Psych

I took care of a man today who, according to the convenience store owners where he was found, "went totally crazy." When we got there he was on the floor, writhing like a fish out of water as eleven police officers stood over him catching their breath. He was handcuffed and lying face down, screaming as he struggled against his bounds. He covered his posterior with his hand, madly swatting away some invisible insult. "He's raping me," the man screamed. "Why are you letting him do this to me?"

When we flipped him over and onto the stretcher he hardly seemed to notice. His face ran with tears, his mouth wide open in anguished cry. Every once in a while he would catch my eye and plead with me that I make "this guy" stop. I tried to ask him what happened, what was going on. Looking into his eyes I tried to offer him a way out, a softness beyond the hell that he endured. He looked right through me. His reality was too much for him to bear, too potent to ignore.

I did my best to perform an assessment. He had a strong, regular radial pulse at about 134, his skin hot and diaphoretic. His lung sounds seemed to be clear between screams. I did a rapid trauma assessment and found nothing. PEARRL. Unable to obtain a medical history, meds, or allergies. I wasn't even sure I had his first name right. I tried to give some nasal cannula oxygen, but the man kept shaking his head whenever I got close, screaming with rapidly depleting energy and fighting the best he could. I resigned myself to simply trying to calm him down, which didnt work either.

Patients like this are not uncommon in the city. They get into the back of the ambulances - willing or, sometimes, unwilling - and refuse to budge. We do routine assessments, going through the motions to be thorough, knowing all the while that we cant really touch these people. The barriers are too high, the insults are too deep. They look at us with the eyes of experience, tired of the same questions. Most have done this before and seen failure, their pockets filled with medications and crisis intervention business cards. Again we both try.

Its easy to burn out on these patients. Perceived futility is an especially hot ember. I'm not sure how long-term, adept clinicians handle this. Do they relax in the system, mindlessly going through the motions in efforts to provide for these patients another halfway opportunity? ...Or are they convinced of the value of these interventions, actually believing that people this far gone can truly be helped?

Which method is the best for the patient? Which is more healthy for the provider?


On our way to the hospital I sat in the airway seat, behind the patient. I didnt want him to look at me, ask me for help I couldnt give. I spoke to him from out of his view. "Calm down buddy. Try to relax. We're taking you to the hospital, we'll get you some help."

Patron

New Hampshire was bitterly cold. We stayed in dorms on a fire training campus the night before the exam, alone in the lecture halls as we studied our respective examination stations and played cards. The freezing wind battered the windows with blustery sprays of whipped up snow, but we remained warm inside. Three of us, surrounded by the expansive emptiness of rooms waiting to be filled the next morning, huddled over our note cards.

The rooms were full by 7:45, a half hour before the exams were scheduled to begin. Awake with bleary eyes we listened to the nervous chatter of other students waiting to be tested. All wondered how tough the examiners would be, how in-depth the evaluations would get. One student asked me if I could remember the maintenance infusion for Magnesium Sulfate, and I did. He shook his head, frowning. "I really hope they dont ask me about that. I'm never going to remember."

My friends and I, reinforced by practice and tempered by experience, were able to remain calm. It takes something away from the threat of the exam to have been there once, failed, and come back for a second try. Lessons learned through the experience of failure have been those that I remember most clearly during my ride-time internship, and today - with similar lessons learned - I felt prepared. Ready.

Dynamic Cardiology was never easier. Asystole, V-Fib, Asystole, PEA, and out. I cycled through my ACLS, remembering each step, finding time to recall detail that I left out on my first time through the exam. I was ready for infusion rates with fancy dosages, but the need never came. Halfway through an explanation of my last treatment the proctor smiled and asked me to stop. "You're making this too complicated." she said, "Get out of here, have fun being a Paramedic." I left the room with a huge grin on my face. Another proctor standing in the hall laughed at my smile. "Went well, eh?"

My friends had similar experiences, each of them letting out sighs of relief as we met up after the examinations. Fisties and handshakes all around, smiles and congratulations. I bought a bottle of an expensive liquor at the New Hampshire state package store on the trip up, and we all shared a shot in our dorm room before we left. Holding the glasses up high we toasted to the end of exams, the beginning of a new experience.

The liquor went down smooth, warming our stomachs. A delightful contrast - and welcome end - to our cold New Hampshire winter.



***


With both the practical and written exams passed and behind me, I am now a Nationally Registered Paramedic. I next have to apply for my state license, a process that people before me say could take weeks to months. I continue to work my job as an EMT, hoping for the former. Next hurdle to overcome will be precepting.

Micrograms

The woman, 84 years old, lays still on her apartment floor.

