Monday, July 30, 2007

Protocol in the Pits

In addition to the city, the company I work for has a contract with a large music venue nearby, and employees often get the opportunity to do "standbys" at the various acts that come through town. I picked up one of those shifts recently, a large rock concert consisting of multiple bands over the course of the day. Concerts like this are always a little bit crazy, packed with people fueled with alcohol and drugs, spurred along by the music into what often becomes a violent frenzy. This time was no exception.

It is a large venue, but people pack the place so tight that it is often hard to move. We carried portable radios on our shoulders turned up to maximum volume, but it was still difficult to hear the various dispatches over the guitars and yelling. Sometimes you would know to listen to the radio only because your partner had heard it by chance, and we would see eachother, head titled to the radio and hands cupping the speaker: hoping to hear. Eventually we would catch the dispatch, hearing a crackled "section 800, man down" before we would start moving.

Every response carried with it a little bit more adrenaline than usual. We pushed our ways through the crowd, yelling "move! move! make a hole!" as loud as we could. People would turn towards us with a little bit of "who do you think you are" look on their face, and then recognize, moving out of the way as quickly as possible. Sometimes people would take it upon themselves to charge ahead of us, clearing the way bully-fashion in a spontaneous effort of layman heroism. Each time they would smile at us, satisfied, and thank us for doing our job. We thanked them, too.

We carried a lot of people out of the crowds. A lot of people too drunk to stand, vomiting or passed-out, unresponsive or only slightly so. They open their eyes lazily to reveal hugely dilated pupils, often denying having a single drink all day. "Nah man," one patient slurred. "I've been straight all day. I dont drink. Much. I only had twelve." It was impressive. Beers were going for seven fifty apiece.

There was lot of trauma, too. Mosh pits would form along the edges of the cheaper seats, large circles where hyped-up fans ran around aimlessly, pushing and slamming into eachother as hard as they could. We stood and watched for a while as people would run into to the pits for 15 minutes, returning with cuts on their faces and bruises on the arms: smiling like crazy. There are unwritten rules about mosh pits, I learned. If someone falls down, everyone helps pick him up. You dont hit in the face and you dont throw punches or kicks. It is not about fighting, I was told, it's an organized expression of anger and rebellion to go along with the music. Sometimes there were fights though, and we would watch till they ended, carrying out those injured on wheelchairs or stretchers with c-spine equipment.

We were watching one of the bigger bands play when we were dispatched to another "man down" in the middle of the theater. This was probably our 10th of these dispatches, but we charged at it with energy nonetheless, pushing through the packed crowd to find our patient. We found him, in the center of a clearing of onlooking people, slumped on the ground and not moving. Two other crews, having heard the dispatch, showed up as well. We ask if anyone saw what happened, and someone stepped forward to tell us that he was crowd surfing and dropped "right on his head." He hasn't moved since.

We send someone to get the stretcher and c-spine equipment, which was stashed nearby. Someone grabs manual c-spine. I get on my knees in the muddy grass and lean down towards the patient's face, and he opens his eyes when I yell to him over the music. He seems a little lethargic, but is able to answer my questions slowly as he fights back tears. He is maybe 20 years old. His back hurts. He doesn't remember what happened. We get what information we can, and when the stretcher arrives we board and collar him, strapping him tightly to the rigid equipment. Again we push through the crowd, this time towards a waiting ambulance. On the way the patient wont open his eyes. I brush his eyelids lightly and see no response at all. My partner puts his hand on the guys chest to check for breathing, giving me a worried look. He is breathing, but completely unresponsive. We move a little faster.

We pass the patient to the waiting ambulance and we give our reports. We don't know much. We tell the story relayed from the witnesses, the patient's name and age that we got from a friend, and admit that we couldn't do very much of an assessment in there. Too loud, too chaotic. The receiving crew thanks us, hopping into the back of the ambulance to do their work. We grab their stretcher in return and head back into the crowds to find more patients.

We took out twenty-two that day.

