Tuesday, June 2, 2009

On Being Scared

I've been spending weekends as a part time instructor at the local community college, teaching paramedic students about things I've only recently myself become passingly competent.

It's a difficult thing, to stand up there in front of the class and insist that they make decisions about spaces of gray between the black and the white. It is a wide complex tachycardia, the blood pressure is borderline and the symptoms are murky. It is a constellation of potentially unrelated complaints, presenting in unison as if on purpose to deceive. They sit there and scratch their heads, squint at the data with all their might as if the answer will present itself by force.

The next step is always to explain that there will be cases that don't fit the book. In fact, most of them wont, and the choices these students are going to make will have to be well reasoned ones, based not on algorithm or memorized protocol, but rather the larger picture of genuine comprehension. The answer isn't always to give a drug or to shock, but maybe to sit back and wait. ...Give a little bit of fluid and observe. I tell them that there is often more than one right answer, and despite the fact that the paramedic exams are largely multiple choice, working in the real world is much more often about filling in the blank.

The students stare back at me in horror, and I smile. That is precisely the right reaction.

I think it is important that all paramedics look up from their work from time to time and be terrified. There is so much out there that we don't know, a whole world that bustles around us whether we heed it or not. We are charged with making critical decisions for sick patients based on incomplete information and limited experience. It is my opinion that if you're not scared, you're not doing it right.

"I will have no man in my boat," said Starbuck, "who is not afraid of the whale." By this, he seemed to mean, not only that the most reliable and useful courage was that which arises from the fair estimation of the encountered peril, but that an utterly fearless man is a far more dangerous comrade than a coward."

Herman Mellivle, Moby Dick

Tuesday, May 26, 2009

A Reminder

I apologize for the lapse in postings, but things haven't been going so well for me lately.

My second semester of organic chemistry proved to be more demanding than I anticipated, and while I still await my final grades I know full well that they are less than what is required. To make matters worse, I was rejected from a postbaccaleurate program that would have given me opportunity to right my academic record, and my application for a preceptor position at work was also turned down. In addition I've been fighting through a slump of mundane calls in the city, two weeks ago working through thirty-two calls in a row without a single patient in need of ALS.

Frustration and disappointment have truly been the norm, and it has taken a heavy toll. Lately I have found myself questioning my willingness to continue this drive towards medical school, and feeling overcome in way that I haven't experienced in years. I have recovered from stumbles in the past, but it seems to me that my mistakes are begining to aggregate into something worse. It has taken conscious effort to keep my eyes pointed foward, and even when I do, I find that the light at the end of this tunnel remains maddingly distant.

As if on purpose though, luck has granted me a few interesting patients over the past few shifts that have helped to lift my spirits. I have found myself amazed by how my job still has this power over me: to challenge and intrigue in a perspective-changing way, to make me feel new again so that I might again experience first-hand those things that so strongly motivated me to pursue these goals.

This elderly woman suffered an unwitnessed cardiac arrest, had no immediate bystander CPR, and was being resuscitated by another paramedic by the time I had arrived. I intubated the patient, and was surprised to see my monitor print out the following:

A pretty sweet looking rhythm (considering the 10 minutes of aystole that preceeded it), and end tidal CO2 readings over 100mmHg for the duration of my care (please excuse the lapses as we had to disconnect the monitor for an especially tough carry-down). Nevertheless, the woman remained pulseless and even though we worked furiously, we simply could not get her to show any signs of life. I shook my head as we continued our rounds of drugs, CPR, and ventilations. CO2 output like that should mean this patient is viable. A rhythm like that should have pulses. Still, nothing.

I want to know why. Why was the CO2 so high for such a prolonged period? If this was a typical hypercapnia secondary to a respiratory arrest, why didn't the excess CO2 blow off as we continued to resuscitate? Should we have more aggressively hyperventilated? Why did the PEA continue happily for so long, yet refused to produce pulses? Was there mechanical activity producing an undetected hypotension? How could we have known if it was? What exactly was going on here?

I don't have the answers yet, but I am intrigued, and I will find them out. The potential to learn about something new has piqued my interest, and rendered me involved anew in a job that was begining to slip down a slope of disinterist and dispair. Just a few calls like this, and I remembered. I remember why I wanted to become a doctor, my facination with the unknown, and that thirst for new information. I remembered why I once felt so strongly that all of this work was worth it.

I remembered a reason to press through.

Wednesday, April 1, 2009

Realms of Control

Pediatric Advanced Life Support (PALS) is a two-day long course designed to teach front-line providers how to manage the very young when they become very sick. Like so much else in my training, the gritty specifics of the class are by now pretty hazy, but I do remember one thing: how to take one look at a kid and know if she is really sick.

This kid was really sick.

Even in the arms of her mother, her entire body heaved with the effort of breathing. She was profusely diaphoretic, pale, and cool in the extremities. Her lungs sounded rhonchorous, or maybe stridorous, or maybe wheezy. They definitely sounded bad. The shirt she was wearing was covered down the front with vomit from an interrupted meal, and it looked like more was on the way. Blood pressure was low. Oxygen saturation was low. Heart rate was high.

The specifics don't matter. This child was seriously ill with a condition that remained beyond my control. Despite all of my training, the giant red bag that I carry on my back, the uniform, the lights and the sirens, the definitive answer for right here, right now, was to scoop the kid up and run to the hospital.

It is a difficult thing to explain to a terrified family. I told them that I didn't know what was wrong with their child, but I was sure she was quite unwell. I explained that things are likely to get worse if we can't get her to the hospital quickly, and we need to get moving right away. Don't worry about finding her a jacket, don't worry about her shoes. Let's go.

