Sailing Rough Waters

This is a complicated job.

There is a lot to pay attention to. Nuances that must be noticed in proper respect, concurrent details that need to be handled adeptly and smoothly. There is a significant amount of academic knowledge necessary, coupled with a standard of dexterity and physical skill that must be mastered for proper control. There is a social aspect as well: a smooth tone of voice and calm demeanor that experienced medics develop, employed judiciously to an extremely diverse population of patients. The role is one of leadership, of proper resource control and group dynamics. Coupled with a constantly changing work environment, it is important to learn how to adapt quickly, ride the waves and keep the course true.

These challenges were patently obvious to me as a medic student, as I'm sure they are to anyone experiencing this job for the first time. To be faced with these responsibilities all at once is an incredibly frightening prospect, one that is handled to varying degrees of success by those that make the attempt. It is a difficult thing to face all that must be done, to do so under the stress of a medical emergency and the ultimate knowledge that the buck stops at you.

The other side of the coin comes with slowly encroaching senses of calm and competence. I have been on my own for almost 6 months now, and though my body occasionally runs cold with fear at the presentation of something unknown, I have slowly been finding a groove in which I am capable of running. Most of the calls we run are routine, and I am starting to handle them in an almost lethargic manner, robotic in my repeated assessment and treatment. I am calm on scene, expressionless in a practiced manner of unsurprise and experience. I ask the same questions, run though the same routines, and expect little else. The routine has become just that, and I dare say with this limited experience: easy.

It is a sharp change from my first few months as a paramedic student riding 3rd on foreign ambulances, unsteady and nervous as I wobbled my way through repeated assessments under watchful instructor eyes. I remember taking manual blood pressures, placing the scope in my ears and feeling grateful for a few more seconds to think about what I was going to do next while the needle turned downward through the numbers. I was on edge all the time, nervous and thinking a mile a minute. I had to be, I was being watched and assesed. Criticized and reviewed.

I wonder sometimes, running these lethargic calls of routine low priority, if despite my nerves and mistakes back then, perhaps I was a bit more thorough. When you are a student, chest pain is never muscular in origin. Cold symptoms are zebras in hiding, and tucked deep behind every omission was the critical point. Students are exhaustive in their approach, over-the-top in a way that now might generate a smirk from a more experienced provider. It is newb-ish to remain unsatisfied in the face of the routine, while the rugged and seasoned medic is tranquil as he sits with the same patient, content in all that he has supposedly assimilated.

...But has he really?

I have come to grips with the immensity of this job by riding the waves from peak to peak. I keep the course smooth by handling rough waters with a steady hand, calm as I approach a patient wholesale: sick or not sick. Still, I wonder if sometimes the student might have it right, his boat riding wildly over all over the place, jostling and twisting unsteadily while at the same time experiencing everything that the patient has to offer. My demeanor is much more low-key these days, and as I coolly peruse the patient and his host of complaints I feel like I look more experienced. Thinking back, though, I have found myself now omitting things that I might have stressed when I was back in school. I roll my eyes at complaints more, blow more things off than I used to.

The assumption is that my experience and knowledge thus far has afforded me the ability to understand patient presentation so well that it is no longer conscious thought. ...That I am able to assimilate a host of factors at once in rapid succession, assemble them together, and come to the correct decisions without much fanfare. This is the standard that they set in medic school, and the goal of my repeated trainings and research.

I want to remind myself, though, that a calm demeanor does not mean that I have reached the point. I still make mistakes. I still miss obvious things from time to time. Despite the fact that I am starting to feel more competent on scene, I need to remain fervent in my efforts and unsatisfied in my assessment. I have not been around long enough to be calm, and I should probably sacrifice myself to a few more smirks if it means that I am more thorough in the end.

Call me new, but I want to get this right.

On Being Sure

My eyes must have been as wide as saucers as I looked at the strip. Though I have seen EKGs like these during my training and passed between friends at work, I had yet to have a patient capable of printing anything like this.

We were called for the "possible heart," and though the patient was without complaint and looking fine, the nurses pulled me aside and told me that he had a MI a few weeks ago with emergent angiocath and two stents placed. They were drawing a routine troponin today and got a reading of 7.65. Extremely high, and coupled with the significant cardiac history and ECG changes, I was absolutely sure this was the real thing.

I have taken care of a few critical patients thus far during my time as a paramedic, but the occasion still makes me extremely nervous. The urgency set me off balance a little bit, and though I remembered clearly what it was that I was supposed to do, I felt a slight tremor in my voice and a constant nagging pressure of excitement that pushed me right out of my comfort zone. The stress stressed me.

The nurses took a really long time with the paperwork and I snapped harshly at them. I told them flatly that they needed to hurry up because this patient's heart was wasting as we spoke. I criticized that the paperwork should have been done before we got there, or at least assembled during the 5 or 6 minutes we were getting the patient ready and taking the ECG. I wasn't over the top, but I was most certainly rude and they glared back as they handed me the necessary papers. Without apology we rushed off.

In the ambulance on the way to the hospital with the lights flashing, I reassessed. The patient was without complaint, which I thought was odd, but he also had a history of dementia and had a baseline confused mental status. Besides, I thought, plenty of people feel the "pain" of AMI in odd ways: the absence of discomfort amongst all of the other evidence surely mattered very little. It nagged me though, and added to my stress. I asked myself if there was anything I missing, assessed repeatedly, and took several copies of the ECG. All signs pointed to AMI, and though this presentation is foreign to me in the flesh, I was pretty sure I knew what I was dealing with.

I gave a radio patch to the hospital, forgetting that this was not one of the facilities that allowed EMS to activate the cath-lab from the field. When I mentioned the prospect into the microphone, the answer back was confused. They asked me if I was calling for nitro and asprin orders, which I told them I had already given to the patient. Why the hell would I need to call for those meds anyways, I thought to myself. Stress continued to build.

At the hospital, the triage nurses kept us in queue for much longer than I was expecting. Usually they will usher critical patients right through into the trauma rooms for immediate evaluation, but this time they wanted me to linger as they completed the lengthy registration process. They asked me for the patient's social security number, his entire medical history, meds, and allergies. They took the time to print out an identification bracelet, and attach it to the patient's wrist. I showed the nurses the EKG and told them the story, but they seemed somehow unimpressed. They sent us, frustrated, stressed, and confused, to a low-acuity section of the Emergency Department. When he told us, I unknowingly made a disgusted face to the nurse that my partner laughed about later. "You should have seen your expression," he said.

The story was no different with the nurses in the patient's room, who silently listened to my report and without fanfare helped us transfer the patient to his hospital bed. They thanked me and walked out of the room, as if I had just brought them an earache or hangnail.

Again I re-studied the ECG and rehearsed the patient's story. There must be something I am not getting here, I thought to myself. I needed to know, and decided to talk directly to the doctor. She was busy but I interrupted as politely as I could, showing her the ECG and telling the story as thoroughly as possible. She stopped me when I mentioned the recent cardiac surgery, her eyebrows raised with suspicion. "Yeah," I said, "the cardiac history is pretty significant, which is why I was so suspicious this is an MI..."

The doctor swung around in her chair and typed a few things into a nearby computer. She came up with the patient's discharge ECG following the surgery, which looked exactly the same as the ones I had taken not 15 minutes earlier. She let out a sigh of relief. "It's nothing," she said. "Just residual ST elevations." She explained that some patients retain their ST elevations following cardiac surgery, sometimes for weeks after they have left the operating room. Troponin levels are also notorious for remaining high for lengthy periods afterwards. I didn't do anything wrong, she said, admitting that paramedics need to treat "as if," but in the light of this evidence it is clear that the patient is not having a heart attack.

It was news to me, and my heart sunk as I thought about how I had behaved throughout the call. I was stressed and rude, nervous and assertive. I remember reading in class that ST elevation marked the acute phase of a MI, but new knowledge had surfaced to prove that sometimes incorrect, and my face was red as I snuck back to the ambulance to write my report.

We have learned a lot of things as absolutes in school which have turned out be not quite so in real life. There is so much in medicine that relies on the "not always" caveat, often I am frustrated by the inconsistency and struggle to find footholds amongst endlessly shifting ground. A MI will not always present with pain. An altered diabetic's sugar will not always be low. Sometimes patients with critical conditions will display them, sometimes they wont. It is incredibly difficult to tell the truth sometimes, often it is best to conclude that we truly have no idea what is actually happening, and admit that transport to the hospital is the only viable solution.

Such consistent uncertainty makes it difficult to remain assertive about our decisions and advocate for our patients as strongly as we would like. I am embarrassed that I was rude to the nurses, but at the same time I defend the choice as important to the patient's welfare. For every story like this there is another about a paramedic's urgency buying his patient a critically necessary and life-saving evaluation. We have limited tools, limited knowledge, experience, and education. There is an incredible wealth of what we do not know, and yet we must sometimes stand firm and make a decision, baring ourselves completely for either important discovery or embarrassing ridicule.

Handicapped, we find our way through the dim light by grasping to that which matters most: the welfare of our patient.

