Wednesday, May 30, 2007

Two Codes

The experience of a cardiac arrest is something of a mark of distinction among new paramedics. It is a notch on the belt, a necessary experience. Between preceptees, the conversation almost always centers around talk of tubes, code opportunities seized and missed. Preceptors hold their students for weeks and weeks, the ALS calls building up beneath them, full in all else but lacking the fundamental experience of a cardiac arrest. My preceptor was the same way. We need a code, we need a code.

Last week we got two.

My fellow preceptees are jealous. Two codes, two tubes, two opportunities to sample the experience and start to develop my technique. I get asked about it all the time. People clap me on the back and smile, shake my hand and punch my 9-lettered rocker, welcoming me to the brotherhood. I smile back, laugh and joke about the experience.

Thinking back about the calls though, all I remember are the mistakes.

The first code was a man in his fifties, collapsed in front of his coworkers in a large, cubicle-filled room. When we got there a first responder had already shocked the man twice with no effect, CPR was in progress. He lay there still: one eye half open the other closed, ashen gray and dead. I hesitated for a few seconds, taking in the scene. I wondered where I should go first, where I should put the big red bag and set down the monitor. Everyone was watching us, heads and curious eyes popping above the cubicle walls. The room filled with hushed silence, broken only by the rhythmic counting of first-responder CPR.

My experienced paramedic partners nudged me on, filling in the gaps as we performed each task. We got him on the monitor and saw V-Fib, shocked once with no effect and then got the line. I was opening the intubation kit when we shocked for the second time, finding the rhythm changed and organized. Fingers to the carotid find a bounding pulse as sighs of relief and clapping fill the room.

What a feeling that was.

Still more work yet though. I assemble the intubation equipment, and it seems to take forever. Stylet into the tube, find a blade, white, tight, bright, get the ETCO2 ready, the tube holder, 10cc syringe, and my stethoscope. My partners are pushing lidocane and atropine for a bradycardic post-arrest rhythm. I take a deep breath and roll the head forward into the sniffing position, insert the blade and see what I can find. The man takes a long, deep breath as his mouth is illuminated, and I watch as each muscle and flap of tissue rattles in the wind. I follow the blade backwards, into the retreating dark and underneath the floppy epiglottis. Chords cry out to me as big and white and bold as ever. I pass the tube, inflate the cuff, and send in a bagful of air. Moist condensation on the tube followed by good lung sounds and a beautiful ETCO2 waveform in the 50's.

It was at this point during my last code that my work ended. It was during my internship ride-time, and I was satisfied to simply have gotten the tube. Today, though, there was so much left to be done. The man was lying there on the ground surrounded by the debris of a halfway worked code. Wrappers and papers, EKG pads and bits of tape. Wires and tubes ran in every direction.

Together we organized the mess. We got the board under him and strapped him down, figured out an exit strategy and kept watchful eyes on the monitor. I recruited a woman who identified herself as a nurse to bag the patient, gave her careful instructions on how to mind the tube. We all worked together, struggling and groaning to get the man on the stretcher and into the ambulance. Tubes and wires cross and recross into an impossible tangle.

My preceptee asks me what I would like to do next, and I fumble for words. I've never been here before. "More leads" I say, thinking that we should watch the rhythm through a 3-lead ECG rather than the coarse paddle view. "How many more," he asks me, smiling as he probes. A light goes on above my head. Aha! Post arrest 12 lead! He nods and smiles some more. "Anything else?" Again the routine.

He nudges me through the rest of the patient's treatment. Puts me on the spot and with gentle hints I remember what it is that we are supposed to do. Lidocane is hung and I figure out the drip rate. I push versed as the man begins to buck the tube. I patch to the hospital as I attempt to catch my breath. I wonder if I would be able to do all of this if my preceptor wasnt there to remind me.

In the ED we get claps on the back and handshakes of approval. Everyone is happy to see a code-save, and the credit goes directly to my partner and I. I feel undeserving.


