Footprints

Paramedics scramble to bring life back to a man who's own blood, leaked, has choked off vital airways. The struggle is futile and the man is long gone, but all the harder they work. Time passes and they arrive at the hospital. Doctors struggle as well, fighting the inevitable. Death wins the battle, and all involved admit their defeat.

Back at the messy ambulance, paramedics are reminded of their own footprints, wondering all the while if this patient, too, was marked by their efforts. ...Or do those prints wipe as easially away, shamed as an imposition and forgotten as useless?

Clarification

I need to make a few clarifications involving my posts on this blog.

First, I need to say that while the stories/calls/patients/events I describe are real, I have in fact taken a few liberties with details of the accounts. I do not mention names of coworkers and instructors for a reason, and that is because quotes are not direct, timelines are altered slightly, and some details have been changed in order to support the emphesis of the entries.

I mean here not to precicely document events, but rather to detail the lessons I've learned over this period of my education. It has been my experience that these two are often not the same thing. I learn something on every call, but from time to time that lesson will derive from a brief detail of an experience, not from the summnation of all that truly happened. My writing here is aimed at exploring those experiences, and focused on extracting the lessons I've learned from them.

To those who were there with me and may be described in these entries, I ask that you please allow me these liberties. This is not a commentary on your ability or an evaluation of your decisions, this is simply what I have learned from working with you. Sometimes it may be the wrong lesson, sometimes it may be exactly on point: but all of it is a precisely true account of what I was feeling during these calls. Simply put I dont mean to write about you, I mean to write about me.

That said, thank you for reading. I mean to write about me, but I write this for others.

Code

My alarm went off this morning at 0515 and I jumped out of bed feeling like I spent the night waiting instead of sleeping. Today, under the watchful eye of another, I got to be a paramedic.

We had been doing routine ALS all day. Calls that my paramedic partners groan over at work... the dizziness. The probably-not-CVA. The BS difficulty breathing. All those kinds of calls that demand ALS only in order to protect liability. I was excited enough though. I got to start IVs, to perform complete assessments and direct treatments. Our dizziness got a full cardiac workup. The potential CVA got a careful neuro assessment and a rapid transport. The difficulty breathing got some coaching and a sympathetic ear: exactly what she needed. I made a difference, and while I felt good about it, I ached for a "real" call. Something that I can really stretch my legs and test out these new toys.

At 1615, I got my opportunity. We were dispatched priority one to an address 10 minutes south for the "man down unresponsive." My medic preceptor jumped out of his seat, eager for me. "Oh man, thats an arrest!!" It was. Halfway to to the scene we hear the radio crackle over the sirens: "Medic 3, be advised CPR in progress."

Shivers go down my spine. This is it. A confirmed code. The ultimate ALS call, and its my first day. My partner sinks the throttle closer to the floor, and we pick up speed. My heart follows pace and my previously calm demeanor flies out the window. I've been on lots of codes before. Medical codes, dialysis codes, hospice codes, traumatic codes, pedi codes. They are all the same as an EMT. You assist, you work under the guidance and care of someone who knows better than you. Today, though, I am the one who is supposed to know better.

I envision the scene ahead of us: frantic volunteer EMTs pounding CPR into a body on the floor. A BVM squeeze and air rushes through puffed-out cheeks into the lungs and belly. The first few drips of sweat falling down as they wonder where the hell are they??. The arrival of ALS brings a wash of relief as skillful, practiced hands carry advanced equipment ready to make the patient better.

My own hands fiddle endlessly with my stethoscope as we race towards the call. I try to act cool and collected, but my nervousness betrays me to my preceptor's notice. He asks me if I'm nervous and I admit that I am. He tells me its okay. If I'm not nervous, he says, something is wrong. Its a good thing. Excitement and fear combine within me and I feel a rush of energy. I think to myself that this is something I havnt felt since I first started working as an EMT... I notice I am tapping my feet as I chastise myself. Keep your cool, dude. You know how to do this.

As we approach the address we decide that I will go after the airway while my partner will get the line. A game plan set, we pull into the driveway and switch off the siren, simultaneously unbuckling seatbelts and opening the doors. "We're out," my partner says on the radio.