Real Strength

Sometimes it is easy to forget what color our uniform is. It is a lighter shade, of a different material, and carries different insignia. We wear pants that have pockets in very different places, designed that way to accommodate the starkly different gear we must carry and use. On my leg is not a baton and leather gloves but rather a small penlight and a pair of trauma shears. My gloves are baby blue and nitrile.

We dress differently from police officers because we are not to be confused with them. Though our occupations may both be loosely considered of the "public service" department, our duties and skills are enough so that our work may be thought of as mutually exclusive. We do not arrest, bully, or enforce. We have very little to do with the law other than those we must abide by, and our concern of illegal activity truly ends at that which may be considered medically relevant. We work side by side with them, help each other out when we can: but we are not police officers.

And yet our identities are so often confused, even amongst ourselves. I overheard a crew the other day, laughing and bragging between themselves about the manner in which they physically confronted an abusive patient. The man was drunk and violent, spitting venom to the best of his faculties and swinging his arms in a whiskey-induced rage. The crew was proud to say that they handled him swiftly and with the efficiency of a trained force. One EMT grabbed the left arm while the other grabbed the right, and the man was quickly removed from his footing and brought down hard onto his back. He was restrained with a knee in his chest as the ambulance crew tied him down and sniped with comments of their own. The man was antagonizing the crew, and they were proud to say that they didn't take any shit. He got one chance and then down he went, they said.

The story is exhilarating. Fun to tell and fun to listen to, it brings to mind a sense of the "street tough" mentality that many urban EMS'ers aspire to. The story goes that we must be tough, we must remain firm and hard in the face of antagonism. To be compassionate is to be weak, and to give too many chances invites further insult. Subscribers to this attitude wear their choices for all to see. Sleeves are rolled up high and at the bicep. There is often an EMS badge, and leather gloves tucked into the back pocket ready for use. They walk differently, talk differently, and - as it must be - think differently about what this job is about.

But we are not police officers. Though I am hardly on my own an authority on the standard of our practice, I think many would concede the point that our approach is on the outset markedly softer. We don't demand answers but request them. Often we will listen instead of talk. We work hard on our facial expressions so that they do not falter even at the most ridiculous scenario, at the most embarrassing confession. We are worthy of trust because we are steadfast in our compassion, free from judgment, and always, always willing to help. Such is the purpose we serve.

The attitude of the quasi police officer EMS worker is one of boisterous ego. These people are proud to admit that they do not take attitude from their patients, that they elicit their answers by demand and exude an authority of medical necessity. They are the bosses of their ambulances, and will do with their patients what they like. The patient is in their care, and must submit in the name of proper medical care. I have watched this happen. Patients getting bullied around in the back of ambulances, forced with the power of supposed medical urgency and relegated to submit to unnecessary brutish and judgmental attitude. These patients sit on the stretcher, scared and submissive. The EMS worker sits on the bench, proud of his job and convinced of his importance.

Strength does not derive from the volume of our voices. Authority does not come from the issuance of a demand. Our "street cred" will not be determined by our ability to tackle a patient to the ground. No, real strength, real ability is much less flashy. It happens quietly, in conversation between a medical professional and a frightened patient. It happens when a provider will sacrifice for the benefit of those in need. When he fights off his frustration, quells his qualms with the unpleasant.

As often as I have witnessed brutish behavior in the backs of ambulances, I have also seen incredible feats of strength in quiet and uncelebrated patient assessments. Providers willing to forgo their immediate ego for the greater good, listen to an entire story and speak calmly despite an escalating situation. People willing to elicit transports to the hospital by leveraging their own humility, admitting to a lack of knowledge and ability in order to make clear the importance of seeing a doctor. People who sacrifice everything that they have so that the patient will get the best chance at what is available.

This is real strength. Though it may go unnoticed by so many, hidden and overwhelmed by the stories and tales told by the loud and flashy, it is important to know that those who are very good at this job are often also very quiet. Mildly they will accept their victories and walk without a word past the opportunity to boast.

Self assured and confident in the knowledge of their own success, they wait for their next call.

Bad Day

A good friend of mine, also a Paramedic, commented to me the other day that he would "rather be pumping gas" than doing the job that he is doing. I feel his pain.

Frustration with this job tends to peak and trough from day to day. Though we work at different services, our feelings about where and what we do are often similar, and to be honest there are times that I too feel like I would rather be doing something as straightforward and bullshit-free as pumping gas. It is on the other side of the fence, but sometimes you have to admit: the grass is pretty green.

Gas pumpers know what to expect from their job each day. Get dressed in the uniform, come in to work, and you will be pumping gas to people who do not respect you and will treat you like garbage. So far, sounds fairly similar. The difference here is that as a gas pumper, you know and expect this reality. A gas pumper has no delusions that someone will recognize a job well done, that one tank is truly different from another, or if his disposition matters from day to day. The game plan is clear: this job is close to the bottom rung and there is no real hope of anyone believing otherwise.

Though it doesn't seem all that green over there, consider coming into work with higher expectations, but the same reality. Build up a job in your head so that you believe that it matters. Believe that hard work will pay off, that determination will lead to success and tangible benefit. ...An environment where excellence is placed on a pedestal because without excellence the job cannot properly be done. Put extra work into the job so that you believe you are capable of more than what is normally expected, present yourself as a professional deserving of respect and believe it.

...And then have someone spit in your face. Not actually spit in your face, although that has happened as well, but in a manner much more insidious. Crumple up your hard written run form. Toss your opinion to the side. Smirk when you look for a zebra, laugh when you think you may have found one. Look right through you as you as you attempt to give a report. Interrupt. Criticize harshly with incorrect information, and then carry on as if nothing happened when the truth is brought to light. Suggest that a protocol is a "guideline" when you bring up detail, and call it "protocol" when you bring up leniency. Punish good behavior and reward bad. Screw up your paycheck and expect you to suck it up with a smile. Call it a symptom of being "new" when you work hard, when you do things right. When you give a shit. Suggest that experience is a substitution for perseverance. Leave for you a mess in the ambulance, a pile of laziness and open sharps. Talk a big game about "patient care" and then behave like a police officer on scene. Listen without listening. Talk without listening. Care more about the blood than the mechanism, more about the glory than the truth. Put a premium on transfers and a damper on medicine. Believe that education does not matter. Insist that privilege be given and not earned. Hire an 18 year old with no experience to do the same job.

It is painful to look around and see people who used to be like me. People who were once excited with this job, who looked at it as if it were a branch of medicine and not a path to a paycheck. People who let the above paragraph become them. It would be unfair to say that everyone is like this, but I can write with absolute certainty that the percentage is far too high.

It is enough to suck a person in. Like a black hole of overwhelming gravity, the could-be realities of this work are hard to avoid as we spin around the edge from day to day.

I love this job. But I'm glad I'm getting the hell out.

Potato Chips

Called for the allergic reaction, I am greeted at the door by a small child. He looks at me sheepishly, kicking his right leg nervously and looking at the ground. He hands me a scrunched up piece of paper and without making eye contact says "mommy told me to give you this."

I unfold the note and read it at the doorstep.



I tell the child to lead me to his mommy, and he does. Around the corner and up the stairs we find a woman sitting on the floor in the bathroom. Her face is extremely swollen, puffy and bloated. She has a thin body, but her head looks as if it belongs to someone else entirely. Looking up at me from the floor she is alert and anxious, wheezing with each breath.

I drop the red bag on the floor and pull out the yellow pack. Without words we we are at work, my partner is setting up the oxygen equipment. I draw up the epinephrine and push it into the woman's arm.

Her relief is almost immediate.

**

On the way to the hospital, priority two, the woman looks at me with a profoundly thinner face. She is still thanking me, thanking me, thanking me. Her lung sounds are full and clear, skin with a little redness but otherwise in good condition.

Potato chips. She had never eaten that brand before, and likely never will again.

"I shouldn't be eating those greasy things anyways," she says.

Tuesdays and Thursdays

The calls keep rolling in, and as I gain experience with this job and start to begin to feel like I can perhaps have an inking of comfort with what I do, I have been subjecting myself every other day to a completely different experience: school.

Tuesdays and Thursdays are school days. I am on campus all day, in the lecture hall and the lab studying Chemistry and Physics. The material is foreign to me with it's dizzying array of equations, formulae, and mathematical logic- starkly different from the Monday, Wednesdays, and Fridays I spend in the fronts and backs of ambulances. The two efforts seem to require different parts of my brain. Half of the days I think how I have been trained, with what information I have gleaned from experience on the subjects of signs and symptoms. The other days, I have to warp and contort myself around concepts that I have never seen before, about math that I barely recollect in orientations that I struggle to comprehend. I hate the math. I have never been very good at it, and to do well in these subjects means to grind my way through mountains of practice problems, gritting my teeth as I calculate, erase, and re-calculate solutions.

