I am an Emergency Medicine Doctor that does Helicopter and Rapid Response Car besides hospital duty. AMA!

Verified.

Thank you!

Was there any case so bad you thought you wanted to be done with it all? Thank you for doing what you do. I can't say how much I admire people like you.

Yes. I had a premie ( a premature baby) die on me, on Christmas day, while i was transporting him from the maternity to the hospital. There was just nothing i could do to save him, they caught the problem too late(he didn't have a diaphragma and his intestines migrated into his chest and compressed his lungs) and he was too small (900 grams) and too weak. I was devastated, i wasn't a real person for 2 months, just a zombie walking around. I was determined that if they made me transport another baby i would resign and start another job. Eventually i got over it.. I was young and not "dehumanized" like i am now, but even now children hold a special place, i always suffer for children, while adults do not move me almost at all anymore..

PS: i might inadvertently use too much information describing medical stuff.. sorry, professional defect

I was young and not "dehumanized" like i am now

What do you mean by dehumanized?

i see sick people as "cases". I don't get emotional about almost anything job related nowadays. i can eat a sandwich while 2 meters away behind a curtains some one is puking his his guts and blood out, and on the other side someone is dying and having CPR done. Or put the food down, go help, wash and come finish my meal. Children still hurt like hell tho. that i don't think i can ever get used to, especially since i have my own.

Sounds really difficult, how does this dehumanization affect your life outside of work?

i have very little tolerance for hearing people's small ailments and minor hurts. I frequently make a bit of fun of them. "Oh you cut your little finger.. aww man i feel for you. Let me show you this picture of this guy who had both his legs amputated by a train after being electrocuted on the bridge above it and falling 7 meters" Otherwise i'd like to think i'm a pretty normal guy.

EDIT: might not have been to clear here. I am talking about off the job. like when some relative comes visiting my parents and keeps perstering me about his bad kneee etc. the post i replied to clearly states outside of work.

On the job, i will listen to your minor problem as patiently as i can and try to treat you as best i can. Doesn't mean i can't think you are a moron for coming to the ER at 2 in the morning with a couch that you had for 2 weeks.

FWIW, there's a fair bit of literature about compassion fatigue in psychology, and it tends to precede or coincide with professional burnout. You might want to take a look at it, and take steps to preserve your own mental health and possibly improve your standard of care.

You could say we all get to a level of compassion fatigue if you could call it that. I'm a very compassionate person but there is a line when doctors, nurses, and paramedics have to separate our selves mentally to protect our selves. There are some people that take it too far though and in my opinion they can make really bad providers. Hopefully, he's not one of those providers.

Agreed, compassion fatigue and "dehumanizing" as OP calls it are two different things. Compassion fatigue is what results when you took too long to separate yourself - you've invested too much emotionally too many times and now you have nothing left to give. We definitely care about our patients and what happens to them, but we stop ourselves from getting too attached most of the time because really, that person could die in front of us at any moment. I fight for the life of every patient that wants me to, and I still grieve in my own way if we lose that fight. But if you become attached to every patient, you start coping badly with the job and burn out.

you put that more eloquently than i ever could.

that settles it. At 2am i'm heading to the ER with my brand new couch.

haha. caught me. not even gonna edit that one out.

Just because you've seen worse doesn't mean people don't have the right to complain about an ailment.

just because i'm a doctor doesn't mean you should tell me all your hurts when i'm trying to eat my meal in peace.. :P

Plumbing and carpentry, not people. It just happens

actually that's our nicknames for Gastroenterology and Orthopedics :)

Australian paramedic here. I am constantly in awe of you guys! Nothing compares to handing over a critical patient at hospital and you guys saying we did a great job. Keep up the good work!

Thanks. I work very close with many paramedics, and i know what you guys go through ( very few doctors do know for real). Keep up the good work! PS: my one "secret" hope is to move to Australia to work and live.. maybe someday :D

What is the first thing you notice when you reach a scene?

number of victims, number of resources i have (doctors, nurses, paramedics, untrained help, police to contain the area or divert traffic), then triage and get dirty.. and we roll from there. Usually all this is takes place while i'm running "from the choppa"/ ambulance to the scene and the first victim.

How much help is untrained help?

more of a nuisance.

Have you ever arrived at a fatal scene and there was music playing inside the car? If yes, what songs and did that stay with you in terms of triggering a memory of the accident when you would hear the song again?

No music yet( usually the car is too trashed), or i was too focused on the job to notice it. Also it's part of the protocol for one of the firemen to pop the hood and disconnect the battery to avoid fires.

