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.


Anonymous said...

The system that you develop and use will ultimately come with time and experience. It's not easy to come right out of school and already be organized. Given time treating patients, recognizing what to do, and more importantly what not to do; things will improve. Before you know it, you'll be going to calls and realizing that this call is similar to those that you've done in the past. You're still new enough at fulfilling the role of a paramedic that every call is a new experience, challenge and potentially overwhelming experience. Time is your friend.

firefighter girl said...

thank you, thank you for your honesty. 6 months out of school, and I still feel this way quite frequently. It's good to know I'm not the only one! They say it'll click eventually, but I'm still waiting for that epiphany, the one where I walk into a room and presto! know exactly what's wrong with the patient. It's a pleasure reading your blog, by the way.

Anonymous said...

Call natures, as reported by dispatch, are usually far out crap. It's not the dispatchers fault. It's the fault of the prolific EMD protocols. Any sort of abnormal breathing is classified as "Breathing difficulty." Pain from the neck to the knees can go out as chest pain. "Uncontrolled bleeding" can be a leaky dialysis shunt.

My personal most hated nature is "sick". Usually, it's some vague thing that someone has been dealing with for three weeks and tonight is the night they called 911. They don't want treatment. They want "to get checked out" or they want some neb treatments, or something equally silly.

Welfare check can be a DOA, cardiac arrest, stabbing, shooting.

"Overdose" can be a drunk, cardiac arrest, suicide attempt. "Diabetic" can be a drunk, OD, CVA, chest pain. Abdominal pain can be obstetric, chest pain, GI bleed, vomiting, TB, flu, ulcers.

It never ends. It would be just as easy to not have any nature and get only a priority and address. Less tunnel vision that way. I almost got burned one day thinking that the nature was the chief complaint. We got called for a stroke. S/S were strokish. It was low sugar. Another went for a diabetic. It was an OD at a nursing home. Too much oxycodone and duragesic. Sugar was fine. Trusting the nature of the call will burn you. Even something like a shooting can turn out to be something totally different in the end.

I don't need to know why PD is on scene. Just that they're present is fine.

I used to think that, when responding as a second unit in, we had some serious stuff to contend with. Sometimes, it's just that two parties in a domestic violence situation need treatment separately. Or that one crew is dealing with refusals but one person needs transport.

I'm sure this isn't new to you, but something to always keep in mind.