Mastery is coming with time, but the work is harder because of my distaste for it. It took a lot of effort to learn what I know as a paramedic also, but the struggle was eased by my interest. I always kept my medic book open a little longer than required, spurred onward by a thirst for the knowledge. With this science I am taking, though, I am always glad to have finished: slamming the book covers closed with a definite thump. It is a hoop to jump through, and as of late I am becoming more entwined with the idea that I am being tested not on my scientific ability, but on my determination. This work comes easy for some, but for most of us I have come to believe that it is simply a matter of pressing forward, putting the work in even when it is nothing other than horrible drudgery. Those that rise from the dust of this pre-medical schedule do so because they are hardened warriors: eyes fixed towards a goal, mouth hardened, hands calloused. "Throw at us what you will," they say. "We're coming anyways."

My days in the ambulance test me as well, but I have come to find the time as a relief. I am glad to have this experience, this window into medicine that shines enough light into the tunnel so that I can do for a little while longer without sight of the end. The challenges I face as a Paramedic are exciting, tasty glimpses into a bounty that lays ahead. They are tantalizing, and with each patient I leave in the hands of a higher level of care my determination grows. I still groan when it comes time to do my schoolwork, my stomach aches and I loathe every minute, but I will not give up.

My eyes are fixed.

Aztec Gods and Duragesic Patches

Not long ago, Peter Canning wrote about the automatic blood pressure cuffs in the hospital emergency departments. He referred to them, a bit tongue in cheek, as "all-knowing Aztec gods:" capable of discerning the absolute truth of all blood pressures. Often times our manual blood pressures will come up one thing, and upon presentation in triage, the manual machine will argue against our competence and promote an entirely different view of the patient's pressures. When forced to make a choice between the two, the triage nurse almost always writes down the machine's answer. ...Sometimes with a bit of a "yeah, right" look on her face as we stammer and argue our case.

It doesn't stop at the blood pressure machine though. Often the emergency department is an Aztec god in and of itself. We will roll in our patients on our yellow stretchers, attached to wires, cables, and tubes- yards of pink ECG paper dangling from the machine. We list signs and symptoms, pertinent negatives and whatever else to the triage nurse, then submit the patient for review. The nurses will stroll into the room, doctors usually soon after. They will re-do all that we have already done, scratch their chin and order further tests. Usually within a few hours, the results are spit out from the black box and a decision is made. We were right, we were wrong, what were we thinking. Most of the time we were right in our clinical impressions, but with a few patients it could go either way. Those critical ones where everything is crashing down in front of our eyes, where we can do little else than the basics and look for the obvious, we bring them into the brightly lit rooms and sweat it out as the verdicts are cast down from the doctors above.

I envy doctors for the time they have to consider the patient, the tools and tests they have at hand, the extensive educational foundation on which they stand. It is often that I feel as if our portion of the patient care is sloppy and convoluted. We sweat in our vaguely police-looking uniforms, struggle with inconvenient circumstances pressured with time, and are often lucky to get everything done by the time we reach the hospital doors. Once we roll into the emergency department, everything cools down and slows. Experienced and knowledgeable voices peruse what we have been able to assemble and ascertain, calmly asking pointed questions and sorting out the mess. I often walk into emergency departments with critical patients, feeling as though the first task in the trauma rooms is to re-arrange and re-do what I have done. Make sense of the clutter.

I brought a man to a local emergency department last week, confused with a blood sugar of 600. He didn't know where he was, what his name was, or what needed to be done, but he adamantly refused to go to the hospital. It was a battle in his living room, repeating my calm logical necessities to this confused man who could barely compose himself enough to look me in the eye. It took a bit of skill, I think, a bit of experience with this situation to get the man to agree to go to the hospital without a fight. I did it, though, and I was happy for that. He was still confused, and on the way to the hospital (maybe a 3 minute trip) I did the basics from my established routines. IV/Monitor/O2. He was an insulin dependent diabetic with no venous access, but I got the line.

Still though, I wasn't exactly sure what was wrong with this guy. He is sitting quietly, almost falling asleep on the stretcher, while I am thinking about DKA. I wonder if I would be able to see the result of his potential metabolic acidosis with the ETCo2, so I put it on. The number reads 64, and his respiratory rate is 10. Huh. I coulda sworn he was breathing faster than that. The hypercapnia could be the acidosis or it could be his hypoventilation. I take another look at his perscribed medications:

Novolog
Ambien
ASA
Albuterol
Duragesic Patch

The last one stands out like a sore thumb. My EMT partner wrote the list down for me, but I read it and I swear that wasn't on there last time. We are rolling into the emergency department parking lot, and a light bulb goes on above my head. Confusion. Lethargy. Hypoventilation. Perscribed narcotics. This patient is overdosed on opiates! The pupils aren't pinpoint, but they could pass as "small," and I've seen people aepnic on herion with pupils even bigger.

My partner is opening the back doors now.

I curse. Its too late now. We roll him in to the emergency department, and the patient is looking more and more like an overdose with every second that passes. The nurses think so too as they enter the room, listening to my report. "Oh, he's high. Look at him," one of the nurses says. It is so obvious. I was distracted by the argument to get him go to the hospital, the high sugar, the tough IV. Maybe if I only had another 60 seconds in the back with this patient, or had put the pieces together earlier...

They disconnect him from our wires, pull him over to the ED bed, and send a little bit of Narcan through my IV. Almost immediately the man's eyes become more clear as understanding spreads across his face. "Oh boy," he says. "I think I messed up my dosage."

He had two patches on instead of one.

Two Patients Part Two

Priority one across town for a "general sick call." We arrived just in time to find the 62 year old man propped up in bed and finishing his supper.

Firefighters already on scene were taking the man's vitial signs, so I took a report from a family member in the hallway. The patient has been feeling "tired" for about 3 weeks now. He is normally fairly active, but as of late he has hardly found the energy to do much more than sit in bed, watch TV, and read. He doesn't have any particular pain or discomfort, no shortness of breath, no problems with appetite, fluid intake, or bowel movements.

I try to scare a complaint other than "tired" out of the story, but despite my probing questions there truly seems to be little else. The man smiles at me and thanks us for arriving so quickly. He apologizes for having to call 911, "but this weakness just wont go away."

The firefighters report the vital signs to me as BP 90/50, HR 60, RR 20. The man looks a little bit pale, but there is nothing that really screams "sick" about his presentation. We get the stair-chair and wheel the man out to the stretcher, telling a few jokes along the way.

Mostly out of boredom, and partly because of the reported blood pressure, I decide on a whim to work the patient up instead of passing off to my BLS partner. It is a 10 minute drive to the hospital, so I decide to do everything en route and we start on our way.

Sitting on the bench seat I take another set of vital signs.

...And then I take them again to make sure I heard right. The blood pressure is more like 76 over 30, and the heart rate rate, well... I'd better put him on the monitor.



I stared disbelievingly at the monitor for a few seconds, turning my head back and forth between the patient and the yellowish screen. The patient looked fine. ...Like anyone you might see walking down the street. And yet the numbers told quite a different picture. Heart rate hovering between 28 and 32, a dangerously low blood pressure.

The patient sat on the stretcher looking at me. He had asked for a few extra bath blankets, and there he was, buried in cloth pulled snug to his chin, watching as I reached for the yellow medication bag.

He clears his throat. "Is there something wrong?"

Two Patients

I am looking at two different patients. One, expressed through the yellow glow on my Lifepack 12, seems well. The other, sitting in front of me, is the sickest person I have seen in a while.

The woman sitting in front of me is the picture of disease. She is pale and thin, sweaty and doubled over in respiratory distress. She is an IV drug abuser, and it shows. Her arms are bruised up and beaten, veins scarred and driven deep into the depths of her pale, washed-out skin. She is heaving with every breath, textbook in her tripod position. Her lips betray a bit of blue, and her lung sounds wheeze harshly on both her intake and exhaust of shortened breath.

All the while my monitor sits beside me, still and calm. Without a trace of anxiety, the numbers coldly spell out facts measured through colored wires. The oxygen saturation sits pretty at 93%. Heart rate 100. Blood pressure 138/72. End tidal CO2 is 52 with a slightly sloping waveform. The numbers are enough to raise an eyebrow, but the stronger point seems to be the disproportion between the patient and the monitor. I briefly consider tracing the wires to make sure they don't detour to some other, less distressed patient.

The woman doesn't give me much time to think about it. She grabs my leg and squeezes tightly. "Do something, do something," she pleads. Her eyes are sunken in and sickly, but her demeanor is earnest in every way. Everything I have learned and everything I have seen tells me that this patient is sick, sick sick. ...And yet my monitor quietly submits it's objection.

We are in the back of the ambulance and my EMT partner is sitting near the airway seat, gloves on and ready for me to make a decision. For a moment we sit there, her watching my head turn back and forth between the patient and the monitor. I am thinking about paramedic school. The patients I have seen and the advice I have been given. What lesson applies to this situation? I remember it clearly: "treat the patient, not the monitor." The advice seems plain, and I remember the concept sounding reasonable and legitimate. ....But the saturation is decent! She's not even that tachy! The waveform is barely sloping!

