his first intubation on a malnourished homeless woman, and not only ventilate a 7-month-old baby with a Do-Not-Resuscitate (DNR) order, but also assess why an infant would have a DNR in place. When the medic who brings the baby in says “history of brittle-bone disease,” Grange writes, referencing the hundreds of classroom hours he received at UCLA, “the DNR made sense. [The baby] had ... a congenital bone disorder ... his shortness of breath was likely caused by underdeveloped lungs, and ... chest compressions would shatter the precious boy to pieces.”

Few professions demand such diverse skills — in life-and-death scenarios — as those required of a paramedic, who often is a patient’s first entry point into a vast, intimidating healthcare system. And since 1970, when Daniel Freeman Memorial Hospital, in Inglewood, California, implemented the first nationally accredited training program for paramedics, UCLA has been at the forefront of educating and training in prehospital care.

In fact, UCLA’s EMS (Emergency Medical Services) providers began getting emergency medical training on campus in the late 1970s. A decade later, the UCLA Center for Prehospital Care (CPC), which now is part of the David Geffen School of Medicine at UCLA, was established. Developed at little or no cost to the university, the CPC became the broad-leafed tree from which UCLA’s Paramedic Program (which is completely self-funded) would branch out.

“In 1999, Daniel Freeman Hospital’s program was closing, due to budgetary issues,” explains Heather Davis, director of UCLA’s Paramedic Program since 2008 and former education-program director for the L.A. County Fire Department. “UCLA agreed to supply the curriculum and educators, and [Freeman] would provide the building. [In 2015] we moved into a new facility near LAX.”
Davis was the program’s first clinical coordinator and an instructor, working under the leadership of Baxter Larmon, PhD, one of the program’s founders. (Bill Dunne, the current director of emergency preparedness, safety and security for UCLA Health, was the program’s first director.) Davis, who was National EMS Educator of the Year in 2006 and California EMS Authority Educator of the Year in 2010, says many people don’t understand the difference between an EMT (emergency medical technician) and a paramedic. “Most EMTs receive less than 200 hours of training,” she explains, “and none inside a hospital. They’re considered basic-life-support providers who can do things like CPR, AED, oxygen administration, hemorrhage control and the care of patients with medication if it’s already present.”

In contrast, UCLA paramedics train for at least 1,200 hours, including more than 200 hours inside a hospital, where, Davis notes, “Students do high-risk procedures such as intubation and have supervised bedside encounters in the ER, OR, pediatrics, labor and delivery, cadaver lab and preschool. California requires a minimum of 480 hours in the field,” she continues, “so UCLA paramedic students will manage approximately 100 real-life emergency incidents before graduation and lead 50 Advanced Life Support calls. The paramedic is typically considered the medical authority on scene.”

  First Responders  
 

Intern Matthew Knowles and graduate Missy Boswell minister to a victim of trauma.

Gregory Hendey, MD (RES ’93), chair of the UCLA Department of Emergency Medicine, trained with Los Angeles County/City medics during his residency in emergency medicine at UCLA, and he spent 15 years, while chief of emergency medicine at UC San Francisco-Fresno, as medical director for American Ambulance. Dr. Hendey says most doctors and nurses don’t fully understand the challenges paramedics face. “What paramedics encounter on a day-to-day basis is far beyond what we are accustomed to, even in the emergency department,” he says. “They face situations where their own safety is threatened and often encounter uncooperative patients.” Dr. Hendey notes that other societal changes have affected the paramedic’s work in the field. “The medics used to take photos at the scene of a car crash and show them to us in the ED, which helped us to understand the accident,” he says. “But concerns about privacy have changed that. We are well-aware of the many challenges paramedics deal with, and we are very grateful for what they do before the patient reaches our doors.

Mark Morocco, MD (RES ’02), a UCLA ER physician and clinical professor, says his residency training helped clarify the scope of a paramedic’s challenges in the field. “My first ride-along was at County 1, in East L.A., to assess an unconscious patient,” says Dr. Morocco, whose own life-threatening car accident in 1988 and subsequent treatment fixed his path into emergency medicine. “I followed the medics through a maze of different dwellings where there was food cooking, music playing and pets running around. Eventually, we came upon this 80-year-old man, nonresponsive on his bed in a small back room. I looked around and saw this collection of little tequila bottles lined up on every wall of the room; after we got him to the hospital, I went to the paramedic and said: ‘I never realized how deeply into the fabric of people’s lives you go. You’re practicing medicine in places most doctors never get to see.’”

