Decisions

It is tough to have to be the one who makes decisions.

I've spent a lot of time preparing for this, reading my protocol book and leafing through notes. All of the advice is fairly linear. Problem A gets solution B. I've spent many nights learning about solution B, memorizing dosages and routes, committing medical control orders to memory. I know all about B.

What is harder, I'm finding, is that most of the time the problem is not A. ...It is A and C. Or part of A and a little bit not A. Patients are so often a murky gray, presenting in their own fashion a disease hidden by muddled complaints which lack the clear definition laid out in my textbooks. Solution B doesn't always work if the patient is not quite A.

I knew this of course. It is one of those things they teach you on the first day, the poignant advice that carries no weight until understanding is brought to the surface through experience. "The patient hasn't read the book on how to present." Sure sure, I thought. That is what assessment is for, right? That is what we were there to learn. Problem A is characterized by these listed symptoms: you just need to be on the ball enough to know what to look for.

Even when I think I'm on the ball, though, patients keep managing to throw me curves. An outlaying complaint, something that doesnt fit. The lack of a critical symptom. The right words, the wrong presentation. It is tough to keep confidence high when treatment comes down to a judgment call, the most important information for which must come from experience that I lack. Does this patient look sick? It is often hard for me to make the decision and remain firm.

The patient is on the monitor, O2 flowing and an IV established. I've done the glucose and performed my physical assessment, obtained the history and got the complete story. Still, I'm scratching my head with indecision. I look away from the patient towards my right, where my preceptor sits. A questioning look on my face.

He is there, sunglasses on, smiling.

"These are the decisions you're going to have to make."

Highlighted in Purple

Two months I have waited for this, and it has finally happened.

My name is scribbled in the book now as a 3rd rider, dubbed with the honor of a purple highlight signifying me as a new preceptee. Starting only two days from now, I will unwrap the pressed nine-lettered shirts that have been hanging in the closet waiting, and present to work ready for this next step. I get to be a paramedic again.

...Or at least play the part of one.

This news has come so suddenly, the change so abrupt that I cant help but feel naked without time to prepare. I've had two months of waiting, but waiting now seems somehow different from these two days that I have before I am expected to perform. I have been begging for this, prodding my administrators and making weekly frustrated phone calls. With the anticipation of a faraway goal stripped to reveal only harsh immediacy, suddenly everything seems much less glamorous. Oh yeah, I think to myself. I'm supposed to actually remember how to do this stuff.

I have been studying my protocols casually over the past months. I carry the book with me at all times, and I try to flip through the various pages after routine calls at work. I've gone over dosages and various intricacies that elude over time, but I now feel like it has all been inadequate. I need to work harder to make sure I remember. Read this book at least a few more times over, make notes, test myself. The book is beginning to become tattered with use, the bindings bent at the corners and edges frayed, but still it seems that I find something fresh every time I reopen the pages. Some detail I glossed over last time, a chart I misread and mis-memorized.

There is fear about missing a minute detail, of course. But the greater fear is to miss something obvious. Something like oxygen or c-spine precautions. With this increased complexity I have found it difficult to remember the basics- those things that are supposed to happen without thinking. New to paramedicine, I need to pay attention to the ALS, pour my time into it to make sure everything is right. It takes my attention away from the things that are most important. I know that this is a mistake commonly made by new paramedics, and I am putting a lot of thought into trying to make sure it doesnt happen to me. Or my patients.

This weird combination of fear and excitement is exhilarating. I start on Saturday. Wish me luck.

Down 180

Hey everyone, sorry I have been slacking a little bit on the entries as of late. I have been doing a lot of really mundane stuff at work as an EMT, drudging through an impossibly high stack of BLS transfers, emergi-fers and garbage 911 calls. To be honest, I feel like I can only become so introspective, so sensitive about this kind of stuff in my blog entries before even I begin to retch. It seems like I have been dealing mostly with BLS frustration and psychs lately, both of which I have written about multiple times at length. I really need something challenging to fire me up.

Good calls, though, have been at a minimum over the past month for some reason. Our service is down something like 180 calls per week, a stagnation that has left many of us - even those who are not normally so - eager for something... anything exciting. We are all sitting in our posts, listening to the radios for the tide to change. The old guys say these kinds of things happen, periods of good calls come and go in waves. ...But it seems like it has been forever.

I did receive some good news today, though. Apparently the gates have been lifted at work over this blogging issue, and I have finally been cleared to precept by the management. The start date, as it always is, is still tentative at this point, but hopefully I should be changing to a different shirt as soon as next week.

I sure do hope the tide changes by then.

Eyes

We find a young woman surrounded by firefighters and witnesses. She was walking along, they say, and then just out of the blue fell to the ground and started shaking. Her groceries are scattered across the parking lot, broken eggs and a box of cereal. She is looking upward towards us when we arrive, confusion spread thick across her face. Her brow is scrunched down, her mouth slightly open in absentminded slack. She looks at me searchingly. Her eyes ask questions she is unable to formulate, looking for answers she cant yet comprehend.

A man in his 50's grits his teeth as he sweats. His respirations are labored, deep breaths soak in through lips relaxed from fatigue. His wife pleads with him, pleads with us, but the man will not relent and admit his pain. His face is as hardened as it is ashen. Only the softness of his frightened eyes cry out, desperate for help.

A retired man sits in his recliner, surveying the room slowly. He looks at me and then my partner, long and drawn out. There is no comprehension as he stares right through us. I call his name as I touch his hand, and he slowly turns his head toward me. Looking right into my eyes through halfway drawn lids, he has no expression. I explain the procedure to the face looking at me, wondering if he can still hear. Into the vein goes the clear, sticky goop and life returns to his face. I watch the man return to himself as comprehension stacks up behind his eyes. He blinks a few times, awake now. "Where did you guys come from?"