I look at the patient one more time. She is looking really sick. I let out a sigh, and ask for the yellow medication pack. My EMT sets to work, following the predefined path of the critical patient that we have both seen before. We are treating her as such, I have decided. In goes the epinephrine, 0.3mg of 1:1000 concentration, IM. Continuous neb treatments as I search enroute to the hospital for IV access. I cant find any. She's used all of her veins up.

By the time we reach the hospital, the patient has changed much more than the monitor has. Heart rate has come down maybe 10 points, the oxygen saturation up 5% or so. Her end tidal is hovering around 48. The patient, though, is a different person. She no longer looks nearly as sick, and while her sticky sweat still covers pale and sickly skin, she manages to irk out a smile. Her lung sounds betray diffuse wheezes, but nothing like what I was hearing before.

At the hospital the nurses and docs look at me, puzzled. Even the code summary from the objecting lifepack 12 argues against my case.

"But doc," I argue, "You shoulda seen her!"

Rapid Sequence Immobilization

Aided with adrenaline and substances yet unknown to us, the man flexed his substantial muscles and screamed against his bounds. He let out anguished yells, cursing at all of us as we worked to hold him down. He was a big man, and we were all sweating.

My partner and I found him semi-conscious in the grass of a local park about a half hour before. He was lethargic when we walked up to him, his eyes distant and glazed over in some kind of dreamy confusion. He lay about 10 feet away from a twisted-up bicycle from which witnesses said he fell while riding through the park. They said that they knew him personally, that he is a "great guy who is always here with his family." Someone said that he had a history of seizures.

My partner glanced in my direction, and we agreed without words. I put both of my hands up towards my neck and he nodded, heading towards the ambulance for c-spine equipment and the stretcher. I did a quick assessment while I waited for the rest of the gear. No visible traumatic injuries, lung sounds clear, strong radial pulse at about 100, PEARRL. Blood sugar is 200. When my partner came back with the equipment we worked together with firefighters to roll the large man onto the board, securing his head, torso, and legs with snug straps. My partner and I bent our legs and then straightened, grunting as we lifted the massive package up to the stretcher.

In the ambulance the man began to come around. He was confused still, asking repetitive questions and often making statements that made no sense. I did my best to get a history and some background information, but the man was a poor historian at best. I got a full set of vitals, plugged in the EKG, started an IV, and told my partner we could go. The man remained confused the whole way, and despite my reassessments and double checking, I found very little that swayed me from a routine clinical impression of postictal-related altered mental status.

The man began to get a little more agitated as we rolled down the ED hallways towards the triage desk. He lifted his hands up towards the c-collar, but I was able to gently guide his hands away and talk him down. He listened to my words, agreeing momentarily but again reaching towards his restrictions a minute later. I told the triage nurse that it was probably only a matter of time before the patient lost control and ripped himself off of the board. He had that look that we have all seen before: chaos about to happen.

It did happen. About 5 minutes after getting him over the hospital bed, the patient began to lose control. Quiet requests turned into agitated demands, and then into senseless screaming. He pulled his head out of the blocks, the tape snapping and velcro ripping, all the while pulling at the backboard straps and rolling from side to side. The nurses and techs tried to calm him down, offer comforting advice through smooth tones, but the patient would hear none of it. He was on a one-way path, and would not come back. My partner and I jumped in to help, and even with our numbers, we struggled.

The doc strolled in casually, his white jacket crisp and clean, separate from the mess that was rapidly overtaking the small ED room. He asked for the story, and I told him while holding the patient down: a few brief details and a couple questions answered. He tried a round of Haldol and Ativan but it was without effect, and after another 10 minutes of fighting, the doctor casually waved his hand towards the intubation tray. The nurses, anticipating this decision, already had everything ready.

Rocuronium was sent through my IV, and within seconds, the patient was flaccid and docile. It was as if someone had found the patient's OFF button and finally decided to throw the switch, ending almost instantaneously the aggression we had been fighting for the past 20 minutes. Easy as pie, the doctor slid a miller blade into the open mouth, lifted, and passed the tube. It was good, of course. Everything was good.


I met up with the doctor later. The toxicology reports had come back, which indicated that the patient had extremely high levels of PCP in his system. It looked like the patient had smoked some of the drug before his bike ride through the park, and collapsed when the effects hit their peak. The potential trauma was still an issue, but the patient was not. He lay across the hall, silent except for the sound of the mechanical respirator performing it's windy functions.

The doctor and I discussed the drug a little bit when I made a remark about RSI. I admitted that I was glad the patient was calm with me, because I wouldn't have been able to restrain him in the ambulance if he had lost control then. The doctor was shocked to hear that we didn't have the capability to RSI patients. He stared at me, as if I were joking.

"So basically," he said, "either the patient is dead, or you are not going to get the tube?"

I admitted that this was probably the case for much of the time.

The doc sat back in his seat, thinking for a second.

"Jeez. You're right. Good thing he didn't come 'round till you got him here."

Biggest Drill Ever

People who have done this before at Katrina, and others who have had experience with the military all admit that this is the way things tend to go. It was new for me, though.

Nine of us received phone calls at about 0730 on Sunday morning, just five hours after many of us got home after a long shift at the concert venue. The message was direct, but hollowed out and filled with mystery: get up, get packed, expect to leave within the next couple hours. It was chaos from the get-go, as most of us had no idea what to pack, how to pack it, and what might lie ahead. Groggily we all asked whatever questions we could muster when the phone calls came, but the supervisors calling didn't know the answers. All we know is that you are heading out today, probably soon, they said. Plan for seventeen days.

I got up and packed whatever I could think of, wondering if this was a good idea. I had already said that I would go, but this morning I wasn't quite so sure. I packed seven pairs of EMS pants with matching uniform shirts, loads of underwear, socks and various t-shirts. I remembered a rain suit and my MP3 player, a camera and the cell phone. I ran to the store quickly and bought granola bars and travel-size toiletries. When we finally got the call to go, I almost walked out of the door without my boots.

It is a scary thing to respond to a call like this. The storm had not yet hit, and none of us had any idea when, where, or how hard it would. On the TV they were showing frightening looking images of circular swirling clouds in the Atlantic ocean, arrows of potential paths swinging westward and slightly to the north, fading out in uncertainty around landfall. At the airport we huddled around together and nervously chatted about what may lay ahead. There were a few with us who had done this before, and we relied on them for whatever information we could get a hold of. As we sat and waited for our flights a few people told stories of their time at Katrina, horrible and haunting. Some of their experiences made my bones chill.

Through a layover we ended up in San Antonio Texas at about 0100, where a bus driver waited for us with a sign that read FEMA EMS DISASTER RELIEF. Stepping out of the airport was like walking into a sauna. We all staggered a bit at the heat, even at this early hour the air was saturated with thick humidity and almost hot to the touch. We weren't used to this at all.

The driver took us to a base of operations about 20 minutes away. It was obvious when we had arrived at our destination: idling ambulances lined the streets for blocks surrounding the building, which sat aglow from generator-powered overhead lights. There were hundreds of cardboard boxes filled with supplies in neat stacks at various locations outside of the building, and workers walked quickly from pile to pile with clipboards and packages like worker ants sprawling the terrain. The place was alive, and everyone was busy.

We got a quick briefing from one of our administrators, who had taken an earlier flight down. He was sweaty and looked tired already, having spent a number of hours preparing hundreds of brand new Nextel phones. Sitting back from his work for a moment, he informed us that we didn't know when we would be moving out, but it would probably be in a few hours. The main base of operations was at Kelly Air Force base, an hour away, where we would receive further instructions. Until then, he said, we should grab a spot on the floor and try and get some sleep. On the floor? It was concrete with a thin carpet, but we were exhausted. I bunched up a sweatshirt for a pillow and was asleep within minutes.

It was a consistent theme throughout our deployment that information would be both set at a premium and low in supply. From nights on the floor to travel arrangements that changed as sure as hours passed, it seemed rare that our group heard about plans that would actually occur, reliable news about the hurricane's path, or informed truth about large-scale decisions. We were all used to working small-scale: champions of the backs of our ambulances and the source of decisions to be made on scenes. The patient laid out before us in clear presentation of the problem at hand. It was strikingly clear on our first night of this deployment, though, that we would not be experiencing the familiar. Our view was instead from the bottom-up, clouded by rumor and indirect contact with the management, and while we listened and obeyed, the decisions brought down made little sense to us other than that they came from authority who presumably knew better. Uninformed, we entrusted ourselves to the greater machine and blindly did as we were told.

We were awoken twice in the middle of the night from our snoring slumber, asked to perform a few minor tasks, and then let back to bed. Later in the day we were brought to the air force base, packed 6 deep in the back of a modular ambulance along with piles of suitcases. It was sweltering hot, and we sat quietly as the loaded ambulance labored through unfamiliar streets. We all remained in good spirits though, uncomfortable but inspired by the magnitude and meaning of our presence.