This is so great to read!! I am a final year medical student in Ireland just back from emergency department ward rounds with my dad, the first Professor of EM in Ireland. He went to Romania in the early 90's to set up the first emergency department there and has established the HEMS here in Ireland and runs the naval communication service, MedicoCork with a Sikorsky helicopter. It's so great to hear about people in other countries working so hard at it! However, he gets so upset at the difficulties with other doctors and how other specialties disregard what the EMS and ER docs do, is it the same in your country? What is your experience of working in a health service, how do you find you are treated by other doctors? Your patients and the public obviously really appreciate what you do (as do I!)!

It's pretty much the same here, ER, EMD are looked at as inferior to other specialties, and treated pretty badly. But we hold our own, and we know that when something hits the fan with one of their family or patients, they come running to us :D

I don't get too upset over it because so far i have built good relations with the doctors i work with, but other rage alot at snide comments.. i don't really let that bother me.

Congrats on your Father i must say!

Why are ER doctors looked at as inferior? I would assume that being in emergency medicine would be more difficult than many other fields.

It is widely regaded as the most difficult. Drop rates (in my country at least) are about 50% in the first year, and almost 80% do not finish residency. That impression is because we don't "cure" patients usually. We diagnose, stabilize, start treatment, then move the patients to the department that needs to take further care for them( like surgery, intensive care). Thing is, they have to deal with 1 branch of medicine, wekinda hev to know them ALL.(or at least enough to get by).

Hi there! Thanks for doing an AMA!

Have you ever had to respond to a call, then when you actually got there (or saw the damage) thought to yourself, "Well this was completely unnecessary?"

Actually yes, quite a funny story. We got a call from aparently a desperate woman(dispatch talks to them , not us), about her husband that had "his eye hanging out by a thread". We got send as first responders ( usually we have a paramedic crew go first and call us if it's reall bad), got to 9th floor by elevator carrying all the heavy monitor and kits, then had to climb an extra floor on foot to find the aptment. while we were looking for door numbers, a guy we passed leaving he elevator goes "i think you are here for me?".. we of course rush back down, and notice he only has a small bruise under one eye, and is quite intoxicated. Turns out he was trying to open a PET bottle of fermented wine that had built quite a pressure, the cork popped him in the eye and he couldn't see for a few mins, so he called his wife who wasn;t home who got all hysterical. She actually arrived running from work all crying while we were ushering him into the ambulance.. We still laugh about that..

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I am from Romania. I've transported to/from Germany, Russia, Turkey, Hungary, but those are pretty rare. We have EC-135 (Eurocopter) as the main model, and sometimes we use older Mi-18 where there are many victims or EC's are unavailable. Here's some pics: https://www.google.ro/search?q=ec+135+smurd\&client=firefox-a&hs=y4a&rls=org.mozilla:en-US:official&tbm=isch&tbo=u&source=univ&sa=X&ei=qOTsUqSqJpOThQeu8YFQ&ved=0CCcQsAQ&biw=1366&bih=664

The one numbered 334 is the one i've flown most of my mission hours in and actually holds a few records in regards to longevity and mission hours among EC-135's. the range? about 500 km.. 2.5 hrs is max with our load if i remember correctly.

As for equipment, it's in a medical configuration, but i don't think there are any other mods. I do know pilots use NVG's for night missions.

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Yes and no. Usually it's newborns with congenital heart diseases (malformations), that need to operated in better specialized clinics. Other times it's our citizens that have been injured and need to be brought back home.

Peds/Neo transport nurse here in the states. What kind of flight isolette are you using that fits in an EC135? We fly in one on occasion but we find it too small to fit our neonatal flight isolettes and/or limited in the total weight it can carry. 500km is a pretty long range to be in that bird, especially fully loaded. We start considering fixed wing transport at that point.

im not sure what an isolette is? an incubator? yes it's very cramped, i sit with my kees on the ventiilator.. We don't fly 500 km one way. most of the transports are about 150-200 km, and return trip. we do have an airplane for long distance as well.

Have you ever had a case so bad that you had to carry out medical measures that wouldn't usually be done near the incident scene?

Quite a few times. I've intubated while they were cutting the car around us, set chest drain on the tram line before geting him in the ambulance, intubated while transporting a patiend down stairs ( he coded).. i have many many stories, and it's that adrenaline rush that makes this an amazing job.

Are there any scenes from first arrival at an incident that stick out in your memory?

I remember arriving at a multiple victim car crash on the freeway at night and looking around confused because there was no crashed car anywhere, just ambulances. had someone point it out to me, still didn;t see it. It was over 200 meters in the field, and we literally had to step carefully because there were still people thrown from the vehicle that hadn't been found.

