Sunday, December 24, 2006

A System

I'm nervous on the way to every single call.

Our response time to a patient with chest pain is in excess of 10 minutes. I ride along in the back of the fire ambulance, nervously contemplating various treatment modalities. Chest pain patients usually get treatments based on the acronym MONA: meaning Morphine, Oxygen, Nitro, and Aspirin. ...But that is after my assessment. I need to understand the patient's story, the onset of the pain and the patient's previous history. OPQRST. SAMPLE. I remember the differences between right and left sided heart failure. Check lung sounds. Check for distal edema. Do a 12 lead ECG. IV, Monitor, O2.

We arrive on scene and the patient doesnt have chest pain. He fell out of his wheelchair and his left leg hurts. Whoops.

There is no way to plan for this, no way to decide ahead of time what to do. Every patient is different, and the dispatch system leaves us with only the most vague descriptions. I am going to have to become good enough at this so that I dont have to plan, so that when I walk into a house and see a patient I am able to immediately react-- treat based on presentation and previous experience. I need to be fluid with my knowledge, ready with my treatments. Everything must already be on the tip of my tongue.

I am getting better at it. My preceptors say that I ask all the right questions, just that I ask them in a somewhat jumbled and disorganized manner. I ask things as I remember them. Sometimes it takes 5 minutes into a call before listening to lung sounds occurs to me. I learned early in class that the lungs should be first, but I'm busy processing. Busy looking at my patient and trying to understand which path I should go down.

I'm slow.

Experienced medics have told me that I need to develop a system, an initial process that I run through for every single patient. Mental status, Airway, Breathing, Circulation. They're right there on the national registry sheets, but difficult to transform into real life. Do I really listen to lung sounds first on the patient who hurt his leg? I havnt been, but I should. Medics say that once I have this system, I will never miss anything important. I can focus on details while my hands go through the motions of the basics. Nothing, they say, gets overlooked.

I spend days at the fire house trying to come up with a system. This isnt something I can read in a book, not something another medic can tell me how to do. I no longer have instructors at the front of the classroom with laser pointers and powerpoint presentations. These days, my only teachers are those laying on the stretcher, in distress and asking me for help.

I do my best to keep my mind open despite my nervousness and the work I have to do. Every patient teaches me a different lesson.

Sunday, December 17, 2006


Same preceptor, different call.

This time its for shortness of breath secondary to asthma. When we get there, the patient looks like death is just around the corner. She is breathing about 34 times a minute, doubled over in the tripod position and using just about every muscle in her body to breathe. Looking at her as I walk up to the front stoop where she is sitting, I can see how hard she is working. I can see the struggle.

I dont even try to talk with her, I know she cant answer. I take out my stethoscope and listen at four spots along her back. I can hear light wheezes, but not much else. Hardly any air movement. Despite this body heaving underneath my scope, her back pressing upward and downward as she tries to force air out of her plugged-up lungs, the battle is already being lost.

I look at my partner, who stands patiently despite the tremor of the situation. He gives me my moment to take the lead and I do. "Epi. Now." I say. He is already nodding, diving into the bag and finding the vial. I get the patient on oxygen with a nebulised breathing treatment.

"What concentration," he asks me- testing.
"One to one thousand," I fire back, reaching for the syringe. He pulls it back slightly.
"How much."
Point three.
"What route."

He hands me the needle, I push it in. I remember to put the needle in the mini sharps box.

We put the patient on the stretcher and then into the ambulance. Flip on the lights, monitor goes on, oxygen moved over to the main in-house bottle. O2 saturation is at 85% despite the oxygen, treatment, and epinephrine. The patient doesn’t look any better. Lungs sound the same. We do routine ALS, exchanging glances all the while between ourselves. My preceptor looks at me like I am his partner, we work together as fluid as can be. He says things with his eyes that I - as another medic - understand. This patient is in trouble. We might need to tube her. How about another epi.

He gets the line while I call medical control for orders. My report is crisp and clean.