I grab the big orange bag that I learned this morning has the airway kit. The EMTs are in the building still with the patient, but someone runs out to us and says they are already packaged and will be in the ambulance in just a minute. We decide to set up in the ambulance and be ready for when they come. I throw the big bag on the bench and dig towards the pocket on the right underneath the yellow pack. There I find the laryngoscope wrapped up with a full set of shiny blades. I remember back to 3 months ago, when I did my rotation at the OR to get experience intubating people. Which blade did I use? The curved one, the Macintosh. A four. I find it and click it in. White, tight, bright. My partner is setting up drugs. Remembering setting this equipment up lots of times for my paramedic partners, I run through the routine, assembling the rest of the necessary pieces. A 7.5 ET tube. Stylet. 10cc syringe. End tidal Co2. Tube holder. C-Collar. I'm ready.

The patient is coming out of the building, wheeled on a stretcher surrounded by a cluster of volunteer EMTs. One of them is riding the stretcher, frantically pumping on the man's chest. Another struggles to maintain a seal against the mouth with a BVM. They lift the stretcher up and slide it into the back of the ambulance, the patient's head slowly rolls towards me.

He looks dead. There is vomit around his mouth, pooling in his nostrils. He is a big man and I worry that he may be a tough tube. Just this time, I say to myself, let it be easy. Let me get this first one and then I can start doing the hard ones. Please just let me get one under my belt first.

I put my hands on each side of the man's head and tilt forward and up, into the sniffing position that we were taught in school. I let go to grab my blade and the head falls right back to where it was. No good. I try again, this time holding his head in place with my knee as I grab my equipment. I open his mouth with my thumb and forefinger like the nurse anestetist taught me in the OR, slowly sliding the curved blade in above the tongue. Sweeping to the left I am able to open the man's mouth inch by inch. I hear the blade click against the teeth very slightly and I freeze for a second. Dont do that again.

I am able to wiggle the blade into what I think is the vellicula and, lifting upwards, I peer into the mouth. There is a mass of tissue inside, wet with vomit and saliva. Nothing looks familiar. I look harder, and recognize the epiglottis. I need to lift higher. I pull harder on the handle and watch as the flap of skin raises slowly, revealing the dark triangle shape of the trachea behind it. There isnt much space and I cant see very much, but I grab the tube and slide it in slowly. The tip of the tube passes through the cords and I feel the plastic bump along the ridges of tracheal cartilage. I'm in.

I pull the blade out of the mouth and click it closed on the backboard. I look up at my partner with a hopeful smile. "Youre in?" I nod and say I think so. I grab a tight hold of the tube and yank out the stylet. Pass me that bag, I say to the EMT, gaining confidence. I attach it to the top of the tube and give it a single squeeze. Warm, moist air enters the tube as I let go of the bag, fogging up the inside of the tube. Fuck yeah. I'm in.

We confirm the tube with lung sounds. Full and equal bilaterally. Negative over the epigastrum. End tidal CO2 reads 19 already. I secure the tube down and begin pumping air into the man's lungs. Relief washes over me, but this time I am able to suppress signs of it. I act as if I knew I was going to get the tube all along. Of course I got it!

"Nice tube" the medic says after confirming the placement, "I'm impressed."

We work the rest of the code smoothly. The monitor reads V-Fib and we shock. Four times. Epi and atropine are pushed into the veins, followed later by Bicarb and once, when the rhythm looks like V-Tach, 300mg of Amiodorone goes in. We run though the entire list of things to do, following the protocols to a T. Both my partner and I are floating. He got a nice 16 gauge catheter right in the AC by anatomy alone. Nice stick, I tell him. "Hell yeah," he replies.

We arrive at the ED and the doctor confirms my tube. My partner announces to the recessutation team that this is my first day and I got the tube on the first try. Smiles all around. Someone claps me on the back.

The doctor takes a better look at the patient. He studies the monitor and listens to our story. Shaking his head, he issues the order.

"Stop recessutation guys. I'm calling it. 4:48pm."

So much for our toys.

Shooting

This Friday during my normal shift I had a friend from my medic class riding along with us, doing 12 hours of his own ride time. The day was mostly routine, a number of ALS calls but nothing exciting. Old lady short of breath times two weeks. Early morning car crash: "I didnt see him coming!" A transfer. My friend was a little dissapointed. "Where are all the big bad calls you guys brag about here in the city," he asks.

On our way to our last call, something that sounded equally routine, we are re-routed to a shooting. Second car in. At least two shot, one in the head. I let out a yell to our rider in back "here we go!" and flip on the lights. The street is only a few minutes away. The police is already on the radio, asking how far away we are. Always a sign that call is serious.

The address is lit up ahead with flashing police lights. They form a glow into the dark sky around the whole area, a bubble upward which - we hope - will shield us from any further danger. We pass by yellow tape as an officer, holding a black tatical shotgun, waves us through.