We arrived on the outskirts of the base, greeted by an incredible view of ambulances that had already arrived. They stretched off in the distance to vanish points, row after row. I have never seen so many ambulances together in once place. It was difficult to appreciate the view through my camera lens, but I made an effort:


After a brief wait at the staging point, we were brought by bus to another section at the base where we were to stay. It was an extremely large multi-purpose building, expansive on the inside with carpeted concrete floors and pillars spread out in grid fashion. We were given fold-out cots and a blanket, and told to settle down where we liked. Our group picked a spot in the corner, adding a margin of privacy by stacking the cardboard cot boxes in a makeshift wall in front of us. Many others followed suit as they arrived, and in a number of hours the building was a maze of sleeping EMS workers, cots, boxes, and tables.


It was here where we spent the rest of our deployment. We were there for two days, waiting on instructions to move south that never came. FEMA supplied the some 700 EMS workers who responded with ample sleeping supplies, hygiene kits, and food. Information remained spotty and often incorrect, while rumors were constantly passed from camp to camp about what our fates might be. At night when the lights were turned down, flipped-open cell phones were visible across the room like stars as workers searched the internet and friends for updates on the storm's path. We played cards, watched DVDs on laptops, and slept as much as possible.

While we waited, the storm crept onward towards Mexico, never swinging north as so many had feared. Word was passed around about the diminishing storm categories, from five to four to three to one.


On Wednesday a large group circled around the center of the room to hear news of our dismissal. Representatives from FEMA and Texas thanked us for our response and apologized for our inconvenience, giving the official word that we could all go home. Everyone clapped, a bit disappointed for the lack of action but ready to leave.

Our group left in a caravan of ambulances at 0500, ready for the 15 hour trip from San Antonio to Gulfport MS. It must have been a sight to see our 18 ambulances rolling down the road, filled with EMTs and Paramedics unshaven and exhausted looking. We emptied our fuel tanks twice, each time gathering at truck stops and joking around, taking photos of our group in front of ambulances that used to be part of our own divisions. Some people were extremely frustrated with the situation, becoming loudly vocal about their discontent from time to time. One group from another division taped signs to the back of their ambulances reading "Lied 2" and "Corporate Puppet" in lieu of our missing license plates. Most of us rolled our eyes at the complaints, though, and the experienced members of our group commented that such frustrations were absolutely typical of large operations like this one. The time-honored military motto of "hurry up and wait" was mentioned often, and despite the frequent frustrations, most of us remained in good spirits.

Towards the end of the drive we crossed through New Orleans and the surrounding areas affected by hurricane Katrina. I had never been there before, but was shocked to see how much of the damage still lingered even as viewed from the highway. We passed countless homes that remained crushed and broken, roofs folded in and windows smashed. I rode with a medic who was in this area for the storm, and he pointed to the left and right as we drove through, talking about where the water was and what the terrain looked like then. We drove over a large overpass which he said was almost taken over completely by the onrushing waters. Looking over the now dry and damaged terrain, it was difficult to imagine the forces that caused so much wreckage.

Many of us, myself included, were at least in some small way disappointed that Hurricane Dean stayed so far south. We wanted at least a little bit of "action," and wanted to charge into broken areas and work. Seeing this destruction, though, firmly grounded us. The extent of what a hurricane can do was never palpably clear to us, and realizing what disaster was avoided, all we could do was thank god nothing like this happened again.

We took flights the next morning out of the south and back home. On the way we discussed FEMA and the response, whether we would come back on the next deployment. Just about all of us said we would. Though the hurricane did not hit US land, this was in effect the largest drill FEMA has ever conducted, and with the experience under our collective belts, we each look forward to coming back and doing it better- next time.

Dean

Hey folks, sorry its been a while since I've posted, but it is going to be even longer now. I got word last night several people from my company including myself are getting deployed to Texas to help out with the potential aftermath of hurricane Dean. It is still unknown whether it will actually hit Texas, or what kind of damage it will cause if it does, but FEMA is trying to get us down there ahead of time, and my flight leaves today at 3:00 for Atlanta.

I'll return with lots of photos and stories.

Protocol in the Pits

In addition to the city, the company I work for has a contract with a large music venue nearby, and employees often get the opportunity to do "standbys" at the various acts that come through town. I picked up one of those shifts recently, a large rock concert consisting of multiple bands over the course of the day. Concerts like this are always a little bit crazy, packed with people fueled with alcohol and drugs, spurred along by the music into what often becomes a violent frenzy. This time was no exception.

It is a large venue, but people pack the place so tight that it is often hard to move. We carried portable radios on our shoulders turned up to maximum volume, but it was still difficult to hear the various dispatches over the guitars and yelling. Sometimes you would know to listen to the radio only because your partner had heard it by chance, and we would see eachother, head titled to the radio and hands cupping the speaker: hoping to hear. Eventually we would catch the dispatch, hearing a crackled "section 800, man down" before we would start moving.

Every response carried with it a little bit more adrenaline than usual. We pushed our ways through the crowd, yelling "move! move! make a hole!" as loud as we could. People would turn towards us with a little bit of "who do you think you are" look on their face, and then recognize, moving out of the way as quickly as possible. Sometimes people would take it upon themselves to charge ahead of us, clearing the way bully-fashion in a spontaneous effort of layman heroism. Each time they would smile at us, satisfied, and thank us for doing our job. We thanked them, too.

We carried a lot of people out of the crowds. A lot of people too drunk to stand, vomiting or passed-out, unresponsive or only slightly so. They open their eyes lazily to reveal hugely dilated pupils, often denying having a single drink all day. "Nah man," one patient slurred. "I've been straight all day. I dont drink. Much. I only had twelve." It was impressive. Beers were going for seven fifty apiece.

There was lot of trauma, too. Mosh pits would form along the edges of the cheaper seats, large circles where hyped-up fans ran around aimlessly, pushing and slamming into eachother as hard as they could. We stood and watched for a while as people would run into to the pits for 15 minutes, returning with cuts on their faces and bruises on the arms: smiling like crazy. There are unwritten rules about mosh pits, I learned. If someone falls down, everyone helps pick him up. You dont hit in the face and you dont throw punches or kicks. It is not about fighting, I was told, it's an organized expression of anger and rebellion to go along with the music. Sometimes there were fights though, and we would watch till they ended, carrying out those injured on wheelchairs or stretchers with c-spine equipment.

We were watching one of the bigger bands play when we were dispatched to another "man down" in the middle of the theater. This was probably our 10th of these dispatches, but we charged at it with energy nonetheless, pushing through the packed crowd to find our patient. We found him, in the center of a clearing of onlooking people, slumped on the ground and not moving. Two other crews, having heard the dispatch, showed up as well. We ask if anyone saw what happened, and someone stepped forward to tell us that he was crowd surfing and dropped "right on his head." He hasn't moved since.

We send someone to get the stretcher and c-spine equipment, which was stashed nearby. Someone grabs manual c-spine. I get on my knees in the muddy grass and lean down towards the patient's face, and he opens his eyes when I yell to him over the music. He seems a little lethargic, but is able to answer my questions slowly as he fights back tears. He is maybe 20 years old. His back hurts. He doesn't remember what happened. We get what information we can, and when the stretcher arrives we board and collar him, strapping him tightly to the rigid equipment. Again we push through the crowd, this time towards a waiting ambulance. On the way the patient wont open his eyes. I brush his eyelids lightly and see no response at all. My partner puts his hand on the guys chest to check for breathing, giving me a worried look. He is breathing, but completely unresponsive. We move a little faster.

We pass the patient to the waiting ambulance and we give our reports. We don't know much. We tell the story relayed from the witnesses, the patient's name and age that we got from a friend, and admit that we couldn't do very much of an assessment in there. Too loud, too chaotic. The receiving crew thanks us, hopping into the back of the ambulance to do their work. We grab their stretcher in return and head back into the crowds to find more patients.

We took out twenty-two that day.

With all the excitement and bustle of the concert, traumas run and drunks shuttled, everything seemed to settle down for the last few main acts. It was as if everyone took a deep breath and admitted that this is what they came to see, and there would be no more foolishness. We didn't take anyone else out after that point. Instead we settled down, as close to the stage as possible, and watched the last of the show.

We had great seats.



**

At the end of the shift we returned to the main office, sweaty, exhausted, and covered in mud. We exchanged stories from the day. There were a lot of amusing drunks, and angry ones too. One of my friends got punched directly in the face by a patient while he was transporting to the hospital. He said he saw stars, and then jumped on the guy with the help of another crew to restrain him.

I met up with the crew that took our crowd-surfing injury. The paramedic frowned as I asked him about it. "The guy had no neuros below the waist," he said. "The doc in the trauma room said that there was a T-9 fracture and that it looked pretty bad." The patient was intubated in the ER and taken upstairs. "They weren't sure, but the docs were pretty pessimistic that the kid would get anything back as far as motor control."

I was shocked. What? A spinal fracture with life-altering neuro damage? The kid was just one of many, a repeat of a ton of calls that we did that day: routine in both mechanism of injury and treatment provided. We did a good job protecting the spine, but only because we did that for everyone, routinely.

Retrospect is an amazing thing, but it felt good to look back and know that we all rested firmly on protocol, and followed the guidelines where they mattered most. Our treatment was solid, backed by everyday caution and routine methods. We did the right thing for this patient despite the fact that we had no idea how important those things would turn out to be. A little bit scary, but I guess that is what protocol is for.