Enroute to your facility, 20 minutes out with a 51- five one - year old female from home in respiratory distress. The patient has a history of asthma, right now working very hard to breathe. Diffuse wheezes in both lungs, the patient isnt moving very much air. She had 3 puffs from an albuterol MDI prior to our arrival and we've given her 0.3 mg Epi SQ, 2 breathing treatments DuoNeb, all without change. Currently respiratory rate labored at 34 per minute, o2 saturation 84%. Blood pressure 167/72, heart rate 123. This patient has no cardiac history, I'm calling for a second 0.3 mg SQ epi and 125 mg solu medrol. Again our ETA is 20 minutes.

The doc gives us the orders without hesitation. "Drive safe," he tells us.

I draw up the medication and push it in. We reassess, reassess, and reassess. The patient is getting better. I can hear air movement in the lungs now. O2 saturation is up to 95%. She can speak now. "Thank you," she tells us. "Thank you thank you, you guys are awesome, thank you!"

We pull into the hospital and wheel the patient into the emergency department. They have a room waiting for us with a doctor already there. Three nurses standing at attention. Our patient is crying, deep sobs with long, clear breaths in between. I listen to each breath and marvel at how smooth they are. The ED team looks at us like we are crazy. "Is this the asthma? The one with the epi?"

I look at them with triumph on my face. "Yep. It is."

My partner and I, sitting in the EMS room, hunch over our run forms in silence. He stops for a moment in the middle of his writing, looks at me slightly. As stoic as can be. "Now that was more like it."

He goes back to writing. I can hardly do anything but grin at the blank run form.

Hell yeah.

Wednesday, December 13, 2006

Real Life

A lady with chest pain boggles my brain with a complicated story of complaints. She had a knee surgery last week, no, the week before that, and after falling a few days ago she was brought to the hospital and worked up for "clots in my leg." Today the pain in her leg is worse and radiates upward along the left side of her body, into her chest, and to the posterior into her back. She denies difficulty breathing, but the pulse ox. reads 80%. Lung sounds are hard to hear because the woman refuses to take deep breaths due to the pain. She takes one deep breath and I think they are clear.

This story takes me too long to assimilate. I gather information from the patient, a worried family member, and a clueless volunteer EMT: all of which give me different stories, all at the same time. The patient's complaints bring to mind a dizzying array of potentially life-threatening conditions: pulmonary embolus, myocardial infarction, thoracic aortic aneurysm, the list goes on.

My precepting medic sits behind the airway seat all the while, leaned forward slightly as he stares at me.

The patient is already on oxygen, and the monitor is halfway on when my preceptor notices the pulse ox reading. He demands my stethoscope and listens to the woman's lungs himself. All is silent in the back of the ambulance while he evaluates my work. He looks up at me, frowning as he takes the scope out of his ear. "You called that clear??" He says it loudly, harshly. "Those lungs are NOT clear. They are decreased. All over." I wonder if I misheard, or perhaps this woman simply didnt take a deep enough breath for him to hear. It doesnt matter. I'm the student, I'm wrong. ...And her pulse ox is still 80.

I miss the IV. The vein is fairly obvious, and I stuck right on top of it, but I think it moved, or I moved, or something. I fiddle around with the needle for a few seconds as I feel the heavy eyes of the paramedic on me. I dont see him, but I know his face is angry. "Out of the way," he says, grabbing the needle from me. He holds the plastic end of the catheter lightly, and with the ease of experience, moves the needle no more than 1/8th of an inch upwards and to the right. The catheter fills with blood. He's in. The silent cabin fills with my embarrassment.

The monitor is all over the place. It looks like V-Fib. I give up on trying to figure out the rhythm. I pick out what I think are QRS complexes and note that they are regular and at an acceptable rate. The patient has good radial pulses which are also regular and in sync, so I dont worry about it for now. I attribute the rhythm to noise generated by the bumpy ambulance.

I try again to evaluate this patient's pain. This is perhaps the fourth time I've asked the same questions, but I just dont understand the story. The chest pain increases greatly with palpation and respirations, it is ten out of ten and "squeezing" in nature. It started this morning during breakfast. I ask questions in short bursts, rapid succession of memorized lists. I revert to standard questions as my mind goes blank trying to think about what the hell is going on. I go through OPQRST in order, without real regard for evaluating the patient's answers or following up on details.

My medic is visibly angry.

I do a stroke scale, which is zero. I manage to palpate the patient's body looking for deformities or bleeding. No deformities, everything hurts when I touch it.

