Effective Immediately

My day with the Chief went very well. We did a few routine calls, a man who had fallen down a flight of stairs with an obvious closed tib/fib fracture, another man who's plaster ceiling had fallen down on his head while he was washing the dishes. I assessed the patients, directed other crewmembers on scene, and made treatment decisions based on my clinical impressions. I was nervous, and sweating in the 90 degree heat, but apparently avoided screwing up too badly as at the end of the shift I got a handshake and congratulations. "Do your best to kill as few people as possible," he said with a smile.

And I was done.

It seems a little odd now, after having jumped through so many hoops, filed so much paperwork, and paid all of my dues: here I am now with nothing else to do other than go out and work. What do you mean I'm cut loose to practice on my own? You mean I get to go out all by myself, with just an EMT?

I received a letter today from my Medical Control hospital:



Effective Immediately, but the feeling hasn't quite yet hit home.


My first shift as a paramedic will be tonight. 6pm till midnight or so, I am doing a quickie shift with a good friend of mine watching over a boxing event. I guess I should brush up a little on my trauma protocols?

A Final Ride

All of sudden, the day is tomorrow.

I've known for a while now that my preceptor has been just about ready set me out on my own. He has mentioned it several times, but the day was always weeks away, obscured by an unknown buffer of time. There were always a few more shifts in between then and now, a few more free lessons available for me to learn. A few more reasons to put it out of my mind.

Not anymore though. I found out this evening that tomorrow I will ride with the Chief Paramedic, my last 8 hour evaluation before I am (hopefully) cut loose to perform on my own. We will ride together for the shift, him driving and me running all of the calls. We will jump all of the good dispatches and then he will watch from the side with eyebrows raised, I imagine, as I sweat my way through each of the assessments.

I am excited for this - I have been waiting a long time for it - but right now none of it seems all that fun. My esteemed readers, please wish me luck. It could very well be that this time tomorrow, I will be out on my own.

A Potent Lesson

The man looks up at me from his bed, surrounded with the trappings of his daily life. Within reach are carefully arranged remote controls, for his bed, tv, stereo, and nurse. His pillows are arranged just-so, tucked under his legs and back in an assembly that surely took weeks of trial-and-error to get just right. Photographs of family and friends surround the bed, adorned with gifts and trinkets, flowers and balloons. He is 82 years old, relegated to bed by age and disease, chosen to stay there through consent forms clearly indicating his wishes: Do Not Recesustate, Do Not Intubate, Do Not Hospitalize.

He looks at me, sweating. I dont even get to ask what is wrong before the problem presents itself, making it's own introduction. The man's muscles flex and bend inward, all 4 extremities tightening and releasing quickly as electricity claims control for the millisecond. A shock from his implanted AICD. The man's face portrays equal amounts of annoyance and pain. "It's been happening all day," he says. "Just go ahead and get me to the hospital so they can turn this damn thing off."

Aware of the man's advance directives, I ask what it is that he would like us to do on the way. We have drugs that may help stop the shocks, I would like to give them a try if it is okay with him. Exasperated with the painful shocks, he reluctantly agrees. I explain what I would like to do, and the man waves his hand- "Do what you have to do, just make this stop."

On go the white, black, red and green wires:


Except for the jolt of electricity every 60 seconds, the man is without complaint. I ask all of the pertinent questions, perform my exam and search for more, but there doesnt seem to be much other than what is printed on the EKG paper, and the occasional flexing and arching of electricity. The blood pressure is 130/80, SPO2 99% on room air, the man is without pain or shortness of breath.

I leave the monitor on print, capturing the various outrages of the man's irritable heart:



I watched the rhythm widen and become narrow again, it's irregularity and rate alternating unpredictably, punctuated by discharges from the man's AICD and perhaps his pacemaker as well. I recognize a-fib underneath, but waver at a clear interpretation of the faster, shockable rhythm. The man sweats uncomfortably, bracing as he awaits his next scheduled shock. He asks me if we can get a move on. I call the faster rhythm a "wide complex tachycardia of unknown origin." Even though I see the rhythm narrow in places, I am nagged by occasional width, and spurred onward by the man's prodding. I am eager to provide relief, and ready to make a decision about the EKG.

I should have slowed down.

I get the man on some oxygen, and start an IV. Acutely aware of the rhythm changes, I make a decision to administer Amiodorone: 150 milligrams over 10 minutes, diluted in 100cc of normal saline. I am an expert at the tasks by this point, and the work goes quickly. It was a difficult IV, but I got it. Our buritrol was broken, but I managed. I mixed up the drug, piggybacked a line, and accurately calculated the drip rate. Like a machine.

We drip the drug in on the way to the hospital, a 10 minute trip. It is at this point that I remember the 12 lead cables. I see them in the back of the monitor as I am looking for something else, bunched up where I put them last and conspicuously unused. I recognize immediately that I should have used them earlier. I look up at the medication bag, and it is halfway gone.