I looked through the schedule when we got back, and signed up for another concert later in the summer. What a shift.

Restraint

"Second unit in, for a psych??"

My partner was incredulous. What a ridiculous call. This facility always has a ton of psychs in it, it's like a nest where they are all kept. They are always fighting with eachother, halfway trying to kill themselves, or looking for attention. To tie up two ambulances on a call like this seemed like such a waste, and we both thought about all of the better things we could have been doing on our lights + sirens response to the address. Surely someone, somewhere in the city was having a heart attack (or something!) and would be denied our help because of this.

We followed the other crew up the stairs and down the hallways, alternating between grumbles and jokes. Directed down another hallway by staff members, we could begin to hear the chaotic scene. A man lay on the floor, prone, with a knee of a police officer square in his back. Two staff members were sitting on his legs, while another tried in vain to hold the patient's head as he thrashed from side to side, screaming, crying, and spitting.

He has a history of outbursts, a staff member tells me. The paperwork read MR, and "Intermittent Explosive Disorder." He got in an altercation with another resident over the amount of cheese that was added to their midday meal, and things have been downhill since. They gave 5 of Haldol and 2 of Ativan about 40 minutes ago and it hasn't made a bit of difference.

I'll say. The room was destroyed. The pile of bodies lay in the center of the room, surrounded by a ring of chairs, tables, and lunch trays that look as if they were ejected circumferentially from some sort of uncontrolled explosion. Everyone looked a bit exhausted, and the cops, sweaty, looked at me with a hint of a pleading expression on their faces. Salvation, in the form of a paramedic. They have come to take this one away!

We pulled the stretcher up beside the patient, and tried to devise a plan to get him onto it. We would all lift at once, each person responsible for a limb. We'll get him up and over, then bring the sheet across his torso and over his arms. The staff warns us: watch out for spitting, kicking, biting, pinching... the works. The patient is looking a little calmer now, though, so we are sure it can be done. Up and over he goes, one swift and smooth motion. He lands on the stretcher with a little bounce and smiles.

...And then he frowns. He jerks his arms suddenly and thrashes about on the stretcher, which sways dangerously from left to right. He is able to get one arm free, and starts clawing at one of the other staff members who pulls back in fear of getting hurt. Another leg free. One of the police officers grabs his shoulders and pins him down, while another attempts to regain control of the free arm. I am too close and he reaches towards me, talons out. He scratches my forehead once before I can get him back under control, drawing a bit of blood. God dammit.

We tie him down, limb by limb, but he continues to fight. He keeps finding one way or another wriggle and cause trouble: first banging his head against the metal stretcher frame, then scratching at his own skin wherever he can reach. He strains and stresses against the bounds, arching his body upward and screaming. The staff look at us with sympathy. They've been through this before, they say.

I decide to chemically restrain him. We cant transport him like this, we all agree, and he is going to hurt himself if he finds a way to manage it. I kneel down and open up my pack. Our protocols allow for 5 milligrams of Haldol combined with 2 milligrams Ativan, mixed in the same syringe and administered IM. It takes me a few minutes to draw the drugs up, and the gelatinous Ativan is giving me a little bit of trouble.

In walks the patient's doctor. He demands to know what is going on, asking for the whole story and expecting us all to stop and explain it to him. I have the staff members explain to him while I finish drawing up the drugs, but he stops me before I am able to administer them. He wants to know exactly what I am giving him, where I am giving it, and if I have called a doctor for orders. He had heard from the other nurses that the patient already got sedatives about an hour ago, and seems shocked that I would consider giving the patient another round.

"How about you just do one of Ativan," he says. "We don't want him to stop breathing, do we?"

His voice is as condescending as it is demanding, and I am a little taken aback as I sit there holding the uncapped syringe. I explain to him that I have Haldol and Ativan in the same syringe, and that this is standard procedure. I express doubt that 4 milligrams of benzodiazepine, administered IM over the course of an hour will really cause anyone of this size to stop breathing. I relent, though. How about I just give him half of the syringe. About 2.5 Haldol, 1 Ativan. The doc agrees and, in a bit of a huff, leaves the room. I feel a bit embarrassed. Taken down a notch.

In goes the drug and we wheel the patient to the ambulance. He fights and claws the whole time, screaming like a teradoctyl and searching for ways to hurt himself or others. The elevator is small, and we all press our bodies against the walls so to add the necessary free space.

In the back of the ambulance I get the patient on the monitor as best I can. The patient is tied down but he bucks and fights each of our attempts. If a wire is near his hand, he will grab and pull. I get a set of vital signs, and put the patient on end tidal capinography along with a face mask to prevent spitting. He is sinus tachy at 120 or so, pressure 130/70 and all looks well. I look at my partner, exasperated. Let's just go.

5 minutes into the transport I notice that the ETCO2 is no longer reading. The apnea alarm goes off, but a quick glance at the patient and he is obviously breathing. Must be the sensor is displaced. I lift off the face mask to readjust, and find that the patient is attempting to eat the sensor. He has it, a lot of it, in his mouth, and is pulling in more each second like a long strand of spaghetti. He is chomping and chewing, staring at me vindictively with each motion of his jaw. I grab one end of the tubing and give a tug. "Give that back! Let go!" He vehemently shakes his head, refusing with clenched teeth. He will NOT give it up. I try a little more, but I don't want to pull too hard on the tubing and break it, losing it entirely to the patient's gaping maw.

I sit back for a second, tired and sweaty as I watch him chew. The apnea alarm goes off again. Fuck this, I think. I reach into my breast pocket where I still have the drawn up meds. In go the rest. The patient lets out a yep as I sink the needle into his muscle, and at the same time I yank the mangled tubing from his mouth. Win-win.

He fights more on the rest of the trip. I sit back at the end of the bench, watching him and the monitor. I try to straighten my uniform out but it is no use. His aggressive activity wanes slowly, and by the time we arrive at the hospital he is resting comfortably, half asleep on the stretcher. He asks me for a pillow for his head and I give it to him.

We roll into the ED triage looking like we're returning from battle. Our uniforms are disheveled and sweaty, hair mussed and composure wrecked. The patient naps pleasantly on the stretcher, as comfortable and content as could be. The nurse looks at us, smirking a little. She heard our patch asking for security at the door.

"All that, for this little guy? He's sleeping like an angel!"

Justifications

In many ways I feel like a blank slate.

I've spent a lot of time in class, in clinical rotations and in the back of the ambulance. I've read thousands of pages of text on these subjects, and experienced real-life successes and failures that have left indelible marks on my character. Constant newfound knowledge makes me a new person every day, though, and each time I get dressed in my uniform I feel as if my plate is again clean: ready for another helping of experience. What will the next day bring to the table?

The same is true with my coworkers. It is very rarely left to doubt that I am the "new guy," and my opinion - if I venture to submit it - is often challenged simply because I am inexperienced. My slate is clean then, too, and a reputation is ready to be built on what choices I make and how well I am able to defend them. More than once I have had to push harder than I normally would, so that a conversation does not end on dismissive point that I am a new medic. I readily admit my inexperience, but I feel a need to stand by my choices and fiercely support them with the academic knowledge that originally inspired them. There is sometimes an understated aggression, passive in it's delivery but pointed in meaning. It is not my nature, truly, but I have felt a need lately to be my own person, and fight battles in order to establish myself as someone worth fighting with.

On scene, too. Will I be the first through the door or the second? I have become conscious lately of which end of the stretcher I stand on. I want to make sure that I am there, with eye contact, when the first responder is going to give his report. I ask the first question, and answer the patient's first as well. I have been consciously thinking about ways to maintain control on scene: the delicate balance between utility and overbearing micromanagement. I still sometimes take the submissive role by habit, though, and find myself setting up equipment when I should be doing medicine. How I handle myself on scene is part of who I will become as a paramedic, and I am often aware the choice between which habits I will choose to acquire.

I have worked a long time to earn the right to wear this patch on my shoulder. I am finding, though, that there is much more than title. Once this becomes normal, once people become used to seeing "paramedic" under my name, my reputation will again come to rest on my character, my knowledge, and how I choose to carry myself.

The title means nothing without justification for it. I have a lot to learn still, not the least of which is figuring out exactly how I will fill this uniform.

Ischemic and Uninformed

The man smiles at me with that kind of nervous smile: half appreciative, half terrified. He was cordial and perfectly polite, laughing at his jokes and ours, but the sound was unnatural. Forced.

The doctor takes me aside.

"This guy has had chest pain for a week. Can you believe that? A whole week!"

The doc explains to me that the man felt a sudden onset of crushing chest pain along with shortness of breath as he attempted his normal exercise routine last Friday. Since then, he has had transient periods of dyspnea and chest "pressures," especially when he exerts himself. The doctor shows me the EKG with flipped T waves in the lateral leads. On the next page of the report are the lab results, and the Troponin levels are clearly elevated. The doc casually rattles off the rest of the man's risk factors. Smoker. Positive family history. Obese. History of hypertension. History of high cholesterol.