The family looked at me, shocked. Can't I do something? I'm not sure exactly what it was they envisioned me doing in their living room, but certainly it was more than to tell them their child was sick. And even though we had fancy looking tools: the cardiac monitor, end tidal CO2 waveform capinography, intravenous fluids and oxygen bottles, the truth was out. All of our training and experience, tools and protocols were nothing but fluff. They were along for the ride, as we were, against an uncontrollable pathology and a random outcome that only the hospital on the hill could really make sense of.

So off we went, down the road above the speed limit with the lights and sirens doing their noisy work. I went though my routine as I was trained, knowing that the efforts would land without much effect. And though it upset me to remain unable to offer any definitive treatment, it helped all of us to know that something, anything, was being done. The hospital was only ten minutes away.

The doctors converged on the supine patient, a ring of white coats bending forward to look over the similarly colored child. They attached monitors and took assays of varying types through the cluster of work. They called resources in from across the hospital, pulled out the stops, and brought experience and reason to bear. It was more than forty minutes before one of them stepped out of the room to talk with the frightened parents.

"Ms. Reynolds," they said, "we're not quite sure exactly what the problem is yet, but we know your child is very ill."

Monday, February 9, 2009

Trauma is Easy

People like to say that compared to complex medical calls, trauma is easy. Just backboard, Oxygen, and bang in an IV, they say. Still, it has been these trauma calls that have been tripping me up lately.

Its about scene control. These patients aren't supine in their nursing home beds with a neatly-printed medical history and medication lists at the ready. There are no nurses with the story, no recent diagnosis to help with the case. Instead we find these patients twisted up in their cars, drunken on the sidewalk or combative on the ground. Taking care of these people isn't simply about their medical problems, but also (sometimes even more so), about resolving the issue at hand. A combative, drunken man dressed in four snowcoats who needs to be exposed and backboarded provides a unique challenge, and I've found myself more than a few times at a loss what to do next.

A man drove through an intersection and T-boned another car at a high rate of speed. When we get there we notice immediately that both cars have significant damage, but only the occupants of the second car are on scene. They tell us that the man who hit them ran down the street, taking with him a small child who was also in the car. A few minutes later the police find the man, and call us over to evaluate him. He is about 30 years old, not making any sense, and gripping a two year old girl tightly to his chest. His left leg is severely deformed with an open tib-fib fracture. How he made it two blocks away from the accident on that leg, we may never know. We can't communicate with the guy. He is either altered, drunk, or doesn't speak english. ...Likely some combination of all three. He won't let go of the little girl, who is now screaming in terror and burying her face in the man's chest. This man's car is destroyed, with intrusion damage into the passenger compartment and windshield starring. We need him backboarded and to the trauma room, but he doesn't seem to understand and he won't let go of that child.

How long do we work with him? How hard do we try to coax the child away from his arms? Do we just pull the two apart and hold the man down as he struggles to get his child back? What is the best for both patients?

I wasn't sure.

Sunday, January 4, 2009

Arbitrary Medicine

I brought a patient to the hospital today who was clearly having a stroke. The Cincinnati Scale was a three out of a possible three and the family was hysterical over the dramatic change that their loved one had experienced over such a short period. They wiped their eyes clear and tried to concentrate when I asked them when this man was last seen in his normal state. It was at lunch, they think. Yes, at exactly twelve twenty they brought him a ham sandwich and everything seemed fine at the time. It wasn't until four hours later that they found him slumped over in his armchair with that terrible slackened look in his face.

My heart sank as I heard the story. A possible four hours since the onset of symptoms puts this patient right around the cutoff point for a clot-busting therapy that might otherwise have made all the difference. At three hours the doctors might have made an exception, or allowed the desperate and emotional family to overpower a general clinical guideline. ...But not at four. The window of opportunity had closed and what was done, was done.

I had the patient's wife sign my paperwork after I transferred care to the hospital staff. She looked at me and gave a genuine thanks for the work I had done. Her eyes welled up as she spoke, and I could tell it took not a small amount of strength for this woman to maintain her composure. She didn't quite understand what had happened to her husband or what events had transpired that would dictate his foreseeable future, but she seemed to know enough.

The difference of an hour. I wondered later what damage it would have done if I had asked the family to perhaps reconsider what time they recalled giving this man his lunch. They had no clue what repercussions such a seemingly mundane detail might have, but I knew. I sat there and listened to it. I wrote it down on my notepad.

The TPA might never have done any good. It would in all likelihood have been a fruitless, expensive, and emotionally taxing exercise that ended with the same (or worse) end. Still, I wonder what the family would have thought if they knew the whole story. ...If they knew how close they came to the potential for a different future.

Something tells me they would have wanted to know.

Saturday, December 6, 2008

The Places I've Been and the Things I've Seen

My job takes me to many different places each and every day. It is part of what I love about this work: that each moment brings promise of some new experience. This is a photo homage to some of the places my work has taken me this year. Any potential HIPAA violations have been edited, changed, or removed entirely.

(Mr Jingles)

(Mosh Pit)



(Extra Mart)


(John Mayer)

(Minding My Own Business)


(The Yale Bowl)

(Pearl Jam)


Sunday, November 23, 2008


I like to be reminded from time to time that I have only just scratched the surface. It helps put things in perspective, and I find the realization of depth to be an exciting thing. It is a major part of what I enjoy about this job, that each day holds the opportunity to learn something new, and that each call holds the potential to reorient my view upon everything else. Lately however, I’ve found these lessons coming from a different source. My lectures and laboratory sessions at school are slowly transforming from dull academia into practical application, and I’ve relished a few opportunities to take new depth with me from the classroom to the job.