Our patient is visible as soon as we park. Laying on his right side in the sidewalk in a pool of dark blood is a body. An EMT from another ambulance steps over him as we approach. "There are two others, shot in the back and chest." He has to shout as he speaks, the scene is smothered in yelling. "...We'll take those" he says, and points to the body on the ground. "This one is yours."

I yell back to my friend to grab the board and collar. This is going to be a scoop and go, my partner says. We get up alongside the patient and I catch myself as I almost kneel in a puddle of blood and unrecgonizble bits of organic material. The forehead looks funny. It is caved inward. The cornrows weaved into the patient's hair look distorted, following odd angles as they run through a new shape in the patient's skull. The blue and red flashing lights do nothing to help visiblity, despite everything it is still dark. The board and collar arrive, and my partner yells for the monitor. He looks at me, frowning. We both know that this patient, shot in the head, is as good as dead.

My partner reaches for a pulse at the patient's neck. His blue gloves are stained with drak red blood as he brings them back quickly. "Hes got a pluse, man." We both notice that he isnt breathing. "Lets just get him into the bus," my partner says, and we do. We slide a board under the patient and lift him up. Both arms swing limply down the sides of the board as we transfer to the stretcher.

Someone flicks on the bright overhead lights in the ambulance. Dark blood is now bright red, and the cave in the patient's forehead is now an obvious gunshot. Grey and white brain matter is visible. The patient looks like he is about 12 years old. I feel like I am looking at him for the first time. Someone says "jesus christ."

We get to work. An OPA is placed and bagging through the BVM begins. Our rider says he can feel air rushing out of the top of the kid's skull with each compression of the BVM. We attach the monitor and the combi-pads, strap the patient down, listen to lung sounds and survey the damage. The patient is in a wide complex tachycardia that the medic and us two medic students all call VT. We each yell it out in chorus as the rhythm appears on the screen. It releives me to recgonize the rhythm. Out of the chaos of the scene, the chaos of this patient, the rhyhm brings order and stability to the back of our ambulance. The patient still has pulses, too. We know what we are dealing with.

"We need to shock!" My medic says. "Get the pads on!" The pads are already on, two people say. "Well, charge them then!" We charge to 360 and again, in chorus, yell "Get clear! Get clear! Everyone clear!" The shock is delivered, the body flinches.

Blue hands stained with red reach for the neck. There are no more pulses. The monitor still looks the same. PEA. No chrous this time, it is deadened by the result. I hear a "lets go."

I jump out of the ambulance, climbing over strewn gear and a firefighter who is now giving chest compressions. Out of the bright white light and back into the blue-red night. People are standing in a semicircle around the back of the ambulance, watching. An older woman is holding two young children close to her, yelling frantically. "See why I tell you not to mess around in the streets? See what happens! Look what happens!" The children are unreactive, staring at me and the scene behind me.. I cant understand the expression on their faces. It isnt fear, it isnt shock, their eyes arent wide. They look sullen, tired. Just another shooting in the north end. Just another kid dead. More blood on the sidewalk. The older woman is screaming and crying. She must have known something different, sometime or somewhere else.

I flick my gloves off and check my hands. There is blood on my wrist where the short gloves ended, but nothing on my hands. I can drive without getting the front of the ambulance messy. I jump up into the front seat and glance into the back. It is getting calmer. The medic is going for the tube, my friend suctioning as the firefighter does rhythmic compressions. No-one is talking. The reality of this patient has envolped the small space in back, what was a frantic effort to save a life is slowly turning into a recgonition of futility. I have a job to do though. Priority one to the hospital. I get on the radios and tell everyone where we are going. C-Med, police, the company. C-Med patches me through to the hospital and I tell them we are coming:

"Enroute to your facility, ETA 2 minutes with a male young teens. Shot in the head. Traumatic arrest, was VT with a pulse, now PEA. CPR and AlS in progress. See you in 2 minutes."

I catch the end of an "okay, thanks!" yelled into the other end. I envision the microphone bieng dropped and an excited "We've got a code coming in! A shooting!" yelled to the Emergency Department. A trauma team called over the intercom. "They're two minutes out!"

They dont know that our patient is already dead.

We're out at the hospital. There are other amublance crews waiting to help at the entrance to the ER. They heard my patch over the radio and got ready to help. Their gloves are on, bright spotless blue. We wheel the patient with deliberate caution into the ED. We've been with this patient long enough to be calm. Nothing gets dropped, and the report to the trauma team is crisp. The patient is off our stretcher and onto the trauma bed. Our job is done.