"We're sending him to Hospital Z," the doc says. "I think he's gonna need a stent."

We walk back to the patient's room, where my partner is getting the patient ready for the transport. The doctor chastises the man for waiting so long.

"Next time you come to the hospital right away, okay? This kind of thing can kill you. Seriously, kill you. Its not to be taken lightly. Understand?"

The man stammers, letting out a shuddering "okkkkay" as the doctor leaves the room.

I smile at the man, hoping to ease the tension. "Let's get ya all unhooked here so we can get you on our equipment." I make jokes about the wires. There are too many, too long. They're just for show, to be honest. The man cracks another nervous laugh but it is plain that he is preoccupied and afraid. I cant blame him. Textbook presentation for cardiac disease, EKG changes, and elevated enzymes? Its a scary picture.

We hook up our gear and roll the man into the back of the ambulance. I burn off a quick 12 lead for our records.


The man watches me as I read over the EKG. He clears his throat and asks me how it looks. I explain that it seems pretty much the same as the EKG they did in the emergency room.

"You've still got a little bit of an issue on the left side of your heart here, but it doesn't look too bad just yet."

The man seems to be clinging to my every word as he looks at me with wide eyes, and I pause for a moment.

"Have they explained any of this to you?"

The man put his head down.

"Not really. They're so busy in there I didn't want to trouble the doctor with too many questions. Everything was moving so quickly. They said that they're going to try and open up an artery or something?"

I am amazed. How is it that a man could come in to an emergency department, be found to have a serious cardiac issue, and wait till he was on his way to surgery before he begins to understand what is happening? The man sat patiently in that department for at least an hour, sitting quietly through the tests and exams, as EKG wires were plugged together and discussions between doctors occurred just out of earshot. All the while, in the dark.

He picked up on the tone, though, and it wasn't good. He tells me that more than once he was spoken to about "coming to the emergency room earlier," and that he shouldn't have waited a week. He knew that there was something wrong with his heart, but not exactly what, where, what it means, or what exactly could be done about it.

I lean forward from the bench and show him the pink printout. I point to the lines on the paper, explaining that some are going down when they should be going up. I pull out his old EKGs from the file so he can compare, explaining the difference between ischemia and infarct in layman's terms. "Its almost as if your heart is short of breath, and is getting bruised up because of it," I explain. "...But the danger is that it can get worse, to the point where it cant be helped." We talk about vessels closing and opening, about supply and demand.

He asks me questions. Lots of them.

"If a part of my heart dies, will it grow back?"

"Does this mean that I wont be able to get up and do things anymore?"

"What are they going to do to me at the Hospital? Will I be awake the whole time?"

"Is any of my heart already dead?"

I answer each question in turn, using basic language that I hope the man fully understands. He clarifies what he doesn't, and listens intently to my replies. We spend the entire trip to the hospital talking about cardiac physiology, treatment modalities, and prognosis. I exhaust my knowledge upon him, and when I get to the end, I remind him to ask his doctor when we get to the hospital.

I tell the man: this is your heart, and these are your decisions. You have a right to know about what is going on, and nobody can do anything without your permission. Do not be afraid to ask questions. Insist that you are informed, and advocate for yourself as much as you are able to. It may not seem like it, but you are in charge.

I left the man on his new ED bed with a firm handshake, and he thanked me with an emphasis that echoed through me for the rest of the week. I truly made a difference in this man's day, helping him through a difficult time with academic knowledge, patience, and a caring tone.

It was easily the most satisfying thing that I've done as a paramedic so far.

Tachy

Dispatch asked us to intercept with a BLS unit south of our location. They were headed towards us out of a quiet nearby town, and asked for paramedic help as soon as they saw their patient.

He was 45 years old, racked with disease for years that seemed to count double their time. The man looked 80, easialy. He was unresponsive with a glascow coma scale of 4, gaining only one point for his occasional incomprehensible moans. His body remained slack, absolutely still despite whatever stimuli we could deliver. I rubbed his sternum hard with my knuckles. Nothing.

Despite his calm demeanor, though, his body was a cataclysm of active turmoil. His respiratory rate was just shy of 50 breaths per minute, his heart counting 190 beats in the same time. None of us could get a blood pressure manually, and the automated machine spit "NIBP Timeout" back at me over and over again. I thought I could find a radial pulse, but maybe it was nothing. The pulse oximeter refused to read, and end-tidal CO2 returned a measly 10 mmHg.

I ask as many questions as I can think of, rapid fire as I try to get a sense of the story. The patient has a history of brain abscesses and has been declining over the past few weeks. The family told the EMTs that this has been his baseline mental status for the past week, and that they called 911 only because it seemed he was having trouble breathing. I am struck by the story. Unresponsive like this for a week? Really?

I get the EMTs to insert an oral airway and start assisting the man's breathing with a bag-valve mask while I do the rest of my assessment. The eyes have a dysconjugate gaze to the upper left, and pupils are sluggish to react at about 3 millimeters. Lung sounds are with bilateral rhonchi, but filling up adequately with each squeeze of the BVM's bag. The skin is warm and pink at the core but mottled and slightly cyanotic towards the extremities. Blood sugar is 146. A rapid trauma assessment is without significant finding. On goes the checklist while I start an IV. I plug together the monitor cables and get these in reply:





The man is in shock, crashing in front of my eyes but I cant pinpoint an exact cause. The eyes and mental status suggest a neuro event, although the vital signs defy the textbook Cushing's triad. ...And the family says the mental status is baseline. The 12 lead shows a significant tachycardia, and generalized ischemia across the man's heart. The blood pressure is too low to read. Sepsis? PE? I dont know.

I get the patent in trendelenburg and open up the IV, reviewing my options. I think about intubation, but we are 5 minutes from the hospital and the man is biting on the OPA. I dont think I have time, and the BVM has been pretty effective. Full, equal lung sounds and the end tidal CO2 is slowly coming back up as the EMT controls the man's runaway tachypenia.

Looking at the patient, and the monitor, I feel that I need to do something about the heart rate. The hypotension could very well be related to the tachycardia, and while it is possible that the heart rate could be compensatory for some unseen hypovolemia or otherwise, I doubt it. I remember from ACLS that heart rates over 150 are very rarely compensatory, and still, at this rate cardiac refilling time must be seriously hindering effective output.

We are 3 minutes from the hospital and I draw up adenosine. 6 milligrams, and a 10 cc normal saline flush behind it. I push print on the monitor and flush both syringes through the line. As we come to a stop in the ambulance bay I stare intently at the monitor.

No change whatsoever.

In the hospital they listen to my story with raised eyebrows. They are skeptical about the family's story too, but accept what I have to give them. The man is paralyzed and intubated, bloods drawn and x-rays taken. The team converges around the man, working intently as they pass lines and instructions to eachother. The man codes. Four times, resuscitated each time with jolts of electricity as I write my run form. When I return with paperwork the team is sweaty and tired. Empty boxes of epinephrine litter the floor. They are mixing up an epinephrine drip to maintain the blood pressure, and the doctors are calling more doctors to discuss what could possibly be wrong. Nobody knows yet.

**

It was a good call in many ways. There was a lot to do in a short amount of time, a complicated story to assimilate and an important treatment decision to make. It was a job to remain calm and focused, to get things right and make sure I didnt miss anything important.

I ran through the call with some of my coworkers, and there are always raised eyebrows around the time that I mention the adenosine. I know. I knew it then, too, but I felt that I had to do something about that heart rate in the face of the rest of the patient's presentation: and I stand firm that there was value in the choice both as a treatment and as a diagnostic tool. If it worked, great. If it didnt, a pathology eliminated.

I may or may not have been right. Maybe the heart rate was actually a compensating effort. Perhaps the rate was completely unrelated to the rest of the presentation. Maybe I should have focused instead on doing something else. I dont know, and as far as I've heard thus far- neither do the doctors. It is a little frustrating to not know, to remain in the dark after such a fervent effort.

I did my best though, and I stand by my decisions. In work where often nothing is certain, and choices must be made quickly and accurately based on experience and talent: I think that counts for something.

Planet Paramedic

I feel like a different person. I am acutely aware of the new patch on my shoulder, yes, but there is more than that. I have done a lot of this before. Routine clinical practice in school, calls on my ride-time internship, more calls while precepting. All of them, experiences designed to bolster my confidence and add wisdom to my choices, but still: sitting in the front of the ambulance - the paramedic with an EMT at my side - I feel like I am in a new and strange place.

The feeling strikes me as contrast to those Peter Canning expressed in his most recent blog entry. He writes how things havnt seemed to "stand out" lately, that he could write about some of the things he has seen, but he has been there before- written about it and now considers it old news. He's met a lot of amusing patients, seen the good medicals, and was there for the big traumas. ...And yet the experiences no longer seem to stimulate as much as they once did. Peter is experienced. Stable.

I sure as hell cant say that for myself. I've seen a total of 4 patients so far in my career as a cut-loose paramedic, and each one has seemed so important, so groundbreaking, that I really had a hard time choosing what I wanted to write about.