Organic Chemistry is a beautiful science. It is famously difficult, the “weed out” class for pre-medical students everywhere, and this semester has taught me exactly why. It is a science that requires a particular kind of continuous knowledge, applied together in the assembly of functional chemical compounds. To understand organic chemistry is to understand a particular set of tools that are used to create highly specific, exotic chemicals out of cheap and common starting materials. The process is often arduous, but the fruits of this labor are the fuels and medicines that shape our lives today. There is good reason people have put such work into developing our understanding of this science.

I have been lucky to associate some of this science with my work on the road. These studies have taught me about the importance of detail. To know a thing is to understand how and why it behaves the way it does, to understand it from every angle. This kind of scientific intimacy brings to light exactly how delicate our tools are, and how specifically they are engineered.

Above is a drawing of the chemical structure of epinephrine. These specific orientations of carbon, oxygen, nitrogen, and hydrogen might seem like unnecessary detail, but this structure holds within itself a real power. My studies have taught me how to pull that flat drawing out into three dimensional space, to give life to that compound and make it real.

That drawing above isn’t just epinephrine. It is more specific than that. The forward orientation of the hydroxyl group (the “OH” near the top) is particular to this form of the compound, and is specifically named (R)-(-)-Epineprhine, or Levo-rotary Epinephrine. This is to differentiate this particular orientation from its isomeric sister: (L)-(+)-Epinephrine (Dextro-rotary Epinephrine) in which the “OH” points in the opposite direction. See, epinephrine has a point of rotation (a point of “chirality”) that enables the molecule to exist with the same chemical formula, but slightly different three-dimensional orientations of the components. The phenomenon is called stereoisomerism, and it is more than just academics. A small change in the three dimensional shape of Epinephrine is what differentiates the biologically active from the not biologically active. Levo-rotary Epinephrine is the vaso-constricting, heart-stimulating, bronchi-dilating drug we are familiar with. Dextro-rotary Epinephrine, however, is essentially inactive. Our bodies, in all their wisdom, produce an enantiomerically-pure product: the levo-rotary epinephrine only.

Stereoisomers such as Epinphrine can be separated into their individual isomers (“enantomers,” in this case), or can be combined together into a mixture. When enantomers are combined together in equal proportions, Organic Chemistry calls the mixture a “racemic” mixture. When we give patients the drug we call “Racemic Epinephrine,” we are actually giving a combination of the active form of Epinephrine mixed with an inactive form of the same chemical compound. This technique has a blunting effect on the potency of the drug, which is the desired effect. I was surprised to learn that the technique we use at my service to perform this treatment is slightly different. We don’t technically administer “racemic” epinephrine because we don’t have dextro-rotary Epinephrine in our drug bags. Instead, we take regular levo-rotary Epinephrine and mix it with saline, achieving the same blunting effect.

The same holds true for our diabetic patients to whom we administer Dextrose. I have been asked in the past why we give dextrose to patients who are hypoglycemic. Organic and stereo chemistry provides the answer. In fact, dextrose IS glucose, just the dextro-rotary isomer of it. (Dextro-rotary + Glucose = Dextrose) The chemical compound is oriented in a specific way, like epinephrine, and it is only this orientation that is synthesized by the body to create energy. It is by convention that we call glucose created outside of the body “dextrose,” and that created inside the body “glucose.” They are both the same thing.

It is all scientific detail. Esoteric, to be sure, but the depth is there for anyone who is willing to look. For a paramedic and pre-medical student such as myself, I find the incredible complexity of these subjects fascinating. To learn about epinephrine and dextrose in this way makes me wonder about everything else we do. There are layers and layers of understanding underneath each of our drugs, underneath our procedures, policies, and practice. We do what we do out of little but faith that there exists science and understanding to provide a foundation for these treatments. We accept our protocols wholesale because we have to, as they are the assimilation of greater minds with greater perspective. To scratch the surface of this knowledge, as I have done in class, does little more than add a sense of humility and wonder for that which I do not yet understand, and to provide a motivation to move forward and learn more.

In the future, I have bigger plans for this surface than a mere scratch.

Tuesday, November 18, 2008


This neighborhood is particularly bad. Stout, two-story brick buildings are tightly clustered around an intersection of narrow, pot-holed streets. Through their iron barred vantages, these unfortunate residents overlook a scene of densely overgrown brambles, adorned with rubbish and punctuated with rusty iron poles pointing out at bent angles. Slackened laundry lines hang from a few of the poles, dipping close to the ground as if the life had been sucked right out of them. One of the ropes leads to our patient’s building, and she sits there with the door half-cocked, waving us over from down the street.

She is in a pair of neon pink pajama pants and a long white t-shirt. Against the sullen gray background of her neighborhood, the woman looks suddenly three-dimensional. Her image pops out towards us as if she had been drawn in, rack focused by an artist looking specifically for contrast. There is a smile, too, and it seems equally out of place.

“Oh thank you so much for coming,” she says. There is genuine appreciation in her voice, and warmth in character that we did not expect to hear.
“Please, follow me right up this way.”

She turns around and leads us up a darkened staircase, around to the right and into a small room. There is a single air mattress on the floor and an older TV sitting on a milk crate. On the screen is the title menu from a 101 Dalmations DVD, which plays a hushed Disney lullaby on continuous loop. A small boy of perhaps two or three years is sleeping prone on the mattress.

She’s whispering now.
“I feel so silly calling you guys, but he just fell asleep. His asthma was really bad all night. I gave him three or four puffs of his medicine but it kept coming back. It’s so scary hearing him wheeze like that, I just didn’t know what to do.”