A young man in his 20's walks in through the front door, lugging a big red bag and something that looks like a television screen. He looks around the room from left to right, searching for what he has been told he will find. A voice calls and he zeros in, finding the light switch and kneeling down. He smiles and asks questions, searching through the bag for what he needs. His manner is confident, focused.

His eyes, though, betray a hint of uncertainty.

A single light

The house was huge. Atop a large hill with a view so good the city taxes for it, the building was a testament to a lifetime of work. Large, spotless windows looked out over an expansive yard immaculate with a carefully arranged springtime assortment: newly budding flowers, a bubbling brook, and ornate iron wrought trimmings. The home was pristine in detail. New in condition but old in design, everything seemed to maintain a sense of timeless style.

Our dirty, diesel ambulance grumbled up the long driveway, spewing fumes and emanating a presence that, even as the driver, I felt somehow contaminated it all. We were called for a "lift-assist" only, a call so doomed to be boring that it fouled our moods and depressed our spirit. Frowning, we approached the house with our gear.

We were met at the door by an old man who was very happy to see us. Deep wrinkles on his face seemed to add volume to his smile as each crease and fold followed in turn, reaching upward as they contributed to his healthy grin. "Oh thank you for coming," he said. "Right this way. She fell on her way to the toilet and I just couldn't get her up. Just skin and bones she is, there's no meat left. She really shouldn't be walking around like that anymore."

We followed him through the house, an agonizingly slow pace as the man hobbled from one step to the next. Passing through an expansive kitchen and a luxurious living room, I marveled at the home. Absolutely beautiful. Around a few corners and down a hall, we turned right into a room lined with wood. There, on the floor, was an older woman laying face-down. She was positioned just next to the hot tub, a large marble edifice covered with more wood and leather. The tub was dry. It looked like it hadn't been used in years.

The woman had her eyes closed. She looked exhausted, her head resting on a makeshift pillow fashioned from towels pulled from hangars on the wall. Wrapped around her was an old, yellowed bathrobe. The material looked thin and fringed at the edges, a hole here and there. Although she was covered I could see that the woman was extremely thin. Ghostly thin. Just skin and bones, covered with the tattered remnants of a robe, the woman let out a small sigh as we introduced ourselves.

The man interjected immediately, apologizing for the lack of formal introduction. "She's very tired," he said. "She's been there on the floor for some time now, I just couldn't get her up. There's nothing to her, no meat on her body, but I dont have the strength anymore."

We smiled back. No problem at all. We're here to help. My partner kneeled down and touched the woman's hand. He asked about how she fell, if she remembers everything that happened and if she has any pain. The woman, seemingly mustering great effort to find the strength to do so, answers quietly. She slipped on the tiled floor. There is no pain. She doesn't have the strength anymore. "I've lost all my muscle."

We lift her up together even though one of us could have easily handled the task alone. The woman was even thinner than she looked. Like picking up a bundle of sticks. We sat her down on a chair as she sighed with relief.

The man, again. "The doctors think she has cancer. In the stomach, they say. We did a bunch of tests last week but they want us to start chemo right away. They havn't even seen the results from the tests yet!" The man's wrinkles dropped downward into a hardened frown. "How can they be sure she has cancer if the results aren't in yet?"

My partner and I both know the answer, but dont let it escape. The cancer must be that obvious, so plain to the doctor that the tests were only a formality. Look at her. Skin and bones, no meat left at all. Something is eating her away from the inside, hollowing her out. Neither of us imagine that the diagnosis was all that difficult to ascertain. The woman is deathly sick.

I ask her if she would like us to take her to the hospital. It is probably a good idea, I say. Falls are sometimes a sign of something else, and if you're feeling extra tired that might be another warning sign. How about we take you to the emergency department and have the doctors take a look at you.

The woman raises her head upward, which until now remained hung downward between her legs. Her eyes came to life as she emphatically shook her head no. "No more hospitals. I'm so sick of the hospitals. I was just there for 9 weeks, and look at me. I just want to rest." I try again in vain to get her to oblige, but she will not relent. "If you could please just help me to my bed. I'm so tired." The man agreed.

We helped her to her bed. Down the carpeted hall and left into a small room, we moved slowly as my partner and I each guided an elbow. The room was packed with personal belongings. A TV in the corner, bookshelf on the far wall. There was a small sink in the room that looked like it had been added, and a mini fridge under the bedstand. The large room was cramped with the necessities of daily living: items from every room of the house concentrated into one small space.

The woman explained. "This is where I spend most of my time now, since I've lost so much weight. I dont have the strength anymore to move from room to room, so I had all of the necessary stuff brought into here." The woman, despite an effort to project a smile, betrays a saddened frown. "No muscle on my bones anymore."

We tucked her in and brought her remotes close. Made sure she was comfortable. She thanked us profusely throughout, asking for our names and writing down the company we work for. She promised to call our bosses and sing our praises. "You boys are so nice," she said. The man knelt on the side of the bed, tucking in the covers and arranging the pillows.

We showed ourselves out. Walking through the house on our way, we noticed for the first time how empty the other rooms looked. A hot tub that hadnt been used in years, couches covered and left alone, lights off and drapes drawn. It is easy to keep things looking immaculate when you never use them anymore. A lifetime of work and success, spread out to lavish comfort and then forgotten in the face of disease. Their world shrunken down.

We coaxed our dirty ambulance back to life as it growled and spit in protest. Rumbling down the driveway, I could see the shape of the enormous house against the night sky. Only one light remained on in the entire building. A single room illuminated.

The light faded in the distance as we headed to our next call.