The second code was in a nursing home, a large woman found pulseless and aepnic by a surprised nurse just after lunchtime. Again, my partner and I arrived to find work had already been done. Another paramedic was working on the line as frightened nurses tried in vain to pump CPR into the huge body bouncing on the facility bed. They were bagging, too, and the patient's belly was huge. I glance at the monitor quickly only to see CPR noise, and the first paramedic on scene informs me that the rhythm is asystole.

I think of nothing other than the intubation. Again I assemble my equipment quietly at the patient's side, paying singular attention to the list of tasks that precede passing the tube. I hear the medic at the IV site announce that he got a line as I continue to ready my equipment. Gathering up all of my things, I ask the nurses to stand aside as I snap the laryngoscope open. The woman is huge and I wonder how tough the tube will be. I got the last one though, I think. I shouldnt have a problem with this one either. Hands on both sides of the head as I roll forward into the sniffing position.

A voice from the other side of the patient. "I guess I'll just go ahead and push epi and atropine then, huh."

I look up quickly, ebarrassed. "Oh, yeah," I reply. "One milligram of each please." The medic shakes his head as he goes for the drugs that he has already made ready.

Into the mouth I go with the blade. The tongue is huge and I fight it to the left, lifting and pressing forward as I try to avoid the teeth and raise mounds of tissue. The light at the end of my blade seems to smother and snuff amongst the wet masses inside. I find the epiglottis, though. Lifting as hard as I can with one hand, I am only able to see a peek of the chords. I reach for the tube and try to pass it into the spot. The tube obscures my limited view as I pass it through. My partner asks if I am in and I dont know. A bagful of air through tube and we get nothing back. No noise in the lungs, no fog in the tube, no reading on the end-tidal CO2. Gurgling in the belly.

I curse as I pull the tube back out. "One more try," I say. Nobody is doing anything as I struggle. They all watch, waiting for instructions from me that never come. Frustrated with the tube I am oblivious of everything else.

In with the blade I go again. The position of the blade is much better this time and I see the cords immediately. The tube goes in smoothly and everything checks out well. ETCO2 hovers at 10. I have no idea where I put the laryngoscope after that moment. It might as well have vanished out of my hand.

I am now aware of everything else that needs to get done, and I give feeble instructions to my partners who follow through and fill in my gaps. Everything is a mess. Worse than last time, this code is bigger, messier, heavier, longer, and more futile. I ask someone to maintain compressions as the new ACLS suggests, but it is impossible as we are moving around corners and through hallways lined with wheelchairs. Nothing seems to go right, and I'm not helping.

We do CPR on the way to the hospital, pushing another tube of epinephrine in every few minutes. I tally the number of tubes we push on a scrap of paper. The rhythm never changes even once.

In the emergency room we wipe sweat from our foreheads and give a breathless report of the futile code. The hospital staff makes a cursory effort, and the patient is pronounced dead a few minutes later.

I've gone over these patients hundreds of times in my mind, wishing that I had another chance to run through the calls. The mistakes are so obvious to me now, so plain that they stand out clearly as they nag and pester. I need to control the scene instead of focusing on the tube. I need to look at the big picture instead of zeroing in on a detail. I need to better delegate tasks and assume a leadership role. I need to remember what it is that I am supposed to do, what priority it takes, and how to practically get it done.

I realize I am new to this, but I wonder how many newbie mistakes are acceptable. I feel embarrassed for what I've missed, guilty for the things I could have done better. I need to do these calls over again.

I've made a list of things that I want to focus on next time. Hopefully I get the chance at least once more, before this precepting support structure is yanked out from beneath me and I am left alone to stand or fall. I fear that I cannot yet support my own weight, and yet the time is soon approaching that it will be required of me.

To my patients and coworkers, their families and myself: I promise that next time will be better.

