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The First Responders

By David Geffner

Published Oct 1, 2016 8:00 AM

UCLA’s Paramedic Program is one of the toughest in the nation, and the instructors training the next generation of lifesavers wouldn’t have it any other way.


In this simulation, intern Matthew Knowles and graduate Missy Boswell minister to a victim of trauma. Photos by Pete Bohler.

There’s a moment in his riveting memoir, Lights & Sirens — The Education of a Paramedic, 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 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, “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.”

FIRST FROM THE START

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


Matthew Knowles and Missy Boswell.

In the late 1970s, UCLA’s EMS (Emergency Medical Services) providers began receiving emergency medical training on campus. A decade later, a group of UCLA doctors and administrators founded UCLA’s Center for Prehospital Care (CPC), from which the Paramedic Program grew. One of those founders, Todd LeGassick ’87, M.P.H. ’92, is currently executive director of the now fully self-funded program.

“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. Just last year we moved into a new facility near LAX.”

Davis, who was named National EMS Educator of the Year in 2006 and California EMS Authority Educator of the Year in 2010, says many people don’t know 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, hemorrhage control and [assisting] patients with medication if it’s already present.”

In contrast, at 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 [airway management] 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.”

UCLA’s world-class 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 will all result in termination.

As the profession has evolved, UCLA educators have helped lead their students into sub-specialties such as critical care, hazmat, aeromedical, tactical, wilderness, event and community paramedicine, “which includes paramedics as educators,” notes CPC co-founder Baxter Larmon. The last method was pioneered here. Twenty years ago UCLA was the first institution to have seasoned paramedics — instead of other kinds of medical professionals — train students.

WORDS AND DEEDS

Critical thinking distinguishes a paramedic’s education at UCLA, 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.

Severo Rodriguez, executive director and CEO for the National Registry of EMTs, says the 12,000 paramedics who gain national certification through his organization each year take a two-part test: computer-based cognitive tasks and hands-on psychomotor tasks.


A simulation of student Konrad Kryzwicki and instructor Peri treating a victim for blood loss after a skateboard accident.

“When we look at the performance of UCLA students on the cognitive exam, it’s obvious how robust their program is,” he says. “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. ... UCLA paramedic students are incredibly well-prepared.”

For example, L.A. Fire Department medic Senay Teklu recalls an environmental emergencies lecture given by longtime program faculty leader Brian Wheeler while Teklu was in the program. “When we talked about water emergencies,” Teklu recalls, “he deferred to students with lifeguard experience. Mr. Wheeler made the subject matter so personal it made me want to be the best medic I could be.”

BRAVE NEW WORLDS

In recent years, demands on prehospital care workers have grown more complex. From Sandy Hook to Orlando, Dallas and Nice, paramedic educators have increasingly responded to “mass casualty events.”

“The approach to these types of attacks, formalized in the 1980s, was ‘Never become part of the incident,’” says Joshua Binder ’88, a former clinical coordinator for UCLA’s Paramedic Program and now an L.A. County fire captain based in Hawthorne. “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 stabilized. 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.”

Larmon says UCLA has been working with the state of California to pilot expansion in the scope of practice of paramedics and their practice locations to fill gaps in the health-care system.


In a simulation, instructors Senay Teklu and Jesse Peri attend to a man experiencing cardiac arrest.

“This initiative is known as Community Paramedic and/or Mobile Integrated Healthcare Delivery,” he 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 impacting the total cost of health care.”

Davis says UCLA paramedic students have experiences found only at one of the world’s best teaching hospitals — such as doing Grand Rounds with UCLA physicians or taking a human anatomy lab led by CPC associate medical director Atilla Uner M.P.H. ’01, who performs a full dissection.

“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] within the first four weeks,” she 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.”

Davis continues, “The paramedics in this county take care of 14 million people, and each class of 42 students leaves UCLA with the opportunity to have an enormous impact on their different communities. I could go back to my truck, but 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. But finding a clear airway, Hanrahan asked to see what he’d choked on and was shown a medication patch for fentanyl, a powerful narcotic that wasn’t used in L.A. County at the time, so non-UCLA paramedics couldn’t recognize what was happening.

“Pat realized the medication had been absorbed by the baby’s mucous membranes and he was in respiratory arrest, not choking,” Davis recounts. He 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!”