On go the six black wires:



The rate is still fast, but nothing else is the same. It was as if I had wiped away a dirty window and looked again, amazed with a new vision- unobstructed and clear as day. This rhythm is not wide at all. It is narrow, irregular, fast. It is a-fib. Any day of the week, a-fib.

I stare at the strip, drained. The Amiodorone is almost all of the way in now, and while the drug is far from the wrong one (it may still help), it should not have been my first choice. A-fib like this gets calcium channel blockers, not general antidysrhythmics. Mine was an appropriate treatment still, but a less effective one - and something that I will have to explain to the doctor who will surely ask why I made such a decision.

The patient, unaware, rests comfortably. I look up from the EKG paper as he touches my knee. "Thank you," he says. "This is much better." His heart rate has come down slightly, to about 150, and the AICD has stopped shocking. The diaphoresis is gone. I tell him he is welcome, grateful for his relief.

In the ED the doctor does ask me why I chose Amiodorone. He looks over the strips quickly as he moves between charts. "That looks like a-fib or flutter. Pretty fast, too." I offer a weak explanation that the rhythm appeared wide at times, and that I felt that this drug was a safe call considering the varied morphologies. He shrugs, and says okay. At least he's not getting shocked anymore. I shrink back away and try to disappear.

Paramedic friends of mine say that I'm too hard on myself. I should have done a 12 lead first - especially on a stable patient like this one - but they pat me on the back and tell me I still did well. It's hard, they all say, to make these determinations quickly, in the back of the ambulance surrounded by the chaos of a patient in pain and buried under a mountain of other tasks that must be done at the same time. "Dont overthink these things," one medic tells me. "Just next time make sure you get that 12 and you'll be right on."

Still though, I'm angry with myself. I was eager to get to the treatment, moving too quickly for a necessary second glance at the rhythm. It was embarrassing to come into the emergency department, to give reports to doctors that I respect, fully knowing that I didnt quite do the right thing and, worse, that the cause of the problem was an omitted step. These kinds of mistakes can turn out well, like they did this time, or they can be deadly. It is a scary thing, and I really need to be more careful. This was no benign error.

This is something I will not soon forget. I feel strongly that the resilience of this kind of lesson is equal in proportion to the amount of danger the inciting mistake imposes. This was a small omission which could have posed a significant danger to a different patient. The importance of such an opportunity to learn consequence-free is not lost on me, and I will make great efforts to make sure that the memory sticks. I will squeeze this for what it is worth.

I overheard a new medic the other day, worried about his upcoming ride-time as a new preceptee. He was nervous, explaining that he hoped he didnt "make too many mistakes." To the contrary, I think. May he make lots of mistakes. Let them pile up underneath him, build up his experience and stick with his memory. May his errors remain free from serious consequence, but packed full of value, so that next time the choices will be clear and ready.

I am new. I will continue to make mistakes. I cannot hope that they will not happen, only that when they do I am able to claim from them the fruit of experience, and pass the benefit to my next patient.

I will be better next time.

New Paramedic and Aspiring Doctor

I wrote in my last entry that I hadn't thought about medicine over my vacation. That isnt quite true.

While becoming a paramedic has dominated my thoughts these past few months, I often find myself looking back on it all- angry that I've let the greater goal slip from consciousness. I still want to go to medical school, to take my education further and move onward. Paramedicine is seductively interesting, though, and snares me each day with its excitement, newness, and promise of more. There remains a fantastic depth to this work that I am far from understanding, and yet the sum of it all is assumed - by my other mind - to be shallow at it's end. With so much new to me, I am supposed to prepare for the point at which it will no longer suffice.

I've found it incredibly difficult to put that effort forward, with each daily experience tingling with challenge and intrigue. I love the work. I learn something new every day, meet different people and experience scenes that I can barely translate to type. How could this ever come up short?

It will, though. I am tenacious enough for this kind of knowledge, eager enough about medicine that I can see myself stretching my capabilities out to their limits. I will continue to read, explore, and learn. I will become better, more experienced, more adept. At some point, I think, there will come a time when I want more. More medicine, more knowledge, more freedom, more money, more everything. Despite all of my excitement about paramedicine, that feeling is still there. Nagging.

Nothing is easy, though. I need to take a full time position at work, so that I can get health coverage and a regular paycheck. At the same time, I still have to take a year each of Chemistry and Organic Chemistry so that I can prepare for the MCATs and eventually apply to school. The two do not necessarily jive well. I am last on the seniority list at work, relegated to the last - least desirable - shift at work, which may or may not coincide with the lecture and lab classes I need to schedule. Fees at the college approach $1500 per 4-credit class, of which I need to take 2 per semester in order to finish within a reasonable time. Money is tight, time is worse. ...And all along, the siren song of EMS maintains it's relentless tug. Even after all of that: the idea of medical school scares the shit out of me.

And yet I remain firm. This needs to get done. I will put my head down, work my shifts, learn my lessons. Stay sharp and keep my eye focused on where I am headed.

Cruising

I thought I'd explain why I havn't posted in a few days.