The woman looks younger now as she tells the story. For the first time I notice that she can’t be more than eighteen or twenty years old. Despite her bright clothing and young face she looks haggard and worn out. Exhausted. At the end of her story she throws her hands up and lets them fall limply to her sides. She is wide-eyed and eager for help, looking at us searchingly for our reply.

I wonder if she honestly believes we might just pack our things and go. Perhaps we would decide she lacked merit and leave them both there in that apartment to rot.

The way she looked at us then, it seemed she was ready for anything.

Sunday, November 9, 2008

Blind Faith

Working alongside so many medical professionals of varying qualification and experience has given me a profound respect for that which I do not know. It is not a rare occurrence that I am confronted with a patient who suffers from a condition that I have never heard of, or with which I am only lightly familiar. These circumstances are particularly frustrating for me, because instead of drawing from my own experience and knowledge, I am forced to rely entirely on what I am told by the nurse or doctor on scene. Many times I feel I am not getting enough information, and other times I feel like the information may be incorrect. Still, my personal lack of education on the subject limits my ability to question, and hampers my greater understanding of this patient who will soon be under my care.

We were called last week to a small clinic for a patient who we were told had shortness of breath. The patient had undergone a procedure during which he was sedated with Propofol and placed on his left side while maintaining his own airway. When the procedure was over and the sedative discontinued, the patient complained of “a little sore throat” and some nasal congestion. At that point in time the measured oxygen saturation (SPO2) dropped from a baseline of 97% to 92% for a few minutes (then returning back to baseline). Concerned, the clinic performed a chest x-ray and thought they saw some infiltrates in the lower lobe of the left lung. They wanted this patient brought to the emergency room for evaluation and, as they put it, twenty-four hour monitoring of the oxygen saturation. They were apparently worried that the patient had aspirated during the procedure and was on the verge of some sort of pulmonary emergency. The patient, now completely without complaint having never noticed any shortness of breath with an oxygen saturation of 99% on room air, looked confused and frightened.

I admit I don’t know much about the risks involved with laterally positioned patients under Propofol sedation. I don’t know how to read a chest x-ray and I only understand a little about what a lung infiltrate is. I have a good familiarity with pulse oximetry and clinical assessment though, and this case raised a few flags with me. I was skeptical, but the doctor told me this story with such earnest interest and concern that I couldn’t help but be impressed. He had the paperwork all ready and asked us if we were capable of monitoring the pulse oximetry while transporting this patient with the lights and sirens on. He said that he had spoken with the physician in the receiving ER and they would be anxiously awaiting our arrival. Barring what I was told and what I saw with the patient, everything about this call seemed to suggest something serious was going on. Still, there the patient sat with a weak story, no complaint, and no sign of any trouble.

I wanted to raise my eyebrows and ask a few tough questions. Are you sure the pulse ox was reading correctly? Didn’t you listen to lung sounds? Didn’t you listen to your patient? How likely is it that the shadow you saw on the chest x-ray is a physiologic change and no emergency at all? Are you sure this patient really needs to go to the EMERGENCY room? Is there something I’m missing here?

…But I couldn’t. The truth is, I don’t really know enough about any of this to be questioning a physician’s impression so directly. I am anecdotally familiar with pulse oximetry and the tendency for the sensor to slip and read low. I know that even healthy patients sometimes read low on the pulse-ox for benign reasons, but I am not sure of the exact mechanisms and science behind pathologic reductions in those same readings. Surely this physician was much more familiar, and I feel I must have some (if even blind) respect for the decisions that come from such experience and training. He must know something that I don’t. The same goes for the x-ray. Surely the radiologist understands the difference between pathologic and physiologic changes on a plain film. Who am I to question him, even if the story just doesn’t seem right?

And so we transported the patient as we were told. I sat in the back and plugged in the pulse-ox, talked with the patient and did my regular assessment. I didn’t find anything wrong with him, and the pulse ox sat at 99% for the duration of the trip. When we got to the emergency room the triage nurse rolled her eyes. She sent the lady to the waiting room.

I know a lot of medics who would have argued with the doctor. Some of them have no problem asking those pointed questions and wearing their distain for a questionable call on their sleeves. Relaying this story to an experienced medic I know, I was chastised and told to rely on my own assessment. “Did the patient look sick to you,” I was asked. When I replied that he didn’t, the answer was “Then he probably wasn’t.”

He’s right, the patient probably wasn’t sick. It was probably a bunch of trumped up nonsense arising from a cautious physician worried about iatrogenic disease and the resulting repercussions. I saw that within my first minute with these people on scene. …But I had no way of being sure. I trust my assessment and I trust my experience. I am proud of my abilities and I think I am a capable provider. Still, I know that there are sharp lines that divide what I know for sure and what I do not, and there is much more of the latter than there is of the former. If a doctor tells me his patient is sick and I don’t think he really is, would it really be prudent to follow my instincts over his? I’m not so sure.


Research after the Fact:

A pulmonary infiltrate is the filling of airspaces within the lungs with fluid, inflammatory exudates, or cells that increase the visual impression of soft tissue density on a chest x-ray. Sometimes this can be a pathologic finding, but there a is also a potential that the condition may be physiologic, where normal airspace folding and collapse creates the same visual impressions (“Atelectasis”). The left lower lobe is the most frequent location of benign atelectaisis in ICU patients. (source)

In a recent study on critical care monitoring, pulse oximetry accounted for almost half of 2525 false alarms (1). In another study looking at patients recovering from anesthesia (2), 77% of low pulse-ox alarms were false in nature. A recent survey (3) found that highly trained medical professionals may have little understanding of pulse oximetry and it's clinical application. In that survey, 30% of physicians and 93% of nurses thought that the pulse-ox measured PaO2. (It actually uses a measure of hemoglobin oxygen saturation to esimate arterial saturation, SpO2).