The doctors look at the child on the table, frowning. The same look my medic had when we first looked at the body laying on the dark sidewalk. I hear them say "no, look at him. He's gone." A few efforts are made, and on no change of the patient's condition, the patient is pronounced dead.

It takes us over an hour to clean the ambulance. There is blood everywhere. From the patient, from bloody gloves, from soiled equipment. We spray a disenfectent on everything, wiping carefully to leave no trace behind.

I find my medic partner sitting alone in the EMS room, staring at his EKG strips and a blank run form. He looks awful. None of us have seen anything that bad before, but this was his call. It was his patient. I was there to help, as was the medic student and the firefighter, but this patient was in my partners care. The outcome rests on him. I tell him that he did a good job. Our times were great. The kid was dead anyways and we did our best. The doctors said we did a good job. All of this, positive, but my partner's expression doesnt change. He asks me about the cardioversion. "Do you think we should have shocked him?" He asks me. He's upset about missing the intubation as well.

I sit with him as he writes the run form. There were probably twenty police officers on scene. Four people in the back of the ambulance, at least 10 people in the trauma room, two of us in the EMS room, and one medic writing the run form. One of him. This patient was his. He was the paramedic, THE guy treating the patient. Despite everything and no matter everyone, there was one person making decisions for this patient during the last minutes of his life: the medic.

He sits there, hunched over the run form as he runs through the call in his mind.





Edit (11.26.06):
To clarify out of respect of those involved with this call:

1. The medic did not "miss" the intubation. The patient was an extremely difficult (if not impossible) tube with the amount of blood involved. Constant suction was unhelpful in clearing the airway enough for intubation.

2. Defib/Cardioversion was absolutely indicated for this patient based on the assessment performed and presenting conditions of the patient. There are details left unmentioned in the above entry that support this decision.

3. The call was run VERY well considering the conditions we were under. I worry that based on this story, some readers may think poorly of those I wrote about simply because of the way the entry was written. Please refer to a newer entry, entitled "Clarification" posted on 11.26.06 for further information.

Looking forward

I am 24 years old now: a mere child among my coworkers, and an infant among my aspirations.

I graduated from Boston University in 2004 with a BA in both Psychology and Philosophy- a major chosen more out of amusement and momentary interest rather than lasting career-choice. Since then, my efforts and thoughts have rested heavily on medicine. I became an EMT-B during my Junior year at BU, convinced by my roomate Rich that it was both exciting and profitable. He was only half lying.

I have come to love the job, and with it- medicine. My aim has since been set higher towards dreams of becoming a Doctor, something I wrestle with constantly as the reality of my academic history and the contrasting demands of medical school are more sharply drawn to focus. Since my graduation from BU I have worked as an EMT in a fairly large urban city, while at the same time bumbled through a post-bacc approach to finishing pre-med science requirements.

Almost a year ago now I decided to attend paramedic school. I wanted *more* medicine. I told myself that this would truly help me decide about medical school (as I have wavered much on the subject), and that it would be fun in the process. I was frustrated as an EMT, knowing enough only to know that I knew nothing, and worse that I could usually DO nothing... made me angry and unhappy at work. Deciding to become a paramedic has refocused my interest in medicine (and medical school), as well as given me solace as to my patient care. Soon, I say. Soon I will be able to make people better.

Currently I am about to start the very last portion of paramedic school: the internship "ride time" period. Over the next month and a half I am scheduled to ride as a third on three different ambulance services, all the while behaving as an actual paramedic: performing assessments, making clinical decisions, and- finally!- treating patients based on my knowledge. Needless to say I am very excited. I have spent 10 months listening to lectures, passing through clinical rotations, and taking exam after exam after exam. Finally I get my chance to test my knowledge and understanding with real patients, in real situations. The prospect has made many of my classmates nervous, but today - still five days away from my first rotation - the excitement has yet to allow another emotion in.


I have created this blog as a means to both document my progress through this process, as well as to - I hope - provide real experience and first-hand insight into those who may be going through the same thing. I also redially admit that I have been heavily influenced by the writings of Mr. Peter Canning, a long-time paramedic who has a blog here on Blogger, has written two books about his own experiences, and also happens to work for the same ambulance service I do. I have a lot of respect for Mr. Canning both as a paramedic and as a writer. I find his words not only heavy with experience (as they are), but also saturated with an interest in the field that we dont seem to see often these days. He looks through medicine into people, a view that I believe serves him clinically, intellectually, and literally- as a writer. To you, Mr. Canning, I tip my hat sir.

Tonight I go to bed. When I wake up, four days will stand between me and my first patient as a paramedic.