With all the excitement and bustle of the concert, traumas run and drunks shuttled, everything seemed to settle down for the last few main acts. It was as if everyone took a deep breath and admitted that this is what they came to see, and there would be no more foolishness. We didn't take anyone else out after that point. Instead we settled down, as close to the stage as possible, and watched the last of the show.

We had great seats.


At the end of the shift we returned to the main office, sweaty, exhausted, and covered in mud. We exchanged stories from the day. There were a lot of amusing drunks, and angry ones too. One of my friends got punched directly in the face by a patient while he was transporting to the hospital. He said he saw stars, and then jumped on the guy with the help of another crew to restrain him.

I met up with the crew that took our crowd-surfing injury. The paramedic frowned as I asked him about it. "The guy had no neuros below the waist," he said. "The doc in the trauma room said that there was a T-9 fracture and that it looked pretty bad." The patient was intubated in the ER and taken upstairs. "They weren't sure, but the docs were pretty pessimistic that the kid would get anything back as far as motor control."

I was shocked. What? A spinal fracture with life-altering neuro damage? The kid was just one of many, a repeat of a ton of calls that we did that day: routine in both mechanism of injury and treatment provided. We did a good job protecting the spine, but only because we did that for everyone, routinely.

Retrospect is an amazing thing, but it felt good to look back and know that we all rested firmly on protocol, and followed the guidelines where they mattered most. Our treatment was solid, backed by everyday caution and routine methods. We did the right thing for this patient despite the fact that we had no idea how important those things would turn out to be. A little bit scary, but I guess that is what protocol is for.

I looked through the schedule when we got back, and signed up for another concert later in the summer. What a shift.

Thursday, July 26, 2007


"Second unit in, for a psych??"

My partner was incredulous. What a ridiculous call. This facility always has a ton of psychs in it, it's like a nest where they are all kept. They are always fighting with eachother, halfway trying to kill themselves, or looking for attention. To tie up two ambulances on a call like this seemed like such a waste, and we both thought about all of the better things we could have been doing on our lights + sirens response to the address. Surely someone, somewhere in the city was having a heart attack (or something!) and would be denied our help because of this.

We followed the other crew up the stairs and down the hallways, alternating between grumbles and jokes. Directed down another hallway by staff members, we could begin to hear the chaotic scene. A man lay on the floor, prone, with a knee of a police officer square in his back. Two staff members were sitting on his legs, while another tried in vain to hold the patient's head as he thrashed from side to side, screaming, crying, and spitting.

He has a history of outbursts, a staff member tells me. The paperwork read MR, and "Intermittent Explosive Disorder." He got in an altercation with another resident over the amount of cheese that was added to their midday meal, and things have been downhill since. They gave 5 of Haldol and 2 of Ativan about 40 minutes ago and it hasn't made a bit of difference.

I'll say. The room was destroyed. The pile of bodies lay in the center of the room, surrounded by a ring of chairs, tables, and lunch trays that look as if they were ejected circumferentially from some sort of uncontrolled explosion. Everyone looked a bit exhausted, and the cops, sweaty, looked at me with a hint of a pleading expression on their faces. Salvation, in the form of a paramedic. They have come to take this one away!

We pulled the stretcher up beside the patient, and tried to devise a plan to get him onto it. We would all lift at once, each person responsible for a limb. We'll get him up and over, then bring the sheet across his torso and over his arms. The staff warns us: watch out for spitting, kicking, biting, pinching... the works. The patient is looking a little calmer now, though, so we are sure it can be done. Up and over he goes, one swift and smooth motion. He lands on the stretcher with a little bounce and smiles.

...And then he frowns. He jerks his arms suddenly and thrashes about on the stretcher, which sways dangerously from left to right. He is able to get one arm free, and starts clawing at one of the other staff members who pulls back in fear of getting hurt. Another leg free. One of the police officers grabs his shoulders and pins him down, while another attempts to regain control of the free arm. I am too close and he reaches towards me, talons out. He scratches my forehead once before I can get him back under control, drawing a bit of blood. God dammit.