Is there a certain injury you get called out for more often than others ?

If you can call Death an injury, i'd guess that's it. Cardiac Arrest is the most frequent call while on ambulance/RRC, car crashes while on HEMS.

If you are in the helicopter and on your way to an accident scene, if all victims die before you get there, does the helicopter turn around without landing and let an ambulance transport the bodies?

yes we turn around. Ambulances don't transport dead people over here..

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We actually deal quite frequently with inmates that have abused substances which are brought by penitentiary staff and guarded while in the ER.. I'd lie if i said i wasn't tempted sometimes, but i did take an oath and i will follow it or quit. We do tent to leave them to the last, dealing with the other patients first unless they are in critical condition.

What is a rapid response car?

In our case it's a Land Rover or Nissan Pathfinder that carries a fireman paramedic( who also drives), a doctor and a nurse ( and sometimes a trainee/volunteer). It's equipped with all the necessary equipment to provide advanced medical care for 1-x patients( monitor/defib, ventilator, bags and masks, oxygen, etc.. even BIOHAZARD SUITS!) It get there fast, and then other ambulance arrive which can actually transport the victim/s

Thank you for the job you do. How bad does the weather have to be to not go on a call and who makes that decision? Are there times when you think your efforts ate being done in futility and they actually make it?

The go/no go are handled exclusively by the pilots. We as medical crew are forbidden to try and influence their decision in any way( for example by insisting that it's a serious case that NEEDS saved, or it's a kid, or anything). There are several categories for weather that they have, and some limits on cloud height, visibility, chance of freeze.. and also both pilots need qualifications for that type of weather. They also need to consider the weather for when we return, or how much time we have before sunset. (Helis are forbidden to land at night unless it's an airport or helipad with appropriate facilities, and we have to take-off from a scene before sunset, which makes for some "interesting situations": Pilot: we need to go in 5 otherwise we sleep here. Me: i need to intubate and put a chest drain. no way i can go in 5 Pilot: ok, you have 6 mins. Me: ...

Alot of times it's a futile effort..but you do it anyway. Once you get some experience, you can "read" a patient at pretty much a glance. But there have been unexpected survivals and some were really amazing and touching. That's part of what makes this job amazing.

I imagine that in emergency responses there often isn't a lot of room for error.

Have you ever accidentally done or not done something that did or could have ended badly?

How do you deal with that kind of pressure?

I drink and do alot of drugs.

Just kidding. I used to smoke, alot, but i quit. The trick is to have some time to decompress, get a hobby, etc. I Snowboard, play computergames ( a bit too much, but then i was a gamer long before i was a doctor), and play airsoft.

regarding errors ,yes, of course. We are human, we make mistakes sometimes. Important thing is to realise and correct it before it's too late.

Could you share a story, if it isn't too personal, of a time you made a mistake?

i discharged a patient suspected of pneumothorax before waiting to get confirmation from the radiologist because i had looked at the xray and didnt see it, and he was ok clinically. I wrote it off as a cold. He had a small one tho, so next morning i tracked him down, found his grandma at his old adress, got his phone number and called him back to the hospital. He stayed under observation 2 days and got discharged. Would have been fine at home, but i couldn't go to sleep if i just let that go.

Small pneumonthorax, clinically fine, radiologically confirmed? Home with advice on seeking help is the normal treatment, isn't it?

yes, that's correct, but then again, what if it enlarges and becomse tension pneumo? like i said i couldn't sleep if something like that happened by my fault.

Have you ever had someone say to you "please don't let me die?"

Yes. But it's usually the ones not in danger of dying that say that ( or talk or scream). the silent ones are usually the most critical.

What jobs did you do as a junior doc to end up in HEMS?

I did my job properly, did well in pre-hospital care ( ambulance, Rapid Response Car, neonate), and had quite a bit of luck :D if you're asking what my speciality is , it's Emergency Medicine, or Accidents & Emergency. And i started HEMS in my 4th year of residency, rest of prehospital care in my 3rd.

What path through medicine did you take (and what would a regular doc in your field) take to get where you are?

6 year medicine school ->horribly hard exam to pick your residency/specialty-> 5 year residency( on the job) --> horribly hard exam to become specialist--> 1 year specialist so far. And yet i've done so much compared to some other EMD that i feel old :D

Forgive me if this is ignorant-- but do you all have Universal Health Care? If not, are medivac rides in the $10,000's+? Have people refused rides because of how much they cost if they are expensive (medivac and ambulance)? ...(Obviously I'm american, I've heard a few stories like that here because of our health care "system")

universal health care, everything is FREEE!!

