Editor鈥檚 note: is not a textbook, it鈥檚 a field report from the medics who never got to write the manual. Through gritty, brutally honest storytelling, this book dives into the unseen emotional weight of EMS, from burnout to black humor, rookie moments to moral injury. It鈥檚 everything they don鈥檛 tell you in orientation and everything you鈥檝e felt but never said out loud. Written for medics, by someone who never forgot what it鈥檚 like to be one.
If you or someone you know is struggling or having thoughts of suicide, you are not alone 鈥� and help is always available. Call or text the 988 Suicide & Crisis Lifeline to connect with a trained counselor, or chat online at Whether you鈥檙e seeking support for yourself or someone you care about, please know that it鈥檚 never too late to reach out. You deserve help. You deserve hope. Someone is ready to listen.
By Orlando E. Rivera, DNP, MBA, RN, EMT-P
We were built in Hertz trucks
You ever sit in the back of the rig during a transport and wonder how the hell you ended up here?
Not because you don鈥檛 love the job 鈥� but because everything about it feels borrowed. The truck. The equipment. The time. Your own damn body. And somehow, you鈥檙e supposed to save lives with it all.
That鈥檚 EMS. It鈥檚 not built on foundation. It鈥檚 built on borrowed time and barely working gear.
EMS was MacGyvered into existence. It was stitched together by Vietnam vets, street cops, trauma surgeons, and burned-out firefighters who got tired of watching people bleed out in parking lots and living rooms.
The first rigs weren鈥檛 ambulances. They were repurposed hearses, panel vans, Hertz trucks with two-way radios and a Red Cross painted on the side.
Those early medics didn鈥檛 carry protocols. They carried trauma kits, ballpoint pens to relieve tension pneumothoraces, and war stories they didn鈥檛 talk about.
They weren鈥檛 healthcare workers. They were battlefield ghosts. And they didn鈥檛 do it for glory. They did it because no one else would.
Parts of it never really changed. We鈥檙e still expected to fix things with duct tape and trauma shears. Still showing up to chaos with calm in our voice and five solutions in our head. Still charting on software that crashes in the middle of every narrative. Still being called 鈥渁mbulance drivers.鈥�
I remember my first shift like it was branded into me. We got dispatched for a 鈥減ossible DOA.鈥� It was a woman in her 40s. No air, no pulse, no hope. Her 8-year-old daughter was the one who found her.
She asked us if her mom was just sleeping.
There鈥檚 no training for that part.
We worked the code anyway. Got her to the hospital 鈥� dead on arrival. The ER doc called it. On the way back, my FTO finally spoke: 鈥淪ometimes we work it for the kid. Not the patient.鈥�
That鈥檚 when I realized this job has nothing to do with protocols and everything to do with why we choose to follow them anyway.
Burnout doesn鈥檛 look like what people think. It鈥檚 not yelling. It鈥檚 silence. It鈥檚 someone who doesn鈥檛 complain anymore. Someone who shrugs when something goes wrong because they stopped expecting it to go right. It鈥檚 saying 鈥渏ust one more shift鈥� for the hundredth time.
I once worked with a guy named Matt. One of the good ones 鈥� calm, sharp, the kind who could smell a GI bleed and walk into a code already predicting the outcome. One day, we got a call for a fall. Routine stuff. His patient reminded him of his dad.
He didn鈥檛 say much after.
Two weeks later, Matt didn鈥檛 show up for shift. We found him at home. No note. A bottle of whiskey. Open bottle of pills.
That鈥檚 what burnout looks like.
And the worst thing about this job isn鈥檛 the trauma. It鈥檚 the gaslighting. They鈥檒l tell you you鈥檙e vital 鈥� then deny your raise because 鈥淓MS isn鈥檛 a revenue-generating department.鈥� You鈥檒l get a write-up for a missing timestamp while you鈥檙e still wiping blood off your boots.
They want you to act like a nurse, think like a doctor, lift like a mover, clean like housekeeping, de-escalate like a social worker 鈥� and still chart like a secretary.
And when you burn out? They鈥檒l say you weren鈥檛 resilient enough.
But we keep showing up.
Not because the system deserves us.
But because the patients do.
Because someone out there is having the worst day of their life 鈥� and they don鈥檛 need a hero. They need
someone who won鈥檛 freeze.
Someone who knows what sepsis looks like before the lactic comes back.
Someone who can run a cardiac arrest in a hallway with no backup.
Someone who can comfort a mother while bagging her child.
And even when our agencies fail 鈥� we don鈥檛.
Because the system may not see us, but we see each other.
EMS becomes the lens you see the world through 鈥� and the shield you hold between yourself and everything that isn鈥檛 broken. You start noticing skin tone, respirations, posture 鈥� on strangers. You stop answering 鈥淗ow was your day?鈥� because it doesn鈥檛 fit into conversation.
You get good at stuffing grief into a box in your chest.
And when someone says, 鈥淚 could never do what you do,鈥� you want to say, 鈥淚 couldn鈥檛 either 鈥� I just kept doing it.鈥�
Because EMS sharpens you where you didn鈥檛 want to be sharp. Hardens you where you used to be soft. And gives you a sense of purpose no office job can compete with.
But it costs something.
Sleep. Relationships. Pieces of yourself.
Still鈥� we stay.
Not because we鈥檙e heroes.
But because we know what happens when we don鈥檛.
I didn鈥檛 write this chapter for the system.
I wrote it for the medic who just pulled into the bay with a lump in their throat. For the EMT who鈥檚 one shift away
from walking out. For the old dog who thought no one noticed how much they still carry.
And for the one reading this right now thinking, 鈥淗ow the hell did they get inside my head?鈥�
The answer鈥檚 simple.
Because I鈥檝e been there.
ABOUT THE AUTHOR
Orlando E. Rivera, DNP, MBA, RN, EMT-P, is a former paramedic and flight nurse turned healthcare executive with over 30 years of frontline experience. From Puerto Rico to American cath labs and trauma bays, he鈥檚 seen every corner of prehospital and hospital medicine. Now a national educator and advocate, Orlando writes the raw truth of EMS from inside the rig and inside the soul of every provider who stayed too long and loved too hard. Learn more or get the book .
Excerpted with permission from, by Orlando E. Rivera, DNP, MBA, RN, EMT-P Self-published via Amazon KDP (2025)