Tuesday, October 7, 2008

The Other Side of the Glass

I listened to a physician lecture the other night on research regarding Impedence Threshold Devices (ITDs), and couldn't help but be impressed. This physician exudes such a thorough grasp of his medicial science that it was a pleasure to sit back and listen to him expound. Like other experts, he utilizes a language particular to his field so fluid in it's composition and complete in content that the novice listener may easially become lost in the esoterica. He seemed heedless of the complexity of the subject, as if he didn't even notice as intertwined pathophysiologies wove a picture so artfully constructed that we listeners could only partially comprehend. I speak this language about as completely as I do Spanish, which is to say that I know only enough to get by in the situations that I have been preprogrammed to anticipate. Donde te duele, mejor, peor, y cual hospital.

To listen to this physician speak was as much enlightening as it was humbling. I enjoy very much seeing these doctors in their zone, hooking onto a subject and going through their paces as they have been trained to do. I can see that he enjoys it, and I can see that he is at home within the language and texture of the medical literature. He reads an article with a particular flair of skepticism, as if it was up to him alone to pass judgment on the trials that have been laid before him, and with glasses at the bridge of his nose, he does. "This research does not impress me," he says, "and I'll tell you why."

We paramedics sat at this lecture like cub scouts around a campfire, wide eyed and dedicated each minute to their scoutmaster. Our physician handed down samples of his experience that we will never ourselves see. He gave us a window into the depth of knowledge that dictates our actions from the other side of the glass, and he danced a jig that we prehospital providers will never truly learn. Sitting there the other night listening to this doctor speak, the gap between us was never more clear.

It was frustrating to be so acutely aware of this divide. Working a few good calls as a paramedic has the potential to endorse hubris, and perhaps I have fallen victim to it as of late. I know ACLS pretty well, and I'm proud to say it, but a few steps back sharpens the fact that my understanding spreads not much farther than an algorithm and some light associated background. Like it or not, the expertise exhibited by this doctor the other night contrasts sharply with my own.

It motivates, though. I've got role models. These lectures give me an opportunity to keep an eye on what I am working towards. I want to speak that language, I want to understand the detail and have it ready at my command, I want to have that conversation again, informed. As frustrating as it can be to be reminded of my current limitations, it makes real and adds luster to that which - at school - I am working towards.

One semester to go.

Tuesday, September 30, 2008

Track Marks

Do drug abusers ever get sick?

There is a particular posture that can be attributed to healthcare providers of any level when confronted with these types of patients. Maybe it is anger, or disgust. Perhaps it is mistrust or simply exhaustion from all of the shit that smells the same way coming through our doors. Signs and symptoms aside, if you, your chart, or your mannerism stipulates that you are a drug abuser: you will be mistreated.

This week, I watched an ER physician withhold ventilations from an opiate overdose with a respiratory rate of six. "He shouldn't have shot up" was the justification. The kid was cyanotic and looked like shit. When the narcan went in, they slapped him in the face in order to help revive their still unresponsive patient, and when he woke up denying drugs, the doctors told him that the narcan would kill him if he wasn't honest about his drug usage.

Same day, same hospital, I brought in a patient with profound right sided weakness, obvious right side facial droop, and a blood pressure of 180/100- all an acute onset 30 minutes before our arrival at the hospital. The patient was obviously frightened, and perhaps by some lapse of judgment she let loose through her slurred speech that she had used cocaine the night before. Hearing this, the triage nurse rolled her eyes. She got a bed in the hallway and I had to make a scene at the hospital in order to get some attention for my patient.

Impose whatever judgment you will upon these ED providers, but I have personally seen these same people provide absolutely top notch care. I've witnessed them go above and beyond to provide emotional support, and I've watched as their expertise illuminated acute pathologies that only great experience and skill could have possibly recognized. I've seen these people as shining stars within their departments, and even thought to myself that if I were ever injured on the job, these are the people I would like in charge of my care.

But then again, I don't do drugs.

Friday, September 12, 2008

Let the ECGs do the Blogging

Cardiology is one of my favorite aspects of this job. I find electrophysiology fascinating, and I relish every opportunity I get to look over an interesting ECG strip. I know some of my readers share some of the same interests, so I thought I'd post some strips from the past few weeks. I'll let the printouts do most of the talking:

80 year old male found seated in his recliner watching TV:

40 year old female feeling "weak" at Wal-Mart:

The nurses said this patient looked "restless." (This is the patient from Points of View):

Monday, September 8, 2008

Their Emergencies

I met a man and had a short conversation with him. He had a headache, ten out of ten, and couldn't talk about anything else but the pain. We were less than a mile from the hospital when he started mumbling incoherently and then went unresponsive. I found out a few hours later he had an acute subarachnoid hemorrhage, so massive that even the neurology folks stepped back in awe. He was forty years old, and alone in this country without family. For the rest of the day I brought patients into that same ER, placing far less sick people into their cots just a few doors down where this man lay, intubated and alone.


I transferred a lady out of the hospital a few days ago after a ten day admission for a swollen foot. She was pretty old and had a complicated medical history but was cheerful nonetheless. She laughed at some of my jokes and rested while I finished up the transfer paperwork. We fluffed her pillow at the nursing home before we left. Today I passed a number 8 endotracheal tube through her vocal cords and directed CPR even as her ribs cracked under the pressure. I couldn't get an IV and had to drill an IO into her tibia. Futile, though, as despite our sweat and effort the flat lines prevailed. She looked like a different lady than I had seen just a few days prior.