It isnt as if I have had all great calls, either. A seizing, ex IV drug abusing hypoglycemic who woke up after 3 tough IV attempts and an amp of D50, a deformed ankle, female weakness x 6 days, and a drunk. I went through my routines with each patient, assessed, treated, and even downgraded one of them-- but the experiences were so fresh and new. I was shocked to watch a first responding firefighter glance at our patches and then come to me to give his report. It was such an odd experience to act as the final word on scene. We're going to stay here and take a look. We're going to get going as soon as we can. The words came out of my mouth, not for the first time but with newfound impact. I was in charge of the scene, and people listened. Maybe they have no idea how new I am, that this is my first day and that behind my sunglasses, my eyes probably betray this overwhelming uncertainty.

I hung tough though. Played it cool and, I think, made the right choices for these first four patients. Even the routine feels new these days though, and I worry how I will fare when something really tough, some zebra comes along and forces me to make a decision. I hope I make the right choices and, even more, I hope I dont have to make those until I can get a little more experience under my belt. This job seems to favor trial by fire, though, so I doubt it.

Things sure are different here on planet paramedic.



***

I left my last entry with the news that my first shift would be with a friend, standing-by at a boxing event. So it was, although we didnt get any patients. We did, however, get awesome seats to a pretty good show:


Cant complain about that!

Effective Immediately

My day with the Chief went very well. We did a few routine calls, a man who had fallen down a flight of stairs with an obvious closed tib/fib fracture, another man who's plaster ceiling had fallen down on his head while he was washing the dishes. I assessed the patients, directed other crewmembers on scene, and made treatment decisions based on my clinical impressions. I was nervous, and sweating in the 90 degree heat, but apparently avoided screwing up too badly as at the end of the shift I got a handshake and congratulations. "Do your best to kill as few people as possible," he said with a smile.

And I was done.

It seems a little odd now, after having jumped through so many hoops, filed so much paperwork, and paid all of my dues: here I am now with nothing else to do other than go out and work. What do you mean I'm cut loose to practice on my own? You mean I get to go out all by myself, with just an EMT?

I received a letter today from my Medical Control hospital:



Effective Immediately, but the feeling hasn't quite yet hit home.


My first shift as a paramedic will be tonight. 6pm till midnight or so, I am doing a quickie shift with a good friend of mine watching over a boxing event. I guess I should brush up a little on my trauma protocols?

A Final Ride

All of sudden, the day is tomorrow.

I've known for a while now that my preceptor has been just about ready set me out on my own. He has mentioned it several times, but the day was always weeks away, obscured by an unknown buffer of time. There were always a few more shifts in between then and now, a few more free lessons available for me to learn. A few more reasons to put it out of my mind.

Not anymore though. I found out this evening that tomorrow I will ride with the Chief Paramedic, my last 8 hour evaluation before I am (hopefully) cut loose to perform on my own. We will ride together for the shift, him driving and me running all of the calls. We will jump all of the good dispatches and then he will watch from the side with eyebrows raised, I imagine, as I sweat my way through each of the assessments.

I am excited for this - I have been waiting a long time for it - but right now none of it seems all that fun. My esteemed readers, please wish me luck. It could very well be that this time tomorrow, I will be out on my own.

A Potent Lesson

The man looks up at me from his bed, surrounded with the trappings of his daily life. Within reach are carefully arranged remote controls, for his bed, tv, stereo, and nurse. His pillows are arranged just-so, tucked under his legs and back in an assembly that surely took weeks of trial-and-error to get just right. Photographs of family and friends surround the bed, adorned with gifts and trinkets, flowers and balloons. He is 82 years old, relegated to bed by age and disease, chosen to stay there through consent forms clearly indicating his wishes: Do Not Recesustate, Do Not Intubate, Do Not Hospitalize.

He looks at me, sweating. I dont even get to ask what is wrong before the problem presents itself, making it's own introduction. The man's muscles flex and bend inward, all 4 extremities tightening and releasing quickly as electricity claims control for the millisecond. A shock from his implanted AICD. The man's face portrays equal amounts of annoyance and pain. "It's been happening all day," he says. "Just go ahead and get me to the hospital so they can turn this damn thing off."

Aware of the man's advance directives, I ask what it is that he would like us to do on the way. We have drugs that may help stop the shocks, I would like to give them a try if it is okay with him. Exasperated with the painful shocks, he reluctantly agrees. I explain what I would like to do, and the man waves his hand- "Do what you have to do, just make this stop."

On go the white, black, red and green wires:


Except for the jolt of electricity every 60 seconds, the man is without complaint. I ask all of the pertinent questions, perform my exam and search for more, but there doesnt seem to be much other than what is printed on the EKG paper, and the occasional flexing and arching of electricity. The blood pressure is 130/80, SPO2 99% on room air, the man is without pain or shortness of breath.

I leave the monitor on print, capturing the various outrages of the man's irritable heart:



I watched the rhythm widen and become narrow again, it's irregularity and rate alternating unpredictably, punctuated by discharges from the man's AICD and perhaps his pacemaker as well. I recognize a-fib underneath, but waver at a clear interpretation of the faster, shockable rhythm. The man sweats uncomfortably, bracing as he awaits his next scheduled shock. He asks me if we can get a move on. I call the faster rhythm a "wide complex tachycardia of unknown origin." Even though I see the rhythm narrow in places, I am nagged by occasional width, and spurred onward by the man's prodding. I am eager to provide relief, and ready to make a decision about the EKG.

I should have slowed down.

I get the man on some oxygen, and start an IV. Acutely aware of the rhythm changes, I make a decision to administer Amiodorone: 150 milligrams over 10 minutes, diluted in 100cc of normal saline. I am an expert at the tasks by this point, and the work goes quickly. It was a difficult IV, but I got it. Our buritrol was broken, but I managed. I mixed up the drug, piggybacked a line, and accurately calculated the drip rate. Like a machine.

We drip the drug in on the way to the hospital, a 10 minute trip. It is at this point that I remember the 12 lead cables. I see them in the back of the monitor as I am looking for something else, bunched up where I put them last and conspicuously unused. I recognize immediately that I should have used them earlier. I look up at the medication bag, and it is halfway gone.

On go the six black wires:



The rate is still fast, but nothing else is the same. It was as if I had wiped away a dirty window and looked again, amazed with a new vision- unobstructed and clear as day. This rhythm is not wide at all. It is narrow, irregular, fast. It is a-fib. Any day of the week, a-fib.

I stare at the strip, drained. The Amiodorone is almost all of the way in now, and while the drug is far from the wrong one (it may still help), it should not have been my first choice. A-fib like this gets calcium channel blockers, not general antidysrhythmics. Mine was an appropriate treatment still, but a less effective one - and something that I will have to explain to the doctor who will surely ask why I made such a decision.

The patient, unaware, rests comfortably. I look up from the EKG paper as he touches my knee. "Thank you," he says. "This is much better." His heart rate has come down slightly, to about 150, and the AICD has stopped shocking. The diaphoresis is gone. I tell him he is welcome, grateful for his relief.

In the ED the doctor does ask me why I chose Amiodorone. He looks over the strips quickly as he moves between charts. "That looks like a-fib or flutter. Pretty fast, too." I offer a weak explanation that the rhythm appeared wide at times, and that I felt that this drug was a safe call considering the varied morphologies. He shrugs, and says okay. At least he's not getting shocked anymore. I shrink back away and try to disappear.

Paramedic friends of mine say that I'm too hard on myself. I should have done a 12 lead first - especially on a stable patient like this one - but they pat me on the back and tell me I still did well. It's hard, they all say, to make these determinations quickly, in the back of the ambulance surrounded by the chaos of a patient in pain and buried under a mountain of other tasks that must be done at the same time. "Dont overthink these things," one medic tells me. "Just next time make sure you get that 12 and you'll be right on."

Still though, I'm angry with myself. I was eager to get to the treatment, moving too quickly for a necessary second glance at the rhythm. It was embarrassing to come into the emergency department, to give reports to doctors that I respect, fully knowing that I didnt quite do the right thing and, worse, that the cause of the problem was an omitted step. These kinds of mistakes can turn out well, like they did this time, or they can be deadly. It is a scary thing, and I really need to be more careful. This was no benign error.

This is something I will not soon forget. I feel strongly that the resilience of this kind of lesson is equal in proportion to the amount of danger the inciting mistake imposes. This was a small omission which could have posed a significant danger to a different patient. The importance of such an opportunity to learn consequence-free is not lost on me, and I will make great efforts to make sure that the memory sticks. I will squeeze this for what it is worth.

I overheard a new medic the other day, worried about his upcoming ride-time as a new preceptee. He was nervous, explaining that he hoped he didnt "make too many mistakes." To the contrary, I think. May he make lots of mistakes. Let them pile up underneath him, build up his experience and stick with his memory. May his errors remain free from serious consequence, but packed full of value, so that next time the choices will be clear and ready.

I am new. I will continue to make mistakes. I cannot hope that they will not happen, only that when they do I am able to claim from them the fruit of experience, and pass the benefit to my next patient.

I will be better next time.