I run through the basics. Scene is safe, my gloves are on. I note that there is one patient and consider that she may need protection of her cervical spine. She is unresponsive and an assessment of airway, breathing and circulation is performed only to find out that there is none. CPR begins.

On the monitor is V-Tach and I run through ACLS with the smoothness of practice. I remember even the minutiae, the small boxes that get ignored next to the large ones in the algorithm flow-charts. The rhythm changes, four times. V-Tach to V-Fib, to aysytole and - with the help of epinephrine and atropine - a sinus bradycardia. A perfusing rhythm. She is still unresponsive but at least has a blood pressure: 70 over 40. The bradycardia dips dangerously low, into the 30's but I am already on the ball with pacing. I dial up the electricity on the monitor until I see electrical capture but am flustered when the mechanical capture does not come. I hear "the pacing doesnt work, what now" and my heart sinks.

"Atropine," I say, but again the voice: "That doesnt work either, now what?"

Yikes. I remember that I can use Epinephrine but dont remember the dose. I am sitting at a table, in a quiet room with a dummy just to my right. A man sits across from me with a piece of paper in front of him. National Registry practical examinations, and I cant remember the dose.

I waver and begin to sweat as I sit quietly. My feet begin to tap and I look nervously at the examiner. His blank stare reveals nothing. I try and think back but I cant remember the dose. Not even as an EMT for 5 years riding alongside paramedics have I ever seen epinephrine given under this circumstance. Pacing should work, and if it doesnt then surely atropine would. ...But here I am, quiet in a room filled with silence waiting for my answer. The pencil of the examiner hovers over the last line on my assessment sheet.

"One milligram," I say. "IV push". I sink my head as I walk out of the room, knowing that my answer was wrong.

After 3 hours of waiting, I finally hear the results and they are no surprise. I passed every station except dynamic cardiology. Asking if I knew what I did wrong by the exam proctor, I say "epi" and he nods his head. I looked it up when I went back to my seat: the proper dose was in drip form, 2 to 10 micrograms per minute. I could have used Dopamine too. Never would have guessed.

Such a small detail and it is over for me. I left the testing facility dejected, branded as inferior to those who passed and relegated to remedial testing. Not good enough. I find myself angry at the examiner, who asked only me about the epinephrine, and pissed off at myself for not remembering. I didnt even study third line medications, thinking it would never come up. It is always the thing you take for granted, always that fine detail you glossed over in a moment of laziness.

Next time I will remember.




***

I will retest Dynamic Cardiology this coming Sunday at a facility 4 hours from my home. I travel with 3 friends from class and we will make a weekend out of it. A recently cut-loose paramedic confided in me that he had to make this same trip last year along with a few of his own buddies. "We had the greatest time," he said. I promised him that I will be saying the same thing, on Monday.

BLS Still

On an overnight shift at work with an EMT rocker on my arm, we head north for an overdose at a drug rehab center. My partner and I joke about the irony of the call as we cruise up the darkened streets, lights but no sirens.

Arriving on scene I hop out and grab our gear. The EMT bag is so small, light. Inside are the mere basics: some O2 supplies, a BVM, oral glucose, minor trauma stuff. I carry the bag around to the stretcher in back and wonder if I've forgotten something. The ALS gear is so much more difficult to carry: heavy with tools and potential. The bag I carry is sparse, and reflects my capability on this call. I remember to bring the handheld radio in case we need to call for a medic. Probably my most valuable tool, I think.

Upstairs we find our patient leaned back in a chair, alone in a lobby with dimmed lights and the feint sound of a TV from another room. His head is back and he snores with each respiration. A nurse comes out from a side room and hands us his paperwork, giving a look like she is annoyed this would happen tonight, at such a late hour and during her TV program. Her report to us informs us only that she knows nothing about the patient.

I put my hand on the shoulder of the man and call his name. "Anthony." I say it twice, louder the second time as I give his shoulder a little shake. His head moves forward as he sluggishly opens his eyes, dazed. He yawns and stands up, ready to get on the stretcher. I guess this guy knows the drill.

He is alert and oriented times four, a little lethargic but so am I this early in the morning. He is without complaint and the vital signs are stable. Pupils are equal round and reactive to light, perhaps a little dilated. Asked if he has been using any drugs tonight, he admits to 2 bags of heroin "a little while ago" and some vodka afterwards. He inquires as to why we dont just take him to the hospital and quit asking him questions.

Getting him down the elevator and into the ambulance, he is becoming increasingly lethargic. I ask him several times to open his eyes and to try and stay awake for us, that the hospital is only a few minutes away. I make a joke about how our driver will need to stay awake also, but the patient doesnt laugh. He's asleep again, awakened this time by a more forceful shake. In the back of the ambulance I take a look at his pupils again. Now they are pinpoint. Very pinpoint, almost as if they arent even there. He is sleeping again, even as I peel his eyelids back to shine my flashlight in.