Raise your eyebrows if you like, but it makes me somewhat uncomfortable when through their stories, patients become people. A symptomatic tachycardia does not demand empathy. A clonic seizure can't crush a provider's spirit. Only people can do that. Only stories with which we can identify, only smiles and conversations can have that effect.

Prudence demands that we separate the disease from the person. Insult hits much harder than injury, and I think anyone who sees these kinds of things on a daily basis needs to put barriers between these patients and themselves. My paramedic instructor had a mantra that we were advised to live by, that these are "not our emergencies." I remember feeling that the concept was somewhat cold, uncaring, and against the grain of this medical field that I saw as powered through compassion.

Today, I understand its utility.

Tuesday, September 2, 2008

Points of View

We did a really good job, I'm not afraid to say it.

The guy was having a MI and we caught it on the ECG despite a baseline altered mental status and no clear chief complaint. We treated appropriately and gave a report on the way to the hospital that got the cath lab open and waiting for us. Door to balloon time was under 15 minutes, a lifesaving success for which my partner and I proudly accept our portion of the credit.

We followed the patient right up to the cath lab and bore witness as our inferior/lateral/posterior ST segment elevations gave way to a serious occlusion of the proximal circumflex artery. It was exactly where we thought it might be, and in the darkened surgery suite, my partner and I beamed.

We got some handshakes and genuine praise from the ED doctors. They said we did an excellent job, that they wished every call went this way, and that we should keep up the good work. It was only a few kind words but it meant the world to us.

Our supervisor was waiting for us when we returned to the ambulance. He was there when we arrived with the patient, and it seems he noticed in our haste we had forgotten to secure one of the four straps that hold our patient to the stretcher. The other three where in place, but I had removed the top strap because it was causing artifact on the twelve-lead ECG.

Pulling the yellow carbon copy from his stack of citations, he handed me my notice. "You should have put the straps back together before taking the patient out of the ambulance." A written warning. Next offense I'll get suspended.

Out of the clouds, Baby Medic. Back to reality.

Wednesday, August 20, 2008


I rolled him over from his prone position rather unceremoniously, first pulling on the topmost arm and then pushing at his hip in order to force the move. Like a barrel suspended on top of water, the man reached his tipping point and flopped over, rolling downward onto his back.

We were called for a cardiac arrest, but this man was breathing. He groaned after we moved him, and sluggishly flopped there on the bed without the energy (or will) to right himself completely. He looked exhausted. His breath was laden and heavy, his bare chest and protruding belly heaving in slow motion with clear exasperation. He smelled like liquor.

I didn't give him much time to consider his options. "Up you go," I demanded, yanking on his arm and pulling the man upright. He groaned some more as I continued to pull but it was he who relented first, and up he sat as I pulled, tipsy and top heavy coming to rest at the edge of the bed.

My flashlight in his eyes. "How much was it that you drank?" Stern and truly without compassion I wanted answers from the man. Unknowingly or not, he had instigated a dangerous lights and sirens response from across the city, inspired undue concern, and let us all down with his sluggish demeanor and potent breath. His pupils were dilated and equally reactive to light. The man tried to focus on me with the bulb in his eyes, curiously confounded. "Just five," he slurred.

I don't feel sorry for him. I don't feel compassion or energy or willingness to help. I feel exasperated, and I wear it on my sleeve. We roll him out of the apartment quickly, taking little time for comfort or care. He is a waste of our time. He is a chronic abuser, a hopeless cause, a train wreck derived from proportions of choice and circumstance. Forget the ratio whatever it may be, we don't care. Here and now he sits, drunk, and I am without inclination to delve into much more.

It is only until after the call and upon reflection that I am able to truly understand how callously we treated that man. Each step replayed in my mind, I can think of hundreds of other occasions where I would have done something different - either more slowly, cautiously, or with more care - had the patient been someone or somewhere else. ...And yet at the time, in the moment on the call, it all seemed normal. Somehow our behavior was in sync with the environment, and though out of place within our daily routine, temporarily acceptable.

...But that wasn't what bothered me most. It was the patient. Though all of this he sat still, groaning in his toxicity but nevertheless fully aware of his circumstance and the "providers" sent to rescue him from it. The expression on his face was stoic and accepting, conscious of the abuse and yet submissive.

This man was used to being treated this way.

Wednesday, July 16, 2008


I took care of a woman today who fell off of a roof and landed on a pile of aluminum siding about 20 feet below.

Her friends who saw her fall said she landed right on her head and just "crumpled." When we got there she was sitting under a tree across the yard, holding her arm out at an odd angle that resembled some sort of zig-zag. She was pale and diaphoretic, lethargic and mumbling about the pain in her shoulder. It was obviously deformed in at two places, and probably broken in more places than that. The woman complained to me that she couldn't feel anything in her arm at all, and, laying on our backboard on the way to the hospital, asked me if I could confirm whether it was still attached. To reassure her, I told her I would take her left hand and place it on her right elbow. She could help stabilize the extremity as well as remind herself of it's presence. Taking hold of her left hand and bringing it over to her right side, the woman grabbed hold of my hand. "Thank you," she said, "thank you so much." She didn't let go. Not sure of whether she thought she had hold her own hand or was holding mine for comfort, I sat there with my arm outstretched. With only a minute until we reached the hospital I decided that either way, I'd just let her keep it.

