Precepting

According to my certifications, the powers that be, and the paperwork: I am ready for precepting.

I met with the boss this afternoon in his office and sat while he looked over my credentials, eying expiration dates and perusing all that is necessary. I am but one detail short, something that within reason should be taken care-of over the next few days. Assuming everything goes according to plan, I should be presenting for work as a precepting paramedic early next week. My preceptor? None other than Peter Canning.

The past few weeks I have been able to busy myself with the task working and hoop-jumping that “getting ready to precept” entails. Filing forms, photocopying certifications, taking the local protocol exam. All of it, completed in record time as my excitement to put on a paramedic rocker increased. Bolstered with the confidence of first-time exam passes, and spurred onward by a drive to finish before other potential preceptees, I have forgotten to take the time to think about what I was setting myself up for. Today, with the forms filed and the “go ahead” nod only days away: I remember what it was like to be nervous.

The feeling is familiar. Walking into my first day during my internship I felt the same way: confident on paper, knots in my stomach. At least then I was less familiar with what I didn’t know. Today, with 54 internship patients under my belt and additional months of working as an “informed EMT-B,” the gap between what I am used to, and what will be expected of me seems increasingly vast. It has been easy these past few months to simply drive the ambulance and critique ALS through the rearview mirror. My paramedic partners at work have been awesome, most allowing my input into the assessment, my opinion into the decisions. Still, the work was easy. No pressure to be right, no weight on my shoulders if I was wrong. With the red-tape impeding my precepting cut, I no longer feel the comforting buffer between myself and the clinical decisions that I will have to make. Assuming everything goes to plan, next week it will be all me, and it is scary as hell.

I should do fine. I know what I need to know, I’ve studied the protocols and reviewed the details. As much as I am able to, and as far as I can tell, my brain is ready.

My knotted stomach, though, has yet to catch up.

Pedi Arrest

My partner and I raced northbound for the confirmed cardiac arrest. The phone rings and I answer, its a friend in another ambulance who has been listening to the fire radios. "It's a kid," he says. "2 years old."

We're on scene a few minutes later, finding the address already saturated with police officers and firefighters waving franticly as they yell and point the way. We park and grab our gear, just the monitor and the ALS bag. No need for a stretcher to carry a 2 year old.

We find our patient by following the sounds of an anguished mother's screams. She is upstairs, getting dressed as she cries, her hair still wet from the shower she took while her baby stopped breathing. Later we would learn that 15 minutes ago she put her child down for a nap and decided to take the opportunity to shower. Walking in afterwards to check on the crib, she found that her child would not wake up.

The 2 year old was on the wooden floor surrounded by giant firefighters in dirty yellow jackets. Arms outstretched and mouth slightly open, she looked positively motionless. Absolutely still. Her skin was an ashen gray, only a memory of warmth remained.

We dropped the gear and got on our knees to work. I ripped the bag open and found a pediatric sized BVM, throwing it to one of the firefighters to set up. My partner confirmed there was no pulse and the patient was not breathing, quickly reaching for the intubation kit. We work smoothly despite the tremor in our voices as we call out commands. Get that oxygen in here. We need the suction. Find out how long she's been down.

The room is so small.

On the monitor is an apparent v-fib that to our dismay smooths out to asystole when all hands pull away from the lifeless body. Get back to work, my partner says. Good CPR. We try for the tube and the patient vomits. The mother is still screaming from the hallway outside, the room feeling smaller by the minute. My partner looks at the monitor, then back at me. "We need to just go."

We scoop up the baby in our arms and rush back to the ambulance. Behind us is a trail of firefighters and police, each grabbing a piece of equipment as they follow in toe. My partner gives CPR with two fingers and delivers ventilations as she climbs down stairs, over snow banks, and into the back of the ambulance. Another crew and a paramedic supervisor are there to help.

We do what we can. The ride to the hospital is harsh but fast, the three of us supporting ourselves against the stretcher while we give CPR and work on the airway. The baby is still ashen gray and motionless except for its lifeless jostling against the city streets. We're at the hospital within three minutes, and they are ready for us.

Room four! Room four!" They yell as we rush the stretcher down the hallways of the emergency department. Shocked patients, sitting upwards in their beds, forget their own troubles for a moment to see what all the commotion is about. Inside the brightly lit emergency room, doctors and nurses await us next to a hospital cot. We give a report and the patient is theirs. New pairs of hands with fresh gloves reach downward towards the gray child.


***

We all gather around the parked ambulances in the hospital loading dock. Each provider handles the call in their own way. Some tell jokes, some are silent. More than one person turned away with reddened eyes, tasking themselves with cleanup chores in order to keep busy. Just leave me alone for a few, they say.

Our supervisor walks from person to person, shaking hands and speaking softly. You did a good job, he said. The best we could have done. He asks if there is anything he can do, anything we need. Take your time, he says. You guys come first.

Back in the emergency department, they get pulses back. The pressure remains stable with vasopressors running into multiple IV lines. Warm air is pumped into the child's lungs via a respirator machine programmed to compensate for a gross metabolic acidosis. The pupils remain fixed and nonreactive to light.

