I never professed to being a smart man but I am persistent. Paramedic school is not an easy venture. I had just finished my EMT and was putting in my time on BLS ambulance. I was learning my trade but I felt myself growing impatient. I worked with paramedics and not to sound too sappy, I idolized these men and women. One day I wanted to grow up and be just like them. Problem was, I did not even know what I did not know.

What I did know was that after a year as an EMT I could apply to paramedic school. I had the date marked on the calendar when my year would be up. That's the problem -- it was the proverbial "looking at the destination" and not enjoying the journey. Guilty as charged.

Approaching the year mark, I started my application process. I was smarter than the average bear, or so I thought. I would go to a different college than the one where I did my EMT class. My clever plan was to attend the inner city school, the one next door to the trauma center. It was downtown, in the thick of things. What better place to learn my chops? I drove down countless times dropping off forms, registering, returning to dot some "i" or cross some "t" I had forgotten. Was I in or out? I was like a kid waiting at the mailbox for the secret decoder ring to arrive after sending in my 32 box tops and twenty-five cents for postage and handling.

Finally the letter arrived. You know the one I am talking about, big envelope or little envelope. With one you are in and with the other you go around again. I was in. Barely a year after my EMT ticket was minted, I had landed in the "paramedic class." Too cool for my own good, I was going to train "downtown."

Strike One

Boy, was I in for a rude awakening. The pre-class paperwork came in the mail. It had all of the instructions I would need to get ready for the first day. I needed three or four different text books: books on pharmacology, EKGs and the core text book, Nancy Caroline's Emergency Care In The Streets (prepublication edition). It was sold in a big manila envelope that I had to put into my own three ring-binder.

The big shot, University of Gotham, had their medical school down the street from the community college, and their medical bookstore became my Emerald City in this Land of OZ. A trip there was a walk down the yellow brick road and it lead directly to the wizard. He lived behind the "employees only" door and made sure the shelves were stocked with great books and medical paraphernalia of every shape and size. I would wander the aisles amazed at the subjects and book titles. "I could learn this stuff," I would think to myself and here were the books that could teach me. Growing up, my heroes were always doctors and in this bookstore I felt like I had found the place where my heroes were born. I was besotted.

I slept with the Dyna-Med catalog under my pillow. It was a giant wish book because I would soon need every-thing in there. I was going to be a paramedic, for God's sake, and had to be prepared for every possible emergency.

The big day came and class was in session. On that first day I had a sinking feeling, like I did not belong. My classmates were mostly from Gotham Fire Rescue. They were EMTs being funneled through paramedic school by their department. These men and women had their rescue chops. Gotham was a Class 1 fire department with lots of hard-earned pride. I think the female members of the department had more testosterone than I did. I know their biceps were bigger than mine.

The lead instructor was a Paramedic/RN. WOW!!! How could someone have that much education? The second instructor was a captain from Gotham Fire Department. He also commanded the SWAT medics. This guy could read an EKG, start an IV, give drugs, intubate and defibrillate, all while carrying a gun and putting out a three-alarm fire. I was among giants.

On the first day, the lead instructor reviewed the class for us. He discussed clinical sign ups and reviewed the required rotations on rescue, in the ER, the coroner's office and the operating room for intubations. I was struck with terror and excitement. What had I gotten myself into?

As the instructor talked, all the Gotham people just nodded together in affirmation, cool as fighter pilots in a sortee briefing. Confidence oozed and I slipped in it.

As an EMT I had been running emergencies but also a fair amount of routine transport calls, not a steady core diet of rescue calls like the Gotham crew. I was feeling like a 130-pound freshman sitting in the varsity locker room with a bunch of 250- pound seniors. I was outclassed in size and experience.

Class ended; I smiled and nodded nervously to the few guys sitting around me and mustered the best, "See you next week" I could. I tossed and turned for a good part of the night and by the time I was embraced by Hypnos I was no stranger to the cold sweat.

I pushed along; hung in for a couple of months. IV starting day was a dog and pony show. We were required to start IVs on each other. I not only had a fear of being stuck but I had a bigger fear of sticking someone else. We had all read the chapter on IVs and played with the one massacred rubber arm that floated around the lab. This arm was an archaic piece of training equipment, its latex veins more punctured than those of Keith Richards. I might as well have just thrown the 18ga Jelco against the wall for all the good it did me to practice on that crappy busted thing.

I partnered with Joe, the only other guy in the class who was not Gotham Fire. In retrospect I should have partnered with one of the Gotham EMTs. They had veins like sewer pipes and were tough as old leather saddlebags. During the class break, I could have self-administered enough anesthesia (beer) that I would not have cared if my partner drove a railroad spike through my forehead. Hindsight is 20/20. Joe and I pushed on. I managed to get my catheter into a vein on the second attempt. The only thing I remember proudly is that I did not cry/vomit/faint, wet myself or run screaming from the room during Joe's attempt to stick me. I lay there on the floor in a pool of sweat with my legs raised and took it like a man. Good thing I went first.

