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.