We're finally at the hospital. Stepping out of the ambulance, dejected and upset with myself, I begin to remember things that I've forgotten. I dont have another set of vital signs other than those the BLS crew got before I arrived. They were normal then, but who knows if they are correct or even still valid now. I still dont really know what the lung sounds are. I didnt put the patient on the end-tidal CO2 detector, which would have helped describe her respiratory status. I dont know what medications the patient is taking. They are listed on the BLS run form but I never looked. Allergies? I have no idea.

My report to the triage nurse is all over the place. I admit to her that I dont really know what is going on, and explain the details that I was able to confirm. I have to ask to borrow the BLS run form to report the meds, history, and allergies. I dont even remember the patient's first name.

Back at the ambulance cleaning up my mess by myself, I fight off anger and frustration with the hope that this was a mere fluke. I'm better than this, I know I am. I think I am. My medic shakes his head as he walks past me, saying nothing. I follow him as he lights up a cigarette and try to explain myself. I tell him I'm sorry, that I dont know what happened. I know I was all over the place, I say. I know what I did wrong, I just dont know why I did it. I was nervous, and the lady wasnt making any sense with her story. I hope I dont sound like I'm making excuses. I'm trying to rationalize, to find a solution so that this doesn’t happen again.

My medic blows out a puff of smoke. "I could go from top to bottom with that call, and not say a goddamn single good thing about what you did." He tells me what I already knew. I asked questions too fast, and didnt follow up. I misheard the lung sounds. I "fucked myself up" on the IV by not pulling tension on the skin correctly. I put ALS before BLS. I didnt utilize my resources properly. It was a literal cookbook on things not to do during an assessment.

Sitting in the back of the ambulance as we bounce down the road towards our next posting location, I hang my head low. I am so much better than this on paper. I could sit down right now and write an entire flow-chart for the assessment of this patient, complete with differential diagnosises and their associated signs + symptoms. I look at my note cards from the call. Chickenscratch, disorganized. I was one of the top students in my class, but I'm beginning to realize the truth: this is much more difficult in real life.

I'm going to have to learn how to do this all over again.

Saturday, December 9, 2006


Dispatched for the "unknown," and updated as "man not breathing" we raced to the address.

Down the darkened highway and over the Connecticut river, I was calm and collected. I thought about what laryngoscope blade I would use. A miller this time, perhaps. I used a mac on the last call and that went well, but I want to try as many different ways as possible. My partner and I joked about the possibility of arriving on scene and finding our "man not breathing" standing outside his house, waving to us. It would be awful, we thought, if after all this he turned out to be actually breathing.

An ambulance was already on scene when we got there, and as I walked towards the house the patient was already on his way out. 3 EMTs were pushing the stretcher quickly, a frantic look on their faces. One of them was bagging the patient, another holding the O2 tank. A third was pushing the stretcher quickly towards the ambulance.

"Does he have a pluse?" I shouted to them, immediately feeling stupid. Of course he has a pulse, nobody was doing CPR. They affirm that he does, and tell us the rest of the story: "22 year old male found on the floor by his girlfriend who says he was barely breathing and gurgling. We found him breathing at a rate of 4 per minute and started bagging. Dont have an airway yet. Girlfriend says he has a history of ETOH abuse but nothing narcotic." I thank them, and jump into the back of the ambulance.

I'm a little less calm now. The urgency of the EMTs has rubbed off on me a little bit, and I feel my heart start to pick up pace. I set the monitor on the bench seat and open up the big ALS bag. I try to prioritize my actions. First thing we need to do is get an airway, I think. An OPA should do for now. Next is monitor, IV, and drugs. I'm hoping this is another overdose that will wake up with narcan.

The patient is rolled into the back of the ambulance and when within reach, I look at the pupils. I am hoping for pinpoint, but what I see is only moderate constriction-- if at all. I wish that these things would be more definite. Constriction should be obvious, normal presentation should be universal. I am stuck with an assessment that serves only to produce more questions rather than answer them. Maybe opiates, maybe not.

I refocus, opening the patient's mouth and inserting an OPA as I direct an EMT to continue bagging. The monitor goes on and I see a rate of 110, in sequence with a pulse that I check at the carotid artery. O2 saturation is in the high 90's, lung sounds clear and equal with bagging. Good.