I put the patient on oxygen and tell my partner that we need to get going. The patient is changing right in front of my eyes, from alert to lethargic, dilated to constricted. I wonder how quickly he will go from breathing to not breathing. I retake vital signs on the way, do a rapid trauma assessment and watch the breathing. His respirations are at a good rate and depth at about 14, but I'm worried. I get the BVM out of the BLS bag and set it on the bench.

Still 5 minutes left to get to the hospital, I sit back on the bench seat and wonder what else I can do for this guy. I found track marks on my trauma assessment and he admitted to recent heroin use, his pupils are constricted and his mental status is changing. I know what a medic would do here -- what I would do if I had a different rocker on my shoulder -- but right now all I can do is sit back and watch. He has great veins, too.

We make it to the hospital without incident. Our patient is increasingly lethargic but continues to breathe well. My report to the nurse is clean and to the point. I say "he needs narcan" without actually saying it, painting the picture as well as I know how. The nurse, looking tired, glances at the patient and sighs. "No IV?" Nope, I tell her, pointing to my shoulder. "I cant."

We are assigned a room and another nurse comes in carrying an IV kit and a frown on her face. I try and tell her the story but she's already heard it from the triage nurse. She knows what needs to be done as well as I do, she doesnt need me around to tell her all about it for a second time. I ask her if there is anything I can do to help but no, she's got it. I take a step backwards as the curtain is zipped from left to right in front of my face. I need to just get out of the way.

I go back and write my run form in the EMS room. The narrative is breif, detailed in assessment but short in treatment. I reluctantly check the "reassurance" box under treatments provided. Thats pretty much it. Returning to the patients room to drop off my paperwork, the patient is awake and asking for some food. He has an IV in his arm and there is no longer any trace of lethargy. He doesnt recognize me.

As long and frustrating as a lot of paramedic school has been, this has got to be one of the hardest times to endure. I work at least 40 hours a week now as an EMT, forced to keep my new knowledge inside, refraining from moving forward with what I know is best for the patient.

I'm not allowed. Yet.



**


I am scheduled to take the National Registry exams this week, on Wednesday (the written) and Thursday (the practical). I've got sheets and sheets of information spread out all over my desk at home, laminated skill stations and scribbled note cards. Only a few more hurdles left to go, and I'm determined to make it through on the first try. Wish me luck!

Fifty Four

Yesterday at 2000 hours, my ride time came to an end. It was just over 8 hours since my most recent call on that shift, and as the clock clicked over to quitting time I let out a sigh and gathered up my things. I walked around the fire house and shook hands with all of the folks who helped me along the way, thanked them, and told them I appreciated their time and that I have learned alot from them. Each of them clasped my hand firmly, wishing me well and good luck on my exams. I wrapped my paramedic program jacket around myself, stepping out into the cold night towards my car. An anti-climactic ending to a whirlwind of experience.

We are required to submit to our instructors a listing of all patients treated during our ride time. Mine is 54 patients long, ranging in nature from cardiac arrest to the BLS downgrade: all individual experiences that - at the time - were new to me. For the past six weeks I floated from call to call on a high familiar only to the novice. I was excited about starting IVs, pumped to push drugs. ...And there they are listed on my paperwork: 18 gauge IV established, medication administered, a difference made. Fifty four times.

I look at the list though, and feel like it is far too short. 54 calls really isnt much at all. Hardly a sample, a mere taste of the vast array of what I will encounter during my days as a paramedic. There is no question that I am better now than when I started. Better with my assessments, more confident with my knowledge and increasingly proficient with my skills. Still though, I cant help but be impressed with how much more there is yet to learn. There is still so much that I havnt done yet, so many things that I need to do again. As much as I have experienced over these days and as much as I have grown, the clearest lesson that I have come to understand is that my education cannot - and will not - stop here.

I would like to thank all of those who took extra care to help me learn. Tommy Sinkewitz, Steven Ball, Mark Miller, Brian Eaton, Victor Morrone, John Pickert. Others, at work: Greg Shovak, Evan Scarborough, Rick Ortyl. There are some paramedics who would have students simply ride along and stay out of the way. Others take that opportunity and turn it into something greater, fostering growth and passing knowledge. You guys took the hours that I had and helped me make the most of it, and for that I thank you all.


**

My initial intent was to write this blog in order to document only my passage through ride-time, but over these weeks I have found the process to be so helpful, and the response so positive, that I dont think I could do anything other than keep writing. There is still much to learn and much left to write about. I look forward to continuing this blog throughout my experiences as a paramedic, and I hope that my readers are willing to hang around as well. All of the comments and emails have been absolutely incredible: both helpful and interesting along the way. Please keep them coming, and I'll do my part to keep writing.