Monday, May 21, 2007

Ones and Zeros

My preceptor keeps diligent records of my performance on his laptop computer. Spread out in sheets and boxes are the statistics of every call: IV success, percent ALS, percent BLS, airway skills, EKGs, drugs, tough calls, easy calls. The columns span to the right in seemingly endless lists, filled with binary digits designed to add objective value to my successes and failures. On secondary pages are the graphs. Pie charts lay out in colorful detail the number of times I performed certain tasks on specific patients. Lines and bars describe my hit percentage with IV sticks. My preceptor will fill in the details of each call after we finish, diligently plugging ones and zeros into the designated boxes. The graphs automatically adjust, the lines traverse up and down.

At the end of each week he prints out a report and I can see, with three digit accuracy, whether I have improved. Last week the bar graph on my IV percentage went way down. Traumas went up, along with the associated skills. A pie chart suggests that I am getting more experienced with airway maneuvers.

Still though, I wonder if he notices the things that cant be assigned ones and zeros. Looking over the report, there seems to be no value for subjective performance. No cell that captures how I remain calm and polite with the overbearing (yet uninformed) nurse, no graph describing my management and delegation of duties on scene. Nothing that makes note of how I was able to make that suicidal 9 year old laugh all the way to the hospital.

I feel like I am doing well with the things that count. I care about treating my patients well: a philosophy that I believe encompasses accurate medical care as well as comfort and compassion. I try to be mindful of those around me, politely taking reports from first responders and making requests of my help with only the urgency necessary. I know my protocols like the back of my hand, and I dont think my medicine has strayed even once from the standard of care. My first-shot IV percentage sucks, but out of almost 40 patients I can count on one hand the number of patients who I couldnt (eventually) get a line on.

I am acutely aware, though, of the things I have yet to learn. I need to get better at evaluating the whole scene, making a plan early-on, and following through. I want to get better at recognizing potential problems in advance, solving issues before they occur. (Never again will I let a patient seize on me during a 2nd floor carry down with no IV access and the Versed sealed in my pocket) I need to sharpen my ability to make the basics automatic so I can focus on the advanced. I need more time to develop a system so I can do the same thing, every time.

These are things I think about. I am my worst critic, I admit. ...But I wonder sometimes if I couldnt use a few more comments about these subjective things from another perspective. My preceptor says that I am doing fine, that his relative silence on these issues is evidence that I am performing well on my own. I am worried, though, that I am making mistakes that he doesnt see, or missing things that he does not mention.

Despite the boxes and lines, charts and graphs: I yearn for more feedback.

Thursday, May 17, 2007


Her whole body is alive with motion.

Each muscle tremors under tremendous stress, shaking her legs and arms in a disorganized, frantic motion. The knees buckle inward as they collapse, sending the entire body to the floor, writhing and kicking along the way. Her hands grasp air tightly, clawing at nonexistant threats and tossing them to the side. Muscles strain and pull ligaments inward, flexing and relaxing in rapid succession. Her face is running, soaked with wet tears, snot, and spit. With each breath she sniffles to divert rivers from running inward. Her mouth is open and crying, loud gasps from full, stressed lungs.

On the floor writhing, spitting, yelling, flexing, praying, she quivers with life.

In the bathroom on the floor lies her mother, silent. Despite crashes and screams from the next room, the face is rock solid and devoid of expression. Her eyes are motionless as they stare towards the tiled floor.

Her skin is waxy solid, a blue-gray hue.

Wednesday, May 9, 2007

Mistakes and Successes

I've finished my first week of precepting, and as all of you have probably noticed: I havn't posted any new entries.

It most certainly has not been for a lack of things to write about. These past six or seven shifts have been completely full with new experiences, new lessons, and new stories. Already I have done things that I never thought that I might have to do, bore witness to things I hadn't planned for. Working as a paramedic is a completely different adventure, and as of late I have found myself so overwhelmed with experience that I havn't had the time to sit back and expound on them in type.

