Archive for the ‘EMS Mastery’ Category

How I manage My 157 Work Week

January 15, 2018 Comments off

via How I Manage My 157 Hour Work Week

This article is a salute to the single/divorced mom.  This article shows humor in the zaniness of raising 6 kids on her own.

Please like and share this article. She could use some positive feedback.

Categories: EMS Mastery

Narcotic Overdose Mastery

Narcotic Overdose Mastery

Lately, news about the number of heroin overdoses has churned up in my moind some lessons I learned while working as a medic in the Bronx.  I want to share these lessons with the new generation of EMT’s and medics who are hitting the streets.  Some of the lessons are about administering Narcan and others are about interesting calls we handled with some strands of EMS system history intertwined.  Experience is the greatest teacher, but learning from others speeds up your path to mastery.

Naloxone Actions:

Medications work by connecting with a specific receptor site.  Think of a receptor as a dock for a boat, a parking spot for a car or a lock waiting for a key.  When the medication fills the receptor site the interaction stimulates the desired effect. In the case of Heroin or narcotics, the desired effect is CNS depression, anxiety relief, pain relief and sedation.

An antagonist is a chemical that slows or blocks the effect of a medication.  Naloxone is an active antagonist which will push out narcotics from the receptor site and remove the narcotic and stop the effect.  We think of the classic respiratory arrest patient and the dramatic effect of naloxone. After a patient receives naloxone he starts to breathe, regains consciousness and then sits up. I call it the classic ‘wallet sign.” They wipe their face and then check for their wallet. 🙂

Naloxone is a narcotic antagonist that removes a narcotic like heroin or methadone from the receptor sites on the brain.  Blocking the receptors allows a dramatic recovery from unconsciousness and respiratory arrest. There is a good example of this in the movie Bringing Out The Dead, based on the Novel by Paramedic Joe Connelley a Manhattan paramedic.


What does a narcotic OD look like?

A serious OD will be the classic slow pulse, slow respirations, and cyanosis. The surroundings of the patient often include a candle or match, spoon with drug residue a tourniquet in place in the arm and in severe cases the syringe will still be in the patient’s arm.  You may also see that bystanders have poured ice down the patients pants in an effort to wake them up.

What is not a narcotic OD – dilated pupils, powder under the nose, bounding pulse, high BP and agitation.  This is probably a Cocaine overdose.

The continuum of the disease. —

Contrary to what people believe a narcotic overdose can cause tachycardia at the early onset of respiratory arrest.

Signs of an early respiratory arrest secondary to narcotic OD—pinpoint pupils, respiratory depression, pale skin, and tachycardia.

In severe cases, a patient will have unconsciousness, agonal or absent respirations, a slow pulse (bradycardia) and cyanotic skin.


Naloxone is supplied in 1, 2 and 10 mg Ampules, Bristojects and pre-filled syringes.

Dose: 0.4 to 2.0 mg up to a maximum of 10 MG. Usually titrated to the response of increased respirations. Always follow local protocol and wear gloves when dealing with patients suspected of an overdose.  Be prepared to support ventilations, suction the airway and in some cases CPR may be required.

When giving naloxone administer according to protocol and observe subtle changes like respiratory rate change, skin color change, drying of the skin, pulse increase and return to consciousness.


Naloxone does not work on cocaine and marijuana.

Naloxone can make a patient vomit, give them the shakes and also put him into withdrawal if given too rapidly or in too large of a dose.

Q: Why does Naloxone make some people get violent when they wake up?

A: A patient may go into withdrawal when s/he receives too much Naloxone.


Respiratory Arrest:

Ventilation of patients in respiratory arrest is more important than giving Naloxone. Ventilation with an oral airway and a bag-valve-mask (BVM) is the indicated treatment for a person in respiratory arrest from a narcotic overdose.

Q/A? Can ventilation alone wake somebody up from a Narcotic OD when they are in respiratory arrest?

A: Yes. Ventilation alone can return an overdose patient to consciousness and spontaneous respirations. Home remedies:

Treat and transport or call 9/11 if you are a bystander or first responder.


Administering Narcan is a great experience when your patient wakes up and survives.  However, your safety always comes first and I recommend giving Narcan slowly and titrating to respirations.  I quite ride to the hospital with a breathing, dozing patient makes for a is a great day.

Next post will be some Narcotic cases.  Stay tuned.


Please share this post.  

If you read to this point, drop me an e-mail and I will send you a free copy of my book, The Downwind Walk.  

E-mail me at  

Subject Line: Free Book  (valid for first 5 people who do it.)



Categories: EMS Mastery

The Downwind Walk Podcast for my Readers!