I took care of a young boy today who was found unresponsive by firefighters inside a burning building.

They carried his limp body away from the smoke and laid him down in the grassy front yard, franticly waving to my partner and me who were standing by. As the firefighter told his account of the story, the boy began to wake up and cough, reaching out for help from his position on the ground. We scooped him up and rushed him to our stretcher, listening to lung sounds, applying oxygen, and looking for burns. The boy was fully awake now, apparently uninjured but terrified. There was another paramedic on scene who was precepting, and we decided to ride the call in together. I sat in the airway seat and helped as the new medic ran though his routine, watching quietly and helping only as necessary. The sirens were especially loud in this older ambulance, and it was hard to hear the boy's quiet answers to my few questions. I sat forward, tilting my head until my cheek was almost touching the pillow, and face to face the boy and I talked about what happened. We were close enough so that we didn't have to yell to hear eachother, and the boy seemed grateful for it. Quietly he told me that he had fallen asleep and woke up to find flames in the kitchen. When the firefighter came he was so scared he pretended to sleep, not knowing what else to do. He felt okay, he admitted to me, but was embarrassed about what had happened. Amongst the turmoil and noise of the bumpy ambulance, sirens, and a new paramedic running his routine, I think it took only a few quiet words to make this patient feel well again.

I took care of two patients today who reminded me that even "critical" calls deserve a minute's pause and consideration. These are people, not presentations. Men, not mechanism.

Its easy to forget. I'd like to thank both of my patients today for their gentle reminders.

Monday, June 23, 2008

Quiet and Comprehension

There is a certain profundity that is expressed by silence in the face of screaming tragedy. Quiet has a potential to permeate the soul deeper than any cry could, hit harder than the fiercest blow. With somber sadness and a quiet reverence for a life gone in only a few seconds, my partner and I stood over the body of a woman who was alive and working at the machines only ten minutes ago. Now, her skull was gruesomely crushed, open and split onto the cold concrete. The factory, usually buzzing with activity and clanking machines, was totally shut down. The hundred or so workers who manned the iron from nine to five were frozen in their positions, standing in awe. Their smudged faces peeked out from yellow hardhats, betraying a contorted mixture of disbelief, shock, awe, fear, and sadness. Silently, we all stared at the result of an accident that brought the entire factory, and this woman’s young life, to an abrupt halt.

She was assisting on a large iron press, we were told in whisper. The machine exerts several tons of pressure, and through some miscommunication or some other horrific lapse, this woman was caught underneath it on a downward stroke. The result was the worst traumatic injury I have ever seen: a crushed skull and brain matter spread out in a fanning pattern. The face was an unrecognizable mash, attached loosely to a body that lay lifeless in an awkward, contorted position. We didn’t even check a pulse. There was no point.

We conducted our business under our breaths, passing word to the police officers that the patient would be presumed dead having sustained injuries incompatible with life. Firefighters wordlessly began surrounding the workstation with a large opaque tarp, shielding the entire area from the tearing eyes of her coworkers and friends. I was able to get demographic information from some of the factory management, and then quietly made my escape back to the ambulance.

My partner and I stowed our gear and climbed back into the truck. Looking at each other from driver’s seat to passenger, we couldn’t come up with anything other to say than “holy shit.” Silently, we drove back to the ambulance bay.

I’ve been to the scenes of many recent deaths. Car accidents, shootings, various cardiac arrests. Outside of health facilities there seems always to be some distraught family member or friend, loudly exclaiming their grief in either cry or yell. It used to bother me to see the faces of these anguished people, and it was usually with them – not the patient – that I empathized. For some reason or another I don’t usually find myself sympathizing with the dead. They’re gone, and in most cases there seems to be plenty of grieving going on anyways.

…But not this call. It was deathly quiet. The silence was so thick that it had to be managed, considered as its own passive obstacle like knee-high sand. We waded into that factory though oppressive quiet and took in a scene that few should have to bear witness to. We saw a hundred hard-hatted faces, watching and silent as if they were waiting for the woman to take her next breath and spring from that contortion. It was a frozen moment of time, lasting an hour, where consideration and re-consideration of events past left little room for outward emotion or cry. It was unreal.

We were brought in to talk with our supervisors who worried whether we were okay. They were extremely accommodating, asking if there was anything we wanted or needed. They said they knew that the scene was pretty gruesome, that it is tough for anybody to see a body so mangled and dead like that.

But it wasn’t the gore. It was the quiet. Seeing that person lying there frozen where she last moved herself was an extremely powerful experience that I don’t think I will soon be rid of. It was as if the clock stopped immediately after that machine banged downward, and though the area surrounding that small space shuffled and blurred in the background, our dead patient remained in sharp focus, preserved in powerful tragedy on the precipice of comprehension.

…And all we could manage to say was “holy shit.”

Tuesday, June 17, 2008

The Squeaky Wheel

I guess this is what I get for complaining about my chest pain patients. It was my first time with such a standout case, and even though I would have liked to do a few things differently, everything seemed to go well. The cath lab told me he had a total occlusion of the RCA which was stented within record few minutes of us rolling through the ED doors. The patient, smiling, signed my paperwork from his ICU bed.

Monday, June 9, 2008


He didn't even have chest pain. No shortness of breath, either. Just weakness and a little nausea without vomiting. He noticed it earlier this morning and though it bothered him, he let it go in hopes that it would resolve on its own. He had had a heart attack about three months ago and stents put in, but even still he remained doubtful that this was very much at all. "Probably just the heat," he said. And I agreed.