Hearing the news, my partner's jaw tightens. She doesn’t say a word. I'm not sure what to say either. We head back to the office to clean up and restock, attempt to refresh ourselves. Our supervisor is more than accommodating. Anything we need, he offers again.

My partner insists that we go back out onto the road to finish the day. She'd rather work, she says.

We go through the motions of the rest of our shift, trying to talk about something else.

Medical School

At some point there will have to come a time where my caring for patients will have to be substituted for a drive to learn how to care for patients.

Medical school has always been the goal. In the background, mostly, over the past year of paramedic training - but the ultimate goal nonetheless. My motivation to become a paramedic was derived out of a desire to care for patients, to obtain the opportunity to touch them with my own hands and listen to their complaints. The experience has been extremely visceral: a realistic up-front endeavor into the "realities" of medicine that I couldn’t possibly have imagined beforehand. Each day I ride in the back of ambulances, granted the chance to experience these people, bear witness to emotion and - once in a while - do something about it. Despite all of the work that this requires, the genuine strength and depth of knowledge that truly is necessary, this is fun for me.

I don’t mean to sell paramedicine short. How could I, I'm not even a medic yet. Still though, I am constantly nagged by a part of my brain that forces upon me the memory that, yes, this is supposed to be a building block. The bulk that is "Medical Training" still lies ahead of me, a great mass of the unknown that it only illuminated in part by my endeavors in EMS. There is so much more that I could learn. So much more to experience. Medical school provides the opportunity to take that next step: the realization of all that yet remains a mystery. There, I think to myself, they can teach me how to really take care of patients.

All the while, though, I remain fascinated by ambulance work. These patients, and the treatments which I am able to provide for them, make me happy. I ride on calls each day, observing or even myself making a difference in people's lives. We in the ambulance see patients at the moment of their weaknesses and are gifted with an opportunity to lend strength, medical treatment and a calm voice. The feeling is intoxicating.

Medical school is a grounded and sure-fire pathway to excellence. I could have the opportunity to know more, do more, and -- it is assumed -- get more from my patients. The chance requires dedication, though, and a willingness to lash myself to the mast of science and resist the siren call of this visceral EMS experience. I need to give up what I enjoy to obtain something that I think - only through secondhand experience - will give me more in return.

Ostensibly, medical school provides an opportunity for better. ...But I wonder, how much of what I love will I have to give up in hopes that what comes out on the other end will surpass it.

I'm still not sure what to do.

HB

One of our older medics told me a story the other day. He confided in me that he and his partner, over the past year or so, have been involved in a special relationship with a local homeless man who calls himself "Homeless Bob," or HB for short.

The relationship began out of curiosity and boredom. One morning at the beginning of their shift, this medic decided to leave a few dollars and a note, partially hidden in an especially downtrodden part of town. The note read something along the lines of "Take this money as a gift, but please write me back." The drop-spot was a small red shopping basket, hidden among overgrown weeds, trash, and worn away concrete barriers.

Checking the basket every few days, this medic eventually found the money gone and a note - as requested - in return. It was written in sloppy handwriting, uneven lettering scribbled onto a tattered shred of paper. The writer expressed sincere thanks for this unexpected generosity, and praised god for his luck upon finding it.

Homeless Bob continued to write back for an entire year, each time finding some money or gift in the red plastic basket. The conversations grew more frequent, and gifts between the two increased in value. One morning after reading about complaints of sore feet, the ambulance crew left the man a set of workboots, and a warm work suit. Another time a sleeping bag was left. Homeless Bob began to make specific requests for gifts. He asked for money for a bus ticket, since his feet were too sore to walk. He asked for money for clothing or food, some trinket or another. The request was always for cash money, not for objects. Homeless Bob argued that he could "get things cheaper" than the ambulance crew would, so that their money would not go to waste.

The crew would return to the "drop spot" several times a day, checking for new communications. It was the their first stop in the morning. They would sit in a nearby parking lot when posting in the area, from time to time rushing off to help others on 911 calls and then immediately returning. This was their location, their project, their contribution. They were making a difference in this man's life.

One day Homeless Bob communicated that he was interested in traveling to meet some family who lived a distance away. He requested money for a motor scooter, which he said would enable him to get around town as he needed, as well as visit his family as he pleased. Seven hundred dollars, he said, would cover it. They left the money. ..And a little more, for a helmet, gloves, and jacket.

That was the last time they heard from Homeless Bob.


Musing about the experience, this old time medic reclined in his seat. He admitted to me that many times he thought he was crazy leaving all of this money for a man who would probably spend it on alcohol and drugs, waste it instead of seizing the opportunity to better himself. With each letter, though, he felt reenergized in the cause, convinced that the effort they were making truly did have a profoundly positive effect on this man's life. He described the experience as something amazing. Separate from the satisfaction he finds at his job with medical successes, he was able to provide for someone on his own accord: not out of a work obligation, or expectation based on the standard of care. The notes and gifts they left in that basket, he said, were his own choice. ...And from that, he found great satisfaction.

We returned to the drop spot later that day and found the red basket. It was empty, overturned and surrounded by the destruction of a forgotten part of town. The medic sighed as he looked around the area. This is exactly how he found the basket, over a year ago. Not a thing had changed.