We tie him down, limb by limb, but he continues to fight. He keeps finding one way or another wriggle and cause trouble: first banging his head against the metal stretcher frame, then scratching at his own skin wherever he can reach. He strains and stresses against the bounds, arching his body upward and screaming. The staff look at us with sympathy. They've been through this before, they say.

I decide to chemically restrain him. We cant transport him like this, we all agree, and he is going to hurt himself if he finds a way to manage it. I kneel down and open up my pack. Our protocols allow for 5 milligrams of Haldol combined with 2 milligrams Ativan, mixed in the same syringe and administered IM. It takes me a few minutes to draw the drugs up, and the gelatinous Ativan is giving me a little bit of trouble.

In walks the patient's doctor. He demands to know what is going on, asking for the whole story and expecting us all to stop and explain it to him. I have the staff members explain to him while I finish drawing up the drugs, but he stops me before I am able to administer them. He wants to know exactly what I am giving him, where I am giving it, and if I have called a doctor for orders. He had heard from the other nurses that the patient already got sedatives about an hour ago, and seems shocked that I would consider giving the patient another round.

"How about you just do one of Ativan," he says. "We don't want him to stop breathing, do we?"

His voice is as condescending as it is demanding, and I am a little taken aback as I sit there holding the uncapped syringe. I explain to him that I have Haldol and Ativan in the same syringe, and that this is standard procedure. I express doubt that 4 milligrams of benzodiazepine, administered IM over the course of an hour will really cause anyone of this size to stop breathing. I relent, though. How about I just give him half of the syringe. About 2.5 Haldol, 1 Ativan. The doc agrees and, in a bit of a huff, leaves the room. I feel a bit embarrassed. Taken down a notch.

In goes the drug and we wheel the patient to the ambulance. He fights and claws the whole time, screaming like a teradoctyl and searching for ways to hurt himself or others. The elevator is small, and we all press our bodies against the walls so to add the necessary free space.

In the back of the ambulance I get the patient on the monitor as best I can. The patient is tied down but he bucks and fights each of our attempts. If a wire is near his hand, he will grab and pull. I get a set of vital signs, and put the patient on end tidal capinography along with a face mask to prevent spitting. He is sinus tachy at 120 or so, pressure 130/70 and all looks well. I look at my partner, exasperated. Let's just go.

5 minutes into the transport I notice that the ETCO2 is no longer reading. The apnea alarm goes off, but a quick glance at the patient and he is obviously breathing. Must be the sensor is displaced. I lift off the face mask to readjust, and find that the patient is attempting to eat the sensor. He has it, a lot of it, in his mouth, and is pulling in more each second like a long strand of spaghetti. He is chomping and chewing, staring at me vindictively with each motion of his jaw. I grab one end of the tubing and give a tug. "Give that back! Let go!" He vehemently shakes his head, refusing with clenched teeth. He will NOT give it up. I try a little more, but I don't want to pull too hard on the tubing and break it, losing it entirely to the patient's gaping maw.

I sit back for a second, tired and sweaty as I watch him chew. The apnea alarm goes off again. Fuck this, I think. I reach into my breast pocket where I still have the drawn up meds. In go the rest. The patient lets out a yep as I sink the needle into his muscle, and at the same time I yank the mangled tubing from his mouth. Win-win.

He fights more on the rest of the trip. I sit back at the end of the bench, watching him and the monitor. I try to straighten my uniform out but it is no use. His aggressive activity wanes slowly, and by the time we arrive at the hospital he is resting comfortably, half asleep on the stretcher. He asks me for a pillow for his head and I give it to him.

We roll into the ED triage looking like we're returning from battle. Our uniforms are disheveled and sweaty, hair mussed and composure wrecked. The patient naps pleasantly on the stretcher, as comfortable and content as could be. The nurse looks at us, smirking a little. She heard our patch asking for security at the door.

"All that, for this little guy? He's sleeping like an angel!"

Tuesday, July 17, 2007


In many ways I feel like a blank slate.