Nevertheless I thought I'd ride with him to the hospital instead of driving. Maybe he could use a little fluid I thought, or perhaps some medication to control his nausea and make him a little more comfortable. I hadn't teched a call all day and my own boredom probably played as much a role in this decision as any particular sign or symptom. What the hell, right?

The twelve-lead ECG was full of noise from the bumpy ride despite my best efforts, and there was a bundle branch block that further obscured the view. What I could see, though, were some ST depressions in the V5 and V6. They were maybe a two millimeters or so, and I had my doubts that they were much more than a reflection of all else that was wrong on that strip.

Besides, I have been down this road before. ST depressions in a few leads, inverted T waves, small elevations: they get scoffed at in the ED. Especially without a really good story, these minimal, inconclusive ECG changes often bring nothing more than eye rolls and a condescending pat on the back. "We'll look into it, good job." I've heard it many times before.

The hospital flipped out. The nurse's eyes widened when she saw my strip, pointing at the tiny ST depressions as if they were tombstones from the widowmaker itself. She rallied all her resources, worked the patient up and yelled for the doctor who came quick-stepping into the room as I shrank farther towards the corner. Right about this time the patient's family arrived at the patient's room. I had met them earlier at the patient's home and before I left I told them not to worry, that I would take care, and that they should drive safe. We left the driveway without lights or sirens, and I thought I had made a calming impression on the otherwise edgy and nervous relatives.

So much for that. They sensed the tension and the doctor wasn't helping. "The ECG does not look good at all," she said. "I don't like it one bit." The doctor explained the next few steps in quazi-technical jargon that whipped the family right up into a frothy frenzy, and in just a few minutes I wanted nothing more than to make a quiet escape to review the strips again for myself.

They looked the same as they had earlier. Just a few minimal changes. The same stuff that I've brought in plenty of times before and been disregarded and tossed aside. "Oh, that's cute," they'd infer. "Look how thorough the medic is trying to be." I squinted at the paper and looked as hard as my eyes and education could decipher. Nothing impressive. Not even close, really.

A little bit of experience has raised my index of suspicion for acute coronary syndrome to perhaps a ridiculous level. It seems when I print off twelve leads these days, the patient better have huge ST elevations and the most convincing story I've ever heard if I am going to truly consider ACS with any seriousness. T wave inversion? Hah. ST depression? Yeah right. Don't get me wrong, I'll pass the asprin and nitro out like I am supposed to, but as far as actually believing the patient? As far as being willing to present this to the ED as a heart attack? Not on your life. Doctors simply do not want to hear a paramedic's evaluation of the minute. Its cath lab or shut up about it.

But not this time.

Monday, June 2, 2008

Blood Ran Cold

I never want to have that feeling again. That cold rush of fear that runs up and down my spine, instantaneous and unexpected at the utterance of just a few words. Normal one second, the next I am sweating and anxious, shifting my weight from foot to foot and staring intently at the scene ahead.

My patient is dead. He is spread out on the cot, naked and surrounded by nurses and doctors performing CPR, looking over my cardiac strips, pushing drugs, yelling out commands. The scene is organized chaos, but my focus is set upon just one person there, at the head of the stretcher.

Its the doctor saying that my tube is in the esophagus.

The feeling of fear and shame was so intense, so immediate and powerful that I still remember it with utmost clarity today. Surely any paramedic who has been in a similar position can sympathize. I was taken by surprise, having run this cardiac arrest for more than thirty minutes to the best of my ability, exhausted from the effort and glad to turn over care to the emergency department, only to hear this.

The doctor ordered an intubation kit and the nurses scrambled to comply. I caught a few eyebrow-cocked glances from those in the room. An unrecognized esophageal intubation is probably one of the worst things a paramedic could possibly do, and there I was, helpless in front of my jury, waiting for the verdict from a white-coat at my patient's head. My god I didn't know what to do. My blood ran cold and I just stood there, my mouth half open and staring at the scene as it unfolded. What the hell do you mean my tube isn't in??

The doctor put the laryngoscope in the patient's mouth and almost immediately made the claim again. "Yup," he said, "It's in the stomach." I remember the words exactly.

He asked for another tube with an outstretched hand and a nurse quickly complied. With my tube still in it's place, the doctor directed his new tube slowly, deliberately. It bent upward. He tried again, and again. Each time the tube would contort out of place and resist forward motion. He tried moving the blade around, lifting higher and harder. No luck.

I stared at my monitor printout. It listed the end-tidal CO2, which showed readings in the high teens and twenties for the entire trip. I remember listening to the lung sounds and hearing them clearly. Positive in both lungs, negative over the epigastrium. I SAW the tube pass through the cords, and it fogged up with my first few squeezes of the BVM. The patient's stomach remained perfectly flat for thirty minutes of bagging through that tube, and I re-checked the position at least three times on the way into the ER. God dammit, I was sure about that tube.

...But the doctor continued to insist that it wasn't in. He went back with his laryngoscope and dug harder, peering into the mouth from only a few inches away, squinting his eyes and contorting his face. The tube continued to bend on each of his attempts.

A nurse tapped me on the shoulder and I almost jumped. I was so focused on the events at hand, I didn't pay attention to anything else going on in the room. Now it was the doctor getting the half-cocked looks, and the nurse tapping on my shoulder whispered in my ear. "Don't worry about it," she said, "thats a good tube."

It was. It took the doctor a few more tries before he gave up, pronounced the patient dead, and signed my paperwork acknowledging that I had a good tube. He never said a word to me about it and carried on with whatever else he had to do.

Exhausted, relieved, and trembling, I found a quiet corner to write my run form. Its amazing how quickly things can turn around on you with this job.