October 15, 2016 Comments off

I would like to share a podcast with you about wat it was like to work at Ground Zero and deal with 9/11 as a first responder for the FDNY.

I will also be sending out information and videos in upcoming posts about visiting Ground Zero and some of the stories from 9/11.

Please Click Here to get the podcast and take the Downwind Walk with me !

Have a great day and do something awesome in memory of someone we lost on 9/11.


Steve K,wtc-destruction_flag1.jpg

Categories: EMS Mastery

EMS in the Summer of 2016: The Country is Hot and Our Streets are Boiling Over.

August 9, 2016 Comments off

“Hate Takes Too Much energy.” PO Montrell Jackson, Slain Officer, Baton Rouge Police Department   Beep! Beep! Beeeep!  “EMS Unit 5, are you in-service? EMS Unit 5 at 15:10 hours. Beeep!” You…

Source: EMS in the Summer of 2016: The Country is Hot and Our Streets are Boiling Over.

Categories: EMS Mastery

3rd Annual Upstate Prehospital Medicine & Trauma Teaching Day: We Are One

May 9, 2016 Comments off


I am pleased to provide a copy of my E-Book Pulmonary Edema vs. Pneumonia: The Classic EMS Diagnosis, for the attendees of this conference in Upstate NY on May 16th.  The Conference will be held at the LODGE AT WELCH ALLYN,  Located at 4355 State Street Road, Skaneateles, NY.

Information about this FREE Conference can be found at: weareone

****Be sure to stop by the vendor area and check out my book: The Downwind Walk: A USAR Paramedics Experiences After the Terrorist Attack’s of 9/11.   I am contributing the funds raised from this book to help a paramedic who is very ill from her September 11, 2001 work at Ground Zero.  This is the only EMS book about September 11, 2001.   See you at the conference.

Here are the Links to the E-Book:

e-book-pulmonary-edema-sk PDF VERSION


Kindle Version Available on

steve fdny photo



Categories: EMS Mastery

SonoOpinion: Does absence of cardiac activity predict resuscitation failure? #FOAMed

Categories: EMS Mastery

Writing Contest Winner — THE LANGUAGE OF MIDNIGHT, by Nancy Gwillym

September 21, 2015 1 comment

I am pleased to announce the winner of Paramedic Mastery Blogs writing contest. The winner is Nancy Gwillym from Brooklyn, NY.  This story tells the unique story of life in EMS on the Midnight tour. Congratulations Nancy.  You have won a HD Action Cam Digital Video Camera.


The elderly woman leaned on her cane and with her other hand shook her fist at me yelling that not only should I die a slow miserable death but so should my parents who were responsible for bringing me into the world. In her flowery summer dress on this hot summer night she, in many ways, resembled my sweet, late grandma with her grey curls and large glasses. She could have been anyone’s grandmother, standing at the corner bus stop trying to catch the last bus home in time to watch some late night talk show. And here she was yelling expletives at a small paramedic over loud diesel engine noise.

What was the great infraction that warranted this unsolicited criticism? My ambulance was parked in her bus stop and when she had demanded I move it I told her that although we would be quick, we had a critical patient we needed to stabilize first. To be fair this may have been insulting in that we told her what she already knew- she had been standing at the bus stop and had watched all the emergency personnel bring up the bloody mangled body out of the subway station adjacent to her bus top. I was exhausted, sweaty and dirty after carrying our man (along with several pieces of bulky equipment) up the stairs in the hot sauna of the NYC subway system in July. Now being berated by an angry bystander who cursed like a sailor, I was drained both physically and mentally. I asked if she was going to let the police and firemen, who whose vehicles were also in the way of her bus, know how she felt as well. That’s when granny spit out the “F” and the “C” word at me. I guess I just have one of those faces. The darkness of night brings out the best in people.

Anyone who works the overnight has, in some way or another, belittled the work environment of the day people. We’ve mocked, however insignificantly, their endless runs to clinics and schools, the traffic, the crowds and all that incessant ambient noise. We’re inwardly proud of the way we can do things they do while fighting our circadian rhythm. We haven’t changed or adapted our sleep cycle, no one really can, we just deal with it- a happy trade-off to emergency medicine done under the romantic glow of moonlight. Everything at this hour is more intense, more angry, more honest. It feels as if people tend to show less restraint, more emotion. It’s not always a good thing. But the dialog is often entertaining.

After our train job we went in search of refreshment, We worked in one of the highest crime areas of Brooklyn. A major disappointing factor in that is that there are no decent places to get even a snack when it gets dark out. Most of the high end choices for us were found in places attached to a gas station. We lingered around the extensive convenience store selection of power bars when a commotion was heard outside.