UCLA’S PARAMEDIC PROGRAM IS NOT FOR THE FAINT OF HEART. (All L.A. City firefighters who become medics go through it.) Students are challenged by daily quizzes in physiology, pathophysiology and pharmacology, as well as eight major block exams, where expulsion is a real possibility. Two failed exams, failure on a retaken exam, failure on the final exam or failing any skill three times or seven different skills one time all will result in termination. Grange writes that it’s like “college finals week that lasts for nine months.”

Critical thinking is at the core of the program, which culminates in an internship of 20 shifts, each lasting 24 hours, with preceptors (typically with a fire department squad or rescue ambulance) who grade students on everything from determining the mental status of a gunshot victim to the cleanliness of the department’s ambulance after a day of lifesaving.

Steven Rottman, MD, a UCLA emergency-medicine physician and a CPC co-founder, says the academic foundation is what sets UCLA’s program apart. “While it may have been easier to train people in a skill set with algorithms to follow when evaluating a patient, our focus has been exclusively on education,” he says. “With that comes the science and literature to support it to empower our paramedics with a broader knowledge base and the ability to critically think in any situation.” Severo Rodriguez, PhD, executive director and CEO for the National Registry of EMTs, agrees with UCLA’s approach. The 12,000 paramedics who gain national certification through his organization each year must take a two-part test: computer-based cognitive tasks and hands-on psychomotor tasks. “When we look at the performance of UCLA students on the cognitive exam, it’s obvious how robust their program is,” Dr. Rodriguez states. “But what really stands out is the psychomotor portion and how well UCLA students understand when and why a skill is done, and how to troubleshoot the many different responses to an intervention. Bottom line: UCLA paramedic students are incredibly well-prepared.”

Ask any graduate about the beating heart of that preparation, and they’ll point to longtime faculty leader Brian Wheeler, who mixes humor, passion and personal experience to make each moment relevant for students from diverse backgrounds. L.A. Fire Department medic Senay Teklu, a program graduate, recalls a lecture given by Wheeler that focused on specific environmental emergencies, like drowning or hypothermia. “He deferred to students who had lifeguard experience to talk about what they’ve seen and experienced,” Teklu recalls. “I’m from a hot, humid state [where such emergencies are common], and he referenced my own background. Because Mr. Wheeler made the subject matter so personal, it made me want to be the best medic that I could be.”
Grange cites specific calls (in the five years since he’s left paramedic school) that were successful because of Wheeler’s lectures. “I’ve caught a heart attack in a diabetic woman with vague, nonspecific symptoms and an epidural brain bleed in a patient who was initially fully alert and oriented and prevented more than a few very sick kids from falling into decompensated shock,” he says. “On some of these emergencies, I’ve caught subtle — yet critical — symptoms that weren’t picked up by other paramedics on-scene who had not been trained by Mr. Wheeler.”

Key Wheeler phrases that UCLA graduates say still guide them today include: “If you don’t have an airway, you have nothing;” “If you’re not two steps ahead with a pediatric [patient], you’re eight steps behind;” and, perhaps the most meaningful of all, encouraging human compassion for every patient, “The paramedic badge means we don’t judge.”

  First Responders  
 

Instructors Senay Teklu and Jesse Peri attend to a man experiencing cardiac arrest.

SADLY, THAT LAST AXIOM HAS BEEN PUT TO THE TEST IN RECENT YEARS as demands on prehospital-care workers have grown more complex. From Sandy Hook to Orlando, Dallas and San Bernardino, paramedics have increasingly responded to “mass-casualty events,” sometimes even having to save the life of a perpetrator. Dr. Morocco recalls a mass shooting, two decades ago at a Jewish seniors facility in the North San Fernando Valley, where police kept medics from entering the area. “Our former chair [of UCLA Emergency Medicine] Marshall Morgan said it was unconscionable that the medics weren’t allowed to assist the shooter, who was wounded by police and who ultimately bled to death,” Dr. Morocco recounts. “[Morgan] got a lot of pushback for his comments at that time; but not from anyone in emergency medicine. We all understand the job of the medic is totally binary. They want to extract the patient to get the best care — on their rig or in our hospital — as soon as possible. They don’t care if you’re a good or a bad guy.”

Joshua Binder, a former clinical coordinator for UCLA’s Paramedic Program and now an L.A. County fire captain based in Hawthorne, explains that the approach to such mass-casualty events was formalized in the 1980s. “Never become part of the incident,” Binder says. “As we saw with Columbine in the 1990s, first-responder medics were kept behind a perimeter in … the ‘cold zone.’ Patients who might have been saved bled to death.”

Now, Binder says, “Once the police have cleared areas, medics are brought into the ‘warm zone’ for immediate lifesaving measures and removal to triage, even though the shooters may not have been neutralized. The job’s always been inherently dangerous ... but this is another level of risk. Paramedic educators don’t shield students from what could await them.”