Time for the IV. I get a hold of the patient's arm and move it so that I have full access to the underside. I strap on a tourniquet and to my dismay, nothing pops up. No obvious veins. I rub my gloved hand up and down the forearm, pressing lightly over the AC space. Nothing. I begin to sweat as I pull my gloves on tighter. Maybe I'll feel something if it weren’t for these damn gloves. My partner, seeing my difficulty, looks over my shoulder. "Right there," he says, pointing to a spot on the forearm. "See it there?" I dont. I feel over the spot, it feels vaguely spongy but nothing to get excited about. I confirm again where he was pointing, my voice trailing off as I admit that I cant see it. "Go for it," he says, "its right there." He hands me a 20 gauge needle and I stick the patient's arm at the spot where I was told. No flash in the catheter. I'm not in. I move the needle slowly from right to left, feeling with my other fingers as I go. I cant see anything, cant feel anything. I am fumbling in the dark.

I try again with a different needle in a different spot. Again, no flash. I slowly fan the needle from left to right, hoping. I can feel everyone watching me. My partner, the two EMTs in the back of the ambulance, the frantic girlfriend in the front seat looking back. "I'm not finding this vein," I admit to my partner. I suggest that we go with nasal narcan for now. He agrees. I cant tell if he is disappointed or upset with me. He must be. He saw the vein, I didnt. I cant even get a flash. Another failed attempt. This patient needs an IV, and I cant do it.

I look up from the arm, and notice that my partner already has the narcan drawn up with the nasal spray attachment ready. The intubation equipment is out and assembled, ready. The patient has his clothes removed, and a rapid trauma assessment is already done. A blood glucose has been measured, coming up as normal at 124. ...All things that I should have done had I not been struggling with this damn IV. We're already halfway to the hospital and I've got nothing done. I am overwhelmed with the amount of work yet to do, and the incredibly short time I have left to do it.

I move the tourniquet down to the forearm as my partner sprays the nasal narcan. I think I see a small vein in the back of the hand so I wipe with alcohol, take out another needle, and dive in. No flash again. I press the needle all of the way in, desperate to get this vein. I move slowly, gritting my teeth as the pressure of necessity continues to climb. I move the needle one more time, and there it is. The flash chamber fills up with blood. I let out my breath, not knowing that I was holding it. The catheter slides neatly into the vein. "Ive got the line" I say, exhausted. There is no hint of victory in my voice.

By the time the IV is secured down and I have composed myself, the patient is beginning to wake up. He is confused and slightly agitated, asking where he is, who we are, what is going on. The girlfriend in the front of the ambulance lets out a "oh thank god" and begins yelling back at her boyfriend. "Are you okay honey? You scared the shit out of us! You werent breathing!"

I wipe the sweat away from my forehead and take my jacket off. When the hell did it get so hot back here, I think. I feel like a complete mess. There are angiocath wrappers all over the floor, failed IV sharps strewn about. The IV kit is completely destroyed from me rummaging through with one hand as I fumbled with the IV attempts.

I look back at the patient and try to find a reason for this mess that I've made. I spent almost my entire time with this patient trying to get a single IV. It becomes clear to me that all that mattered to the patient: the ventilations, the narcan, the complete assessment and transport, were performed by everyone else other than me. EMTs and my paramedic preceptor were working furiously around me the entire time securing the necessities, while I sat to the side holding the patients arm and played with the needles. My influence on this patient's outcome was zero.

I need to learn to better prioritize. I need to find a better way to get everything done in a timely fashion. I need to learn how to not depend so much on everyone else around me. Sometime in the near future, I will be expected to be autonomous. I will be the only caretaker in the back of the ambulance, left with no EMT to delegate duties to, no preceptor to watch my back.

I am sobered. There is still so much left to learn.

Thursday, December 7, 2006


Waiting in the Emergency Department for a call today, I watched a 84 year old woman come in with complaints of difficulty breathing and eventually deteriorate over the day from alert/confused to dead.

Her family was there the whole day, sitting in steel fold-out chairs at her bedside, rubbing her head, fixing her hair and watching the monitor intently. O2 saturation, they were told, was the number that would effectively chart their loved one's progress- and the number went downward all day. From mid 90's, to 80's, 70's, and eventually zero.