“Shot Rings Out!”

“Two shots were suddenly heard and my partner and I made sure to stay behind the flimsy metal shelving. It was a weeknight and late but it was hardly an anomaly.

We called for assistance on the radio and when it all seemed to calm down a few minutes later, we left the safety of the candy bar aisle for the uncertainty outside. In the middle of the street lay a large man on the ground. He was in between street lamps and it wasn’t easy to make out much except for his size. He was the only one not running around so we started to head his way. Before we got there a door opened and made an audible slam. A large woman, clad in neon yellow active-wear, an ironically smart fashion choice for this darkness, ran into the street towards the man between the street lamps. She was mumbling mostly to herself “Oh-my-god-oh-my-god-oh-my-god.” We were approaching the man at around the same pace but she got there first and threw herself upon him. “Baby! Was you shot? Oh my God you is!” Holy shit! Now, now Julio,” she said, “Whatever you do, don’t panic. You got to be STRONG. You hear me? STRONG! Just like I was when I was shot, just like Uncle Joe was when he was shot, and also like my father, you know, when he was shot. Even though he didn’t make it he was strong right up until the end. Now its your turn. You gotta represent the family. You gotta be STRONG!”

We interrupted the inspiration speech and asked Julio where he was shot. “My arm” he said. We checked out his left upper arm with my partners flashlight and indeed, there was a little bullet hole near his shoulder with some minimal blood. I asked if he had gotten hit more than once. He shook his head and started to cry. Typical thug. I sighed. I’m sure I rolled my eyes. Here was this big tough guy laying in the street, crying. I was embarrassed for “Gangsta” culture. A quick cursory once and twice over with the flashlight and palpation revealed nothing else. He completely ignored us cutting clothes and touching him as he spoke to his family member. My partner, a man of few words, gave me the nod and went to move our ambulance as I took his pulse. I tried to solicit some information from Julio who continued to ignore me for the most part, trying to tell his family member who he needed to talk to in terms of vengeance, I surmised. The woman, thankfully, told him not to worry about all that at that moment, that the most important thing was remaining STRONG.

She turned to me with great concern and sternly said “You ain’t takin’ him to no Woodhull, are you? You can’t take him to Woodhull. They’re the ones that killed my father. You CAN’T take him there.” Woodhull wasn’t a trauma hospital and not even a consideration for us so I assured her that no, we wouldn’t be taking her to the hospital that had apparently “killed” her father. She turned back to Julio, “Get through this, you gotta get through this. Help the lady out, she asking you questions she gonna need to tell the doctors. Talk to her!” she said. He made a face that clearly indicated this was not his priority. My questions about his bullet wound, now that the tears were dry, were more of an annoyance. “Please, all my shit is in my wallet, in my pocket” he told me and then went back to telling the woman who she needed to contact. I went through his front pocket and found his wallet. His pants were super tight and it took me some time to wiggle it out. I opened it up and found his Medicaid card and some kind of ID for a school bus operator. One of them gave me some pertinent information which I scribbled on my glove. I struggled to squeeze the wallet back into a pocket it didn’t seem big enough to fit in and then thankfully my partner pulled up with our truck. I asked him for some medical history and he seemed to be annoyed that I was interrupting his conversation.

After a few of the standard questions about medications and surgeries he turned, exasperated and said “Bitch” though not in any kind of derogatory manner, really. It seemed more of his way of addressing females he was not familiar with. I didn’t take it personally. Sometimes its an accurate term, I suppose. “Bitch, it’s all in my wallet everything you need to know.” He became impatient and told me to get his wallet already, what was I waiting for? A small alarm went off in my head recalling how difficult it had been to remove and then replace his wallet into pants that were straining with the bulk that was already in there. I went over to his leg and gave it a little squeeze. Nothing. “Did you feel that?” I asked. He looked at me confused and it didn’t seem to click for him what was going on. I squeezed again. Nothing. Great. Let’s check out this little bullet hole one more time. His arm was rather large and very soft and fleshy. When you first looked at the hole as he lay on the ground and his arm was pressed against his body and the ground, if you looked directly down on it, it would have appeared to be the front. But if he had sat or stood up and gravity had let everything fall to its usual placement the hole would have been more to the side. And at the correct angle, that wasn’t evident during our initial assessment, there a clear path for the one single hole to point towards his spine. There was no exit wound. The bullet could have been anywhere. And before it stopped it had transected his spinal cord. He’d probably never walk again. It looked like he really did have something to cry about in the middle of the street. I guess the cursing would happen later.