Everyone, thank you.

Crazy

Not exactly known --by myself at least-- for his deep insight into the incintricities of culture and social interaction, I was surprised the other night when I heard Dave Chapelle say something extremely profound about what the EMS community refers to as an "EDP," the Emotionally Distressed Person. He was more talking about himself, I guess, but the logic translates. "The worst thing you can call someone is crazy," he says. "It's dismissive." Chapelle goes on to describe how we use this word --crazy-- not just in a derogatory manner, but also to separate ourselves from the behavior. The crazy person, the EDP, is bizarre and wild-- a scary vision if we were to think that this person was ever normal, ever like us. Instead we differentiate. That person is crazy. Of a different class, a different background. He is not like me.

An old woman kicked me out of her home yesterday. She dialed 911 because she was having chest pain and shortness of breath, a pair of complaints that both demands the attention of health care providers, and rolls off the tongue of practiced, chronic EDPs. People like this know the game, they've learned the magic words. Chest pain. Shortness of breath. Head, neck, or back pain. They are all used, chronically, by legitimate patients and attention seekers alike. We would be remiss to ignore the complaint but, seeing the woman and upon examination, the truth of the matter is clear to even the most green of EMTs. This woman is full of shit.

I introduce myself politely and ask her what can I do for her. She looks me up and down slowly, her eyes peering out above a non-rebreather mask. They narrow as she begins to laugh at my question. Not a mirthful laugh, no, a laugh of foul distain. Without a word she says to me "you? What could you possibly do for me?"

Already having made a decision that this patient was an EDP, my clinical interest - and with it my patience for this woman - goes down the drain. I ask her what is so funny. "You," she says. "You are funny." I'm pissed off. Who does this woman think she is? She calls us for help, and when we get here she finds breath despite her "difficulty breathing" to mock me? I grip my stethoscope harder in my hand, but manage to keep my mouth shut. A jabbing remark slams into the back of my teeth as I keep it in. No, be professional.

I try to start my assessment, but as I reach to listen to her lungs she recoils. She shrieks, screaming "What the hell is that smell?? What cologne are you wearing? Oh my god I cant be around that smell!" I try to calm her down, soothe her into letting me listen "just quickly," but she wont relent. Her cries get louder and louder, as she carries on about how cologne gives her seizures. I can look it up in a book, she says. She has a condition. I take a step away from her, and start to explain that I am not even wearing cologne, but it is no use. She is inconsolable, and begins to cry. "Get the fuck out of my house," she says- her finger pointed to the door. "Get the hell out of here or I am going to call the police!" The police officer standing in the other corner of the room lets out a snicker, which she either doesn’t hear or ignores.

My preceptor nods to me and I go. Screw it, I think to myself. She's full of shit anyways. Crazy.

I stand outside the house with some other police officers and the firefighters who responded. They all joke and make fun of me, and I laugh back. "You smell like a French whore house," they say, "my eyes are watering!" One of them falls to the ground and pretends to have a seizure. Breathless with laughter we call the woman nuts. "What a freakin wacko."

It it is comforting to convince myself that I am not like that woman, that she is different from me in some profound way. She is crazy, I am not. My abiliy to differentiate has become almost automatic. As soon it was obvious to me that this woman was a difficult emotional case, I began to take steps back. I had left her room long before she asked me to.

As easy and helpful sometimes as it may be to separate ourselves from patients like this, I have been finding that medicine --good medicine-- asks us rather to integrate with our patients. The adept clinician establishes a professional relationship that serves both as an emotional backdrop and as a functional tool. I have witnessed this as an EMT, riding with proficient paramedics. Tones of voice drop into practiced words as smooth as silk. Empathy becomes an underlying tone to otherwise indifferent clinical procedures. I have heard medics bring up the topic of imminent needles so expertly that I myself wouldn’t mind getting stuck. All the while, the patient begins to open up. Harsh complaints and antagonistic laughter turn into a story, a history that the provider then translates and condenses, refining from narrative into chief complaint, past medical history, and an exhaustion of pertinent negatives. Often times, I have been able to do nothing but sit back and marvel.

Dealing with these people, these EDPs, requires a lot of experience, patience, and --perhaps most importantly-- empathy. The clinicians that I have seen that do this well do so not simply because this is a practiced routine, but because they truly do care. Empathy is fuel for patience, the reason for excellence.

My natural reaction, I admit, is often to retract from these people and protect myself. I dont doubt that this is the natural reaction that most people would have. Still, in full conscious knowledge of a better way, I wonder how to draw the line. How do I let myself care just enough, so that I can get the job done without sticking my neck out too far?

I hope that for now, it is enough that I simply care enough to care.