I'm surprised by the number of mistakes that I'm making. I suppose that this should be expected, but the devil truly has been in the details. There are so many more decisions that I am responsible for, often it has been all I could do to perform BLS, control a scene, make a plan, and thrust a feeble attempt towards ALS. It is a special skill to remain organized in the face of chaos, to do things methodically so that nothing gets missed and no wires get crossed. It is most definitely a skill that I have not yet come close to mastering. I feel like I wheel each of my patients through the ER doors half-finished, always asking assessment questions in triage.

I find myself constantly hoping for a few more minutes, a moment of calm to sit back and peruse my options. In this city the hospital is always so close, looming down from a few blocks away is the promise of my patient's salvation. How long am I supposed to spend in a patient's house or in the street: assessing, tangling monitor wires and inserting needles? Time is always an issue.

With my attention focused (or spread out, perhaps) on the newness of all of this, I have made some fairly silly mistakes. I splinted the wrong wrist on a fallen motorcyclist, started an IV without spiking a bag first, forgot my oxygen bottle on a 6th floor asthma. Mistakes I would never have made as an EMT-B, but with my new responsibilities I have had trouble remembering the basics: something that I have been working hard to keep from happening.

A step back so that my next one forward is sure.

Along with failure, though, I have had some successes. The purported diabetic who I recognized as an overdose, treated, and laughed with the rest of the way to the hospital. A chest pain that I feel I managed well, offering palpable comfort to a worried old woman. While some calls have left me feeling helpless, I have been blessed with many opportunities to be the face of relief, comfort, and compassion for my patients. My preceptor seems to be reasonably pleased with my performance. He wrote in a recent evaluation sheet he feels that I am both doing well, and capable of better.

I'll make sure that he's right.

Tuesday, May 1, 2007

Switching Seats

It was only a little baby 22 gauge, but it felt like I was pushing a garden hose through sand once I got through the skin. She winced in pain and let out a yelp, fighting the urge to pull her hand back from mine. She grits her teeth, sucking in air sharply with each motion of the needle.

No flash.

I look at the back of the hand, where I had carefully landmarked the tiny vein just a few seconds ago. It was obvious before, but now that I have inserted the sharp under her skin it has retreated to some unknown depth. It doesnt want to be found.

I try to ignore the woman's painful cries and continue my search for the elusive vessel. I use the tip of the needle like a probe, moving slightly to the left and upwards as I get closer... as I must be getting closer to the goal. Where the hell is that goddamn flash? I elect to insert more of the needle, reach farther underneath the skin. Another painful yelp from the patient. She is becoming less able to control pulling her hand back, and I almost lose the needle altogether.

"Just one more second ma'am, I've almost got it. Please try and stay still."

I dont have it though. There comes a point where - after inserting the needle and missing - careful correction becomes blind hunting and hoping. I have lost sight of where the vein was supposed to have been, and now I am sticking in the dark. I've crossed that line. One last time I move the needle upward and forward.

A splash of blood into the tiny chamber.

I wait. Sometimes the small needles take a long time to fill up the flash chamber. The lumen of the needle is very small, it takes time. Just wait a few more seconds, you'll see, it'll fill right up and the IV will be done. ...It shouldnt be taking this long, though. I must have gone right through the vein. One more tiny motion and it is confirmed as a small bulge grows on the woman's hand. Shit.

My preceptor raises an eyebrow. I've missed twice now, it's time for him to take over. I carefully climb over the monitor cables as we switch positions: me into the airway seat and him to the bench. I watch from the penalty box.

He assesses her arm, selects a location, and inserts the needle. Easy as pie, the flash chamber fills right up and the catheter slides without a hitch. The safety needle moves back and locks into position. ...The familiar clicking sound of a successful IV.

My preceptor lets out a little chuckle, smiling at me.

I'm never going to hear the end of it.