John Tew: Good Medicine in Bad Places

By John Tew

It is just five more minutes until lunchtime, and the construction supervisor is pushing his crew hard. The crew has been building a pretensioned tilt-slab construction parking garage for months now, and budget issues are pushing the supervisor to want more and more out of his crew. As the crew prepares to set this last piece of concrete prior to a well-deserved meal, they hear a loud, creaking noise followed closely by cracking, popping, and the unmistakable sound of metal snapping.

Emergency Scenario

On arrival, Rescue Medic 1 is met by the first-due engine officer and is told, “It don’t look good. One worker is pinned by the boom of the crane, and I think he’s dead. I need you and your crew to get over there (pointed to his engine crew who is tending to a worker with a severely broken leg) ASAP.”

How would you as a paramedic look to treat these workers? Have you, as a medic, ever worked on a patient while standing under a hulking piece of steel that just fell and is not yet secure?

Rescue Paramedics

In New York City, eleven 24-hour units (rescue paramedics) are spread throughout the city. Their goals are to provide “Good Medicine in Bad Places,” which means just that–practicing good, solid, and modern medicine in austere environments.  The best of the best, these paramedics look to complete a rigorous screening process just to be able to sit for a test, which, if they pass it, provides them with a ticket to sit with the city’s medical director in charge of special operations and the captain of the unit they hope to work in one day. This one-on-one interview consists of several topics, including an oral scenario with the guy who wrote the protocols.

Looking back at the scenario at the beginning of the article, most emergency medical technicians can treat the worker with a broken leg, but you as a rescue medic have the training, the tools, and the experience (only through the training you received while becoming a rescue medic) to assess the situation given as well as the patient and potentially treat and save the worker who’s pinned underneath crane. On your arrival, you noticed he’s still alive, pinned at the waist with the crane boom, and showing signs of crush injury. After meeting with the construction supervisor and the chief of special operations, it’s determined that although it is possible to lift the crane, it will take at least one hour to do it safely. You advise them that you have the training and the medicine to save this worker, and you devise a plan together.

Rescue Paramedic School

Once accepted into the program, the paramedics are sent to two weeks of class at the technical rescue school on Randall’s Island (“the Rock,” as it’s called). Day 1 consists of two more tests. One is an exam to see where the students are academically; the other is a round of physical tests to determine their conditioning and to see how they react to heights.  On completion of day 1, those who pass are officially accepted into the program.

Then, each day starts with a slide-lecture on a specific rescue discipline as outlined in National Fire Protection Association 1006 or 1670. The remainder of the day is spent in a hybrid environment—meaning that they get both the awareness and operations levels training. They all get certified in awareness, but they also get to crawl into collapses, get lowered on rope, work on victims in a trench, and do basic surface water removals. The first two weeks are technical rescue heavy.

The third week covers all medical aspects of the rescue paramedic program–the new rescue protocols and an in-service on such new tools as portable sonogram; glidescope (a fiber optic laryngoscope with a camera attached); mini pumps and ventilators; and a tool called “iStat,” which in 90 seconds gives you a laboratory report on the patient’s blood work.

The paramedics then take finals. They are assigned as four-person teams and are given several scenarios in which the victim is entrapped in a trench, pinned under rubble in a building collapse, or having a medical emergency and the only way out is by using high-angle ropes or a worker who became incapacitated while operating in a ship’s hold and needs to be removed from a confined space. Each of these scenarios is played out in real time with FDNY firefighters working beside them. The paramedics are to remove the hazards from the equation and assist in medical treatment if necessary.

The finals are given over the course of two or three days. Each rescue discipline is tested in a scenario, and the rescue paramedics work in environments that, although not real, are the most realistic in the country. In this way, they are not climbing into a collapse or confined space for the first time when an emergency call requires that they do so.


After handing off the worker with the fractured leg, your partner joins you at the crane. The fire department is prepped and ready to lift, your IVs are established, and you have started running your crush medicine protocols. The patient is intubated using the glidescope you learned about only weeks before and is on a ventilator. You are ready for the lift. You look to your partner to confirm that all is a go. You feel extremely comfortable knowing that you have the green light. You look to the captain of the fire department and tell him, “We are prepared to lift slowly.” With that command, you, the rescue paramedic have now taken the worker who was labeled “dead” by his boss and given him the best chance for survival thanks to your weeks of training and learning in how to provide “Good Medicine in Bad Places.”


John Tew is a 23-year veteran of the fire service. He recently retired as a firefighter with the Fire Department of New York after serving with Rescue Company 4 and as an instructor at Special Operations Command Training School. Earlier assignments in his career included Engines 307 and 318 and Ladder 143. He has served through all of the ranks of the Hagerman (NY) Fire Department.

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