The family seemed to have an understanding of what was going to happen today, but it was upsetting nonetheless to watch hopeful attention gradually degenerate into helpless waiting. This sister, this grandmother and parent, was a DNR. She had made her decision about this day long ago, when she was lucid, and there was nothing much else to do other than sit and watch. I brought the family coffee and asked if there was anything I could get them. They shook their heads no and thanked me. Everyone here is so kind, they said. They were glad that this is the place that "this" would finally happen. They knew.

When it finally did happen, the reaction was sullen and repressed. One of the women let out a few sobs into a wadded up napkin. An older man held her hand and shook his head. At least this is what she wanted, he said. It was time. She had been sick for years, wavering on a razor's edge between life and death. This is a good thing.

I helped bring her body down to the morgue. The family now gone, we lifted her up by a sheet onto a steel stretcher and attached a curtain above supported by posts on all four corners. Another thick sheet hung over the aperture, providing a square-like appearance that betrayed no clue as to what was underneath. This was better, the tech said, so that people didnt get upset knowing that a dead body was rolling through the halls.

Entering the morgue sent a shiver down my spine. It may have been from the 40 degree chill inside, but it shook me to see the five bodies already there lining the wall each on their own cart and covered in thick zippered sheets. The shapes were amorphous, only head and toe were distinguishable. The tech brought our cart next to an empty spot, and tipped the stretcher sideways so that the woman's corpse rolled out onto the cold steel. No gentle lift with the sheet this time, the family was far from view. The old woman lay there still, her head cocked back and mouth locked wide open as if frozen while taking her last dying breath. She was small, maybe 60 pounds. I helped get her into the zippered sheet, and looked away as the covering was wrapped over her face.

Concealed, this woman that was alive a few hours ago looked indistinguishable from the rest of the corpses lining the walls of the frigid morgue. Removed from her loving family, this old woman was now nothing more than a body: a new task that the morgue workers had to add to their lists. As we rolled our empty stretcher out of the silent room, I heard a groan from the man behind a nearby desk. "Another one, huh? I'll be dammed if I'm going to get out late cause of this."

I dont blame anyone in the morgue. I dont think it is possible to see death like this every single day and be able to maintain the level of respect and somber silence that an outsider might expect. Even the most cataclysmic event, the sharpest of pain is dulled by relentless repetition. We still have to be able to do our jobs well.

I wonder though, how many corpses do you have to see before it no longer matters? At what point will exposure to pain numb me, blunting empathy and revealing only mechanical taskworking? How important is it that I feel for my patients? Does it even matter if I notice emotion, or is my only job to start IV's, shock, and push drugs? How can I continue to do this job for any length of time, and still care?

On the wall of the morgue etched into a wooden plaque is a plea:

Let conversation cease, let laughter flee.
Here is the place where death delights to help the living.

I'm not sure that this would be the same job if I didnt care.

Monday, December 4, 2006


Time passes as nothing happens.

I've been doing shifts of 12 hours each, seeing maybe one or two patients in a whole shift. We are sent as intercept medics for another code, a motorcycle crash, a difficulty breathing-- only to get cancelled halfway there. Another ambulance available. The patient is a DNR.

Instead I spend days joking around with my precepting medics. Talking about calls we've done, calls we may do. I am amazed at the depth of experience that surrounds me. It seems as though these medics have seen at all, rushed to the scene underneath brilliant strobes and wailing sirens, made life-and-death decisions under incredible stress. They've all done it enough so that, to them, these things are now mundane. The bad car crash that happened 8 years ago where two of my highschool classmates died in a car crash and the resulting fire, they were all there.

I cant imagine any of this becoming mundane or routine. I admire these medic's ability to think calmly and clearly in the middle of a stressful call, to recognize patterns based on experience... but I shudder to think that these abilities come only at the cost of numbing repetition. I thrive on the newness of all of this. I want to get better, and I do on each and every call. Every 911 call is a different patient, every patient is a different experience. I am learning by the handful. I hope there never comes a point where I feel like I have seen it all, a point where I no longer care to do something new.

As the hours pass by each shift I sit at the corner desk in the Emergency Department with stacks of notecards, reviving details
to my memory that - still new to me - may save the life of my next patient.