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.


Shane said...

It sounds like another learning call. It doesn't sound as though your preceptor handled the call as well as he should have. Instead of taking the chance to tell you that there was nothing good to say about the call, he should have taken the time to educate you without being condesending (at least that's how it sounds like it was). You knew you didn't do that well on the call, there wasn't a need for him to beat you up about it like that. Offering words of encouragement instead of discouragement will often produce better results on the next call. There are going to be calls like this where you're disorganized. It happens to everyone from time to time...including those with experience. Sometimes things happen to distract us, weather it's something in our personal lives or on the call itself. Being a paramedic student is not an easy task. Many preceptors can be tough on their students, and you're expected to perform well. But take this call for what it is, a learning experience that you can reflect upon and now you know a weakness that needs to be worked upon. And yes, when making the jump from BLS to ALS, you do need to learn to rethink your assessment plans and treatment strategy. A great medic can do this in the middle of a call when they need to. In time, you will be there. Keep your head up.

Herbie the Medic said...

Welcome to a bitch-slap back to reality. It happens.

Then again, your preceptor is an asshole. His job is to teach you, not embarass you.

Brett said...

I had the same thing happen to me a couple of times while i was precepting... my preceptor didnt rip me apart the same way... but i fucked up just as bad... It is hard to have the grades that say your gonna be an exelent medic and then almost feel like you left your brain back in the class room when your with a patient... but this too shall pass... and once you get comfortble with putting the book and the street together things will flow...

Brendan said...

Your preceptor should stick to knowing it all and leave the precepting to someone with a better attitude.

Mama Mia said...

It will get better and you will learn how to work the call. Don't be harder on yourself than you need to be. The whole point of making mistakes is so you can learn from them.