The sun began to rise a few hours later and we handed off our radios and equipment to the incoming relief shift. There was a third person with them, a new intern riding with them for the day. (This was yet another perk denied to those of us at night.) The well rested trio smiled at us and asked us how the night went. “Get anything good?” one asked. “Some old woman yelled at us. You’ll probably read about it in the papers,” my partner answered with a wry smile. The older of the day shift crew shook his head and with a wry smile of his own turned to the intern “These guys who work the overnights are just different. One of the first things you will learn out here is that nothing good ever happens after midnight. But these two, they seem to like it.”

Categories: EMS Mastery

Contest For My Subscribers – Free HD Video Action Cam


I appreciate the fan base that reads my blog.  I have a HD Action Cam with digital video (value $100.00) I would like to give it away in a contest.

The contest consists writing an article for my blog with the theme Nothing Good Happens After Midnights.  Write a story about a call you had that meets the requirements of being Nothing Good After Midnights. The article length should be about 500- to 700 words.  You can include a picture of yourself if you like. Please include a short description about your level of training, and what your career goals are. This is a great way to get started as a writer. I will be glad to give a reference for the aspiring writer that wins.

All submissions need to include a statement in your e-mail that I have permission to publish your article. All submissions will be judged on the story,and its meeting the theme of the contest.

Contest deadline is April 15, 2015 at Midnight.   I wish each of you good luck.  I am glad to be giving back to my blog followers.E-Mail submissions to, Title- Contest Submission.

Good Luck, Good Skill.


Get Out Of My Ambulance, And Take Your Political Campaign with You

Remember that line you’re taught in medic class? “We operate under the license of medical control physician’s and delineated protocols. Please do not interfere with our care unless you are willing to take over patient care and go to the hospital.”

The controversy over the treatment of Ebola and monitoring EMTs, paramedics and nurses exposed to Ebola in the USA reveals the best and worst of politics. EMS protocols are evidence base and driven by the consensus of physicians, not politicians (at least not elected politicians). Imagine if the governor or the president dictated at what blood pressure limit we could give nitroglycerin? Or how many defibrillations we should give during a witnessed cardiac arrest? No, as Chris Berman says, “C’mon man.”

Politicians in our country, or more accurately a percentage of politicians in this country think they can get more votes by interjecting themselves into controversy. I don’t understand the basis for a senator to grill and interrogate the head of the CDC over policy and reaction to the treatment of Ebola patient’s. The CDC are the world experts in dealing with public health emergencies. Dr. Thomas R. Frieden MD, MPH  is the head of the CDC.  Principles of incident command dictate that the person in charge allows the agency with the most relative expertise to take the lead role, under a unified command. The CDC has set policies and procedures for delaying with Ebola and Health care workers exposed to Ebola.

A great leader is one who knows when to delegate and take council from subject matter experts. And furthermore policy making should be an open process, not by a governor making changes and stating, “I don’t have to discuss this with you, the person.”

President Obama is letting the CDC lead the attack against Ebola and health professional monitoring. Good leadership allows the experts to lead when needed and not get in the trenches themselves, this is the difference between leadership and tactics.

I used to say as a paramedic that I was apolitical. This worked well until I needed something from my lieutenant and Ben would say, “Where have you been.” I learned there is no situation when more than one person is involved that is not political.

We as EMS providers need to be more vocal and support politicians that understand the process and the people.

Stay Safe and take the proper precautions. If you do not feel comfortable with your level of training in Haz Mat, speak up and ask for more training.

EMS Screening Questions for Ebola From CDC

NAEMSE has posted this link to the CDC screening questions for EMS.  Thought you might find this useful.

Do you have questions about Ebola or concerns?  Post your question or Ebola Comments Section.


In light of the recent domestic case of confirmed Ebola, the U.S. Department of Health and Human Services (DHHS)’ Office of the Assistant Secretary for Preparedness and Response (ASPR) and Centers for Disease Control and Prevention (CDC), encourage the entire emergency care community to take steps to ensure that they are able to protect, detect, and respond. Specifically, these organizations are requesting your assistance to ensure that screening criteria is placed in all emergency departments, ambulances, and other “first contact” locations.

Every healthcare organization should ensure it can detect a patient with Ebola, protect healthcare workers so they can safely care for the patient, and respond in a coordinated fashion. In order to assist with screening and detection of persons with the signs, symptoms, and travel history consistent with exposure to Ebola, the CDC has developed Ebola Virus Disease screening criteria for emergency departments and for EMS (here).

Additional resources are available at the CDC’s Ebola Website. Please note that the U.S. Centers for Disease Control and Prevention (CDC) is available by calling the CDC Emergency Operations Center (EOC) at 770-488-7100 or via email at


Categories: EMS Mastery Tags: ,
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