Dr. Larmon says that UCLA has been working with the State of California to pilot the expansion of the paramedics’ scope of practice and their locations to help fill gaps in the healthcare system. “This initiative is known as Community Paramedic and/or Mobile Integrated Healthcare Delivery,” Dr. Larmon explains. “UCLA delivered the education program to support all 13 pilot programs operating throughout the state and is testing two pilots in our community. The plan is to decrease the burden on 9-1-1 providers and impacted emergency departments, while improving the experience of patients by decreasing wait times in EDs and improving the total cost of healthcare.”

Dr. Hendey says UCLA paramedics are a true “extension” of the emergency department out into the community. “One of the best examples,” he says, “is a patient having a cardiac arrest. If that person is 10 minutes from our hospital, and they get no care in the field, their chance of survival is very slim . But if they’re lucky enough to have a trained paramedic arrive on the scene within a few minutes and perform CPR and defibrillation, that life will be saved. The same is true with anaphylactic reactions or severe asthma attacks, particularly with very young children. We see patients already improving as they arrive in the ED because of the treatment that medics gave in the field.”

WHILE EMERGENCY PHYSICIANS LIKE DRS. HENDEY AND MOROCCO WILL GO INTO A NURSE’S BASE STATION in the hospital to communicate directly with medics on their trucks, that wasn’t always the case. Dr. Larmon remembers a time when paramedics could only ask doctors or nurses for treatment protocols at one of the 37 different base stations in L.A. County that received emergency calls, resulting in 37 different protocols. “In 1988, L.A. County went to a single protocol [the focus of Dr. Larmon’s master’s degree],” he recalls. “From there, Standing Field Treatment Protocols were developed that relied on evidence-based medicine, and paramedics could begin to care for patients without making base-station contact.”

Program director Davis says UCLA paramedic students have experiences that are unique to being trained at a top teaching hospital — such as attending Grand Rounds or observing a full human-anatomy dissection. “Within the first four weeks of their training, our students put their hands into a human chest cavity [to better understand blood dumps from a catastrophic injury or how the vessels get constricted, leading to lack of a radial pulse],” Atilla Uner, MD (RES ’97, FEL ’99), CPC associate medical director, says. “Our program’s not for everybody. But with a completion rate of 90 percent, and a greater-than-90-percent pass rate on the national licensing exam, the added rigor is clearly worth it.”

  First Responders  
 

Student Konrad Kryzwlcki and instructor Peri treat a victim for blood loss after a skateboard accident.

Dr. Hendey notes that many paramedic-training programs do not have such advantages. “They can’t get inside an operating room, learn hands-on in a Simulation Lab or shadow faculty and residents of the exceptional quality we have here,” Dr. Hendey says. “In many places, paramedics have traditionally been an afterthought. But here, they’re part of our department, with great educators like Baxter Larmon and Steve Rottman who have made a career out of teaching pre-hospital care.”

And, as the profession has evolved, UCLA educators have helped lead their students into sub-specialties, like critical, hazmat, aeromedical, tactical, wilderness and event care. Another area, community paramedicine, “includes paramedics as educators” to train the next generations of paramedics, Dr. Larmon explains. That program was pioneered at UCLA.

Davis, a former snowboarder from Colorado who worked in high-altitude rescue and emergency care, says friends have asked why she gave up her passion for saving lives in the field to come work at UCLA. Her answer is always that L.A. County paramedics take care of 14-million people, “and each class of 42 students that leaves UCLA has the opportunity for an enormous impact on their different communities,” she says with obvious pride. “Sure, I could go back to the truck, but then my numbers would be much more limited. The reach and potential to better how prehospital care is delivered is so much greater teaching at UCLA.”

UCLA-trained L.A. County firefighter Pat Hanrahan is proof of that. He once responded to a 9-1-1 call and found an infant not breathing and the family saying the baby was choking. Finding a clear airway, Hanrahan asked to see what the infant had choked on. He was shown a medication patch for fentanyl, a powerful narcotic that was not routinely used in L.A. County at the time, and the effect of which might have been unfamiliar to a non-UCLA-trained paramedic. “Pat realized the medication had been absorbed by the baby’s mucous membranes and that he was in respiratory arrest, not choking,” Davis recounts. “Pat called for Narcan [the antidote to fentanyl], and by the time they got to the hospital, the baby was breathing and fine. The family thanked the physician at the hospital for saving their baby, and he said: “I didn’t save your baby. The paramedics did!”

David Geffner is a magazine editor and freelance writer in Los Angeles. This article has been adapted and printed with permission from UCLA Magazine, where it was published in the October 2016 issue.

 

 





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