Currently I am aboard a cruise ship, sailing in the Atlantic Ocean towards our next destination in Bermuda. This is a 7 day cruise, and we have already made stops at 2 islands in the Bahamas, spent time on the beach lounging and playing volleyball as we sipped on icy red beverages. It is a much needed break from the 70 hour weeks I have been working in the city, although I look forward to returning on Monday, refreshed and conspiciously tanned.

I have thought very little about EMS or medicine over these days, and I think I'd like to keep it that way. The internet here is very expensive anyways ($0.75 per minute), so I will delay writing further until I return.

To my friends back in the city: would you mind texting me your home addresses? I have something to send, and cant use my phone without huge ship-to-shore charges.

See you all on Monday!

The Front Seat

My preceptor was out on vacation today, so I spent the day doing calls with my EMT-I partner, swapping every other call as technician and driver. It was something of a nice change: to sit in the front of the ambulance again where the AC blows cold and windows surround every view. It feels like a long time that I have been locked in the back of the truck, relegated to the uncomfortable seat and stuffy atmosphere, removed from conversation and left to my own thoughts.

I was reminded again of the experience of driving. Priority 1 to a call, flicking the sirens and blaring the horn. Talking trash about drivers who freeze or do the wrong thing when we come racing their way. It all seems to add to the experience, and I hadnt realized how much I missed it until I got the chance to remember it today. I like to quickly switch the "wail" siren on and off through intersections, creating my own - custom - wah wah wah sound for all to heed. Some people like to use the air horns constantly, blaring for long, drawn out tones as we slip through traffic. I like to use it sparingly, though, saving the obnoxious blast for only those who do something really stupid, or are about to hit our ambulance. I like to keep something in reserve so that I have a "next level" if the situation requires.

My partner drove to a call today, a particularly long distance across town on a priority 1-- his favorite kind of response. He settled into the seat and gripped the wheel tightly with his left hand as the right worked the siren and horn. He is aggressive behind the wheel, moving his body to the left and to the right as if cornering on a tightly wound motorcycle. Our heavy ambulance tilted and swayed in turn. By the time we got on scene we could smell the hot brakes, a potent acrid odor that satisfied my partner in affirmation of a well-driven response. He could barely wipe the smile off of his face. The experience of responses like these are somewhat less enjoyable on days when I am trapped in the back of the ambulance, arms and legs spread out in four points of contact as I attempt to anticipate the next pitch and roll of the lurching vehicle. Today, though, I was in the front.

I got to drive slowly, too. On the way to the hospital with a patient in back, I had the chance to talk with family members or friends who came along for the ride. On one call we took along a friend of a patient, a nurse for 15 years who suffered through the experience of becoming her friend's healthcare provider for the 10 minutes before we arrived. It was horrible, she said. She couldnt separate herself from the situation, become the objective observer that the job really required. Several times she would stop mid-sentence, to turn around over her shoulder and, worried, check that her friend was "still doing okay" in the back. She turned forward, catching my eye each time with something of an embarrassed look: as if she wasnt supposed to behave in such an emotional manner as a "professional provider." She apologized and I told her not to worry.

It was a nice break. Tomorrow I am back in the rear of the truck, my preceptor returning to supervise me on another day's worth of calls. We are hoping for a "good medical," maybe a CHF or a profound MI. I haven't had a chance to use our new CPAP devices yet, either.

I look forward to learning something new.

Survival to Discharge

I found out today that my "code-save" from the other day actually was a code save. A paramedic student doing a rotation in the CICU caught up with me, excited to tell the story of a man who was wheeled in with tubes and wires, wrecked and posturing, only to walk out - under his own power and without neuro deficits - 6 days later.

It boosted my whole week, thats for sure. I wonder if some day I will bump into him walking on the street or in line at a store, a vague recgonition as, yes, that's the guy I helped resuscitate. I wonder if it would be prudent to say anything to him, if that oppertunity were to ever arise. What would I say? What could I expect him to say?

I probably wouldnt say anything.

I got around to digitizing (in my own halfway manner) the strips from that call. With the good news in mind, I thought I'd post them. A story told by EKGs. (You can click on any one of these to get a more detailed view)







I skipped a few to make the story a little more succinct, but please rest assured that there do indeed exist strips with regular 3 leads, and a perfect square-like capinography output overshooting first in the 60's, then coming to rest around 40. The tube was good the whole time, I made damn sure of that.

**

In other good news, I got word from my preceptor that he is "about ready to kick me out," meaning release me from my preceptorship and set me off on my own. We need to schedule a day when I can ride along with one of the company's administrators, to be evaluated and checked just one last time before I am allowed to practice without supervision. I am acutely aware of how much I have yet to learn, but even still I am eager to be given leave to make my own decisions. Peter Canning's preceptee is in a similar position, and she confided in me the other day that she might "never feel like [she has] learned enough," but the time is soon approaching where she is "going to have to learn on her own."

Both of us are just about ready to be cut loose, free to make our own mistakes, pick ourselves up, and learn our own lessons.