All would be for naught. The fear combined with this whole new world of amazingly technical stuff was killing me. I dropped out a couple of months into the first semester. My pride and ego were sufficiently bruised. I gained much more respect for the paramedics with whom I worked.

Strike Two

I got back to work with my tail between my legs. I did my job, worked two or three other jobs, had a few girlfriends and painful breakups, and then tried again when registration opened up.

This time I applied closer to home at my native community college, where I felt a little more comfortable with the layout of the campus and where I knew all of the clinical sites. On the first day of class there was a whole sea of familiar faces and my first-day jitters were gone. I had already done a first day someplace else and besides I was a little more experienced. The time I spent between my last attempt and this one proved invaluable. I paid close attention to things and especially how paramedics did their job and how they problem solved. I was beginning to know what I did not know and started to work at filling in the blanks. It was going to be a long journey.

The semester got started and clinicals ramped up. I was getting coverage for class and lab times. Clinicals were easy to schedule around our A-B-C shift pattern so that part was a breeze. I progressed well through lab but was struggling with the didactics. I discovered something very frightening. I did not know how to study. I could learn skills and perform tasks but my ability to grasp complex concepts was weak at best.

I was stupid. Yup, staring back at me from the mirror was an idiot, or so I thought. I loved the subject. I loved reading everything I could about it, but I was just missing the point. I could not connect the dots.

The didactic learning part was easy so long as it was one concept at a time. I wanted medical problems to be only that. I learned in a very compartmentalized fashion. The complexities of the trauma victim having had a heart attack prior to wrecking his Ferrari into a palm tree eluded me. I wanted my patients to have only one problem at a time. Nay be the day when trauma and medical shared the same broken body and God forbid if an endocrine emergency climbed into the same bed with a maternal issue. The trouble was, my uncooperative patients did not read the book prior to dialing 911.

The complexity of the "big picture" or my lack of ability to grasp it was spinning me around. I hit a wall, my brain overheated and that attempt came to an end. Two strikes. I needed to regroup. What was wrong with me? I could read and write but only in a very linear manner. All of you in EMS know that is not how things work. The funny part was I could do a good job as an EMT, but that was task-oriented. The paramedics dictated patient care and the calls they were not involved in mostly followed a straight and narrow path. I could not hit curve balls...yet. Slow and down the middle was manageable.

It was back to the trenches to regroup and rethink. I worked like a nut, got married and supported my new wife through nursing school. All the while I approached each call as a mini class session. I would pay close attention to the decision-making process and the problem solving the paramedics would do. After calls I asked questions, wrote things down to look up later and worked on changing my mental landscape from "task bee" to "thinker bee."

The Homerun

Soon I was back at it one more time. I sat in a new class with a new set of mental skills that I hoped would help me put together the big picture. I had great instructors who would take their time explaining complex issues and if I became confused I knew to ask for help sooner rather than later. My mental and academic preparation and hard work paid off. This time I finished. I am not positive but I think my instructor wanting to shtup my partner might have had something to do with it.

You can see that when I started this educational odyssey I was not a natural student. I knew what I wanted to do and I had persistence. On reflection maybe I didn't have enough sense to give up. All kidding aside, it was more than that. Becoming a paramedic is not something I just wanted to do because it might be fun, it was something I had to do. It was the completion of a cycle, a natural order and progression.

I carry with me every bit of my paramedic experience from the first day of my first try in paramedic school to the last time I stood in front of a class or turned a wheel. And now I write about it for you. In everything I do there is a little bit of the paramedic driving the decision-making process and my problem-solving set.

I now do something entirely different than prehospital emergency medicine. I provide anesthesia, and you would be surprised at the similarities between the two. Granted, the skill set is greater with anesthesiology and the knowledge base broader and deeper, but the foundation laid by an education in prehospital emergency medicine has served me very well. The same can be true for you.

If you move on from your paramedic career, you will take with you critical thinking and problem solving skills tempered by the heat and pressure of the streets. As those around you seem to lose their heads and come apart at the seams, you will calmly see through the smoke and distractions and distill the problem down to its basic parts. From there the solution will be easy. From a boardroom to a backyard barbeque you will think to yourself, "Airway, Breathing, Circulation, Done." Okay, now we can solve the "issue at hand." Easy. Hell, we invented the easy button.

Aut Disce Aut Discede..........(Latin - Either Learn or Leave)

Stephen Kavalin has been an EMT/Paramedic since 1980. He completed his undergraduate education in nursing at the University of Florida in 1992, and then became employed at Shands Hospital (Gainesville, FL) in the Cardiac Surgery Intensive Care Unit. During this time he also became the lead paramedic instructor and interim program director for EMS at Santa Fe Community College, Gainesville, FL. He later completed his Masters Degree in Anesthesiology at Barry University in Miami, FL and is currently employed as a Certified Registered Nurse Anesthetist (CRNA) at Winnie Palmer Hospital, Orlando, FL. He can be reached at KavalinEMS@aol.com .