Firstly, thank you for saving lives! Secondly, what has been your proudest moment on the job? And finally, any specific stories that you'd like to share, like the craziest thing, funniest thing, etc?

Thanks again!

Saving a 700 gram 28week premie that was in cardiac arrest when i got to him. That was the trickiest intubation of my life, and under the most pressure. He lived at least for another 2 weeks at the hospital, haven't checked after because.. i don't really wanna know if he made it or not. He made it so far because of me.. thats enough for me.

Hello! I just created an account to post a question here and really hope it gets answered. I was reading your responses about you becoming "dehumanized" towards everything you see. I REALLY want to be involved in the medical field but this part scares me most. I empathize heavily with people and don't know how I could handle someone dying at my hands during surgery or seeing someone suffer and knowing that I can't help them. Sorry for writing a novel but it is a question that has been heavy on my heart for awhile now.

There are branches of medicine where empathy server you well. Like Psychology, Psychiatry, Pediatrics to name a few. EM is NOT one of these. What you talk about , seeing people suffer and being unable to help/save them is pretty common, you need to develop coping mechanisms for that otherwise you will go insane or ruin your life.

After so much carnage, how has your perception of people changed? Like if you're at the grocery store, standing in line, can you picture what everyone looks like on the inside of them? Do you have a "God Complex"?

Also, how has your job affected your spirituality?

Thanks for working to save us talking monkeys that keep crashing into things and hurting ourselves.

I see most people as extremely stupid.
I believe in a God, just not the church, or the way they portray Him. I'd say it hasn't really affected my spirituality.

I'm a paramedic and first I'd like to say thanks for your hard work and devotion to helping others in their time of need.

What is your opinion of EMS in general? I'd personally like to see a move for more education and professionalism for services in my area (Atlanta), as well as seeing EMS shift to a career that people are actually able to retire from because of increased and improved retirement benefits, and a decreased burnout rate amongst EMS workers.

EMS is vital, EMS is underpaid, understaffed and overworked. I think that's true worldwide. It needs to change. I honestly do not think i can reach retirement age as EMS. i guess i'll see as i go.

Hello, thanks for doing an AMA

What is the most personally dangerous situation you've been in during your work?

surrounded by about 200 angry gypsies with a relative of theirs dying in my ambulance.

also flying through a storm so bad the pilots thought the plane will break up..

Do you take an active interest in following patients status after your care? The facts that first responders get little info after trauma cases doesn't lend much closure.

Not really to be honest. Or very rarely. I get enough knowing that i stabilized, diagnosed, and got him to where he needed to be alive, and that i did my job well. EM is a high risk/instant reward and i LOVE it that way.

What was the most surprising accident you've encountered?

guy that fell from the shower, on the toilet bowl, broke it and had the nastiest ASS cut i have ever seen. This was a big guy( not fat, big), mind you, and i could put my whole hand into the cut in one of his buttcheeks. Bled like hell too.. Porcelain is a deadly weapon, make no mistake about it.

Hi, this question is not meant to sound antagonistic, but do you think that you can contribute anything to patient care that a well-trained paramedic can't? At my hospital, the helicopter paramedics can intubate, run pressors, and most importantly, get the patient to the hospital so that they can be cared for appropriately. I am sure you are really great at what you do, but you went through a lot of training to not be working in the ED. My guess is you probably got bored/burnt out. In which case, I can understand the change.

Good question. part of the answer is that our paramedics are nowhere near that well trained. they are level 1, which means they can't even put in a venous line or administer drugs. yours are prolly lelvel 4, its a whole different world. There are 2 schools of thought in Emergency Medicine: -Grab and run -Stay and play

grab and run means get the victim stabilise as fast as possible, get to trauma center as fast as possible. paramedics are perfect for that job

we do Stay and Play. That means my car/ambulance/helicopter is pretty much a mobile ICU. i can do anything they can do in an ICU, and some stuff that they do in an OR. I stay there and don;t risk moving a highly unstable patient until i stabilised him enough that i can get him safely to a trauma center. the ADDED BONUS of that is that i can stabilise him better and transport him safer FARTHER away, so he gets to the center he needs insted of the one that's closest.

So no, i am not wasted in the field :D good question

What's your favorite kind of fruit?

Apples, and exotics.. always try anything new i find at the supermarket. But i unfortunatly rarely eat fruit anymore.. gotta work on that..

You okay there?

too much typing :D edited the mistakes out.

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It was my 3rd option after surgical and orthopedics, and i said, why not i'll try i for a year. Then i got hooked.

First of all I would like to say thank you so much for this AMA, because as a pre-med student I want to be a doctor but also wanted to do something exciting and on the field rather than be at the hospital all the time. After reading your post I realized that opportunity is definitely there. Thank you so much again. My questions are: 1. Where would one go to apply for such positions, also what and where did you go for your residency?

1. Since you also work on helicopters and other aerial forms of transportation, is it like in the military (i.e. flight surgeons) where you have to be certified to work in these places? If there is, what kind of requirements are there? For example, a certain level of visual acuity, physical fitness, etc.

3.By being in places where danger is a common occurrence, have you and your fellow co-workers been in situations that you could have potentially died in?

1: I think it depends on your country. for mine, only Emergency Medicine does this kind of job, and only very few hospitals that are part of the SMURD program (it's short for Mobile Resuscitation, Extrication Emergency Service). I did my residency in one of these hospitals and i was accepted for prehospital care. 2: you need to be in good health, not take drugs or medicine, not be sick. There is a mandatory medical checkup before each HEMS shift, with BP, sats, heart rate and you need to fill some statement forms. There are no physical trials or limits except not being nauseous while flying and during heavy weather/heavy brutal manouvres. 3. A few times, but we have strict protocols and orders not to go in if we are at risk. This isn't like the movies, if you get hurt you can't help anyone.

How did you feel during the times when you weren't able to assist due to protocol? Were the consequences for any patients due to this?

I was aching to go in, like a horse chomping and pulling at the bit. You have to understand we are all adrenaline junkies, all the paramedics and nurses and doctors that do prehospital care. You just don't do this job if you aren't. That's why the usualy penalty for going in before cleared is they take you off prehospital care for a while ( could be forever or a long time if you fuck up badly). So that pretty much keeps us in line.

Hey EMD, do you ever show up on a scene and say "Please state the nature of the medical emergency?", like the EMH?

No i usually say "give me the laryngoscope and a 7.5 tube this guy is almost gone".

We have a pretty bad ass dispatch(we do the dispatch as well) and system( usually paramedics go in first, they solve 90% of cases, if not we get called in), and we rarely get sent to cases that are not critical.

what was your very first experience like? would you rather work like back then or right now, as you described "dehumanized"?

I walked into the ER on my first day, and there were a great many people yelling and screaming and being generally very agitated.. and i thought.. "what the hell have i gotten myself into". But after a couple of hours of being pushed around and being in everyone's way, i started to see the chemistry between them and how everyone was loud because they needed to be heard and how 5 severe cases were being treated at the same time and i was pretty much hooked.

I miss the old cramped ER to be honest, now we have a huge new one but we are spread too thin and it's destryoing our ER dept..

Nothing really to say, but as a pilot who has worked at an FBO with lots of medivac flights, you guys are fucking ballsy heros.

So are you guys. Respect.

How do you keep calm when the people around you are panicking? Any tricks you use that seem to work to help you stay focused on the job at hand.

tunnel vision if you can.( unless you are coordinating then step back more, there is always the pull to get in on the action). Cut every insurmountable think into manageable slices and deal with each in turn, otherwise you are sure to panic.

Any interesting stories of jerry-rigging medical devices while in the field? Thanks for doing what you do.

We sometimes improvise, but usually because something fails, not because we don't have what we need. I for one used the secretions aspirator to vacuum the vacuum matress that hold a trauma patient straight and tight, i've used a flashlight held in my mouth to see better during intubating a chemical burn victim's throat. I'd love some sterile duct tape to be honest, the medical equivalent is not strong enough :D

How do you find time for yourself? What do you do to unwind/have fun in your free time?

i hardly do lately. especially with a 3 year old and an extra job besides this one. For fun i Internetz, play games, snowboard ( rarely when i get a chance), and play airsoft. used to love sports but no time now..

What's your 'extra job'?

Medical Hotline at a private clinic chain. people call here if they have some sort of medical "emergency" ( usually a nasty cold, or more likely their child has a fever) and i give medical advice, or send an ambulance if asked for or needed ( never so far).

is your job going to get mnore boring when everything drives itself?

No. Emergency medicine never gets old really, and pre-hospital care even less so. There is always something that amazes me each week..

Have you ever watched the show Emergency!?

yes, i loved it.

Just came to say your a gentleman and a scholar. I admire you for your hard work man.

Thank you.

This AMA was posted 2 hours ago. Saying that you're American, what purpose are you up for this early?

I'm not American, I'm from Eastern Europe, Romania to be precise.

Busiest in the country? Every single ED has that claim

but we can back that shit up with NUMBERS!