I've spent a lot of time in class, in clinical rotations and in the back of the ambulance. I've read thousands of pages of text on these subjects, and experienced real-life successes and failures that have left indelible marks on my character. Constant newfound knowledge makes me a new person every day, though, and each time I get dressed in my uniform I feel as if my plate is again clean: ready for another helping of experience. What will the next day bring to the table?

The same is true with my coworkers. It is very rarely left to doubt that I am the "new guy," and my opinion - if I venture to submit it - is often challenged simply because I am inexperienced. My slate is clean then, too, and a reputation is ready to be built on what choices I make and how well I am able to defend them. More than once I have had to push harder than I normally would, so that a conversation does not end on dismissive point that I am a new medic. I readily admit my inexperience, but I feel a need to stand by my choices and fiercely support them with the academic knowledge that originally inspired them. There is sometimes an understated aggression, passive in it's delivery but pointed in meaning. It is not my nature, truly, but I have felt a need lately to be my own person, and fight battles in order to establish myself as someone worth fighting with.

On scene, too. Will I be the first through the door or the second? I have become conscious lately of which end of the stretcher I stand on. I want to make sure that I am there, with eye contact, when the first responder is going to give his report. I ask the first question, and answer the patient's first as well. I have been consciously thinking about ways to maintain control on scene: the delicate balance between utility and overbearing micromanagement. I still sometimes take the submissive role by habit, though, and find myself setting up equipment when I should be doing medicine. How I handle myself on scene is part of who I will become as a paramedic, and I am often aware the choice between which habits I will choose to acquire.

I have worked a long time to earn the right to wear this patch on my shoulder. I am finding, though, that there is much more than title. Once this becomes normal, once people become used to seeing "paramedic" under my name, my reputation will again come to rest on my character, my knowledge, and how I choose to carry myself.

The title means nothing without justification for it. I have a lot to learn still, not the least of which is figuring out exactly how I will fill this uniform.

Thursday, July 12, 2007

Ischemic and Uninformed

The man smiles at me with that kind of nervous smile: half appreciative, half terrified. He was cordial and perfectly polite, laughing at his jokes and ours, but the sound was unnatural. Forced.

The doctor takes me aside.

"This guy has had chest pain for a week. Can you believe that? A whole week!"

The doc explains to me that the man felt a sudden onset of crushing chest pain along with shortness of breath as he attempted his normal exercise routine last Friday. Since then, he has had transient periods of dyspnea and chest "pressures," especially when he exerts himself. The doctor shows me the EKG with flipped T waves in the lateral leads. On the next page of the report are the lab results, and the Troponin levels are clearly elevated. The doc casually rattles off the rest of the man's risk factors. Smoker. Positive family history. Obese. History of hypertension. History of high cholesterol.

"We're sending him to Hospital Z," the doc says. "I think he's gonna need a stent."

We walk back to the patient's room, where my partner is getting the patient ready for the transport. The doctor chastises the man for waiting so long.

"Next time you come to the hospital right away, okay? This kind of thing can kill you. Seriously, kill you. Its not to be taken lightly. Understand?"

The man stammers, letting out a shuddering "okkkkay" as the doctor leaves the room.

I smile at the man, hoping to ease the tension. "Let's get ya all unhooked here so we can get you on our equipment." I make jokes about the wires. There are too many, too long. They're just for show, to be honest. The man cracks another nervous laugh but it is plain that he is preoccupied and afraid. I cant blame him. Textbook presentation for cardiac disease, EKG changes, and elevated enzymes? Its a scary picture.

We hook up our gear and roll the man into the back of the ambulance. I burn off a quick 12 lead for our records.

The man watches me as I read over the EKG. He clears his throat and asks me how it looks. I explain that it seems pretty much the same as the EKG they did in the emergency room.

"You've still got a little bit of an issue on the left side of your heart here, but it doesn't look too bad just yet."

The man seems to be clinging to my every word as he looks at me with wide eyes, and I pause for a moment.

"Have they explained any of this to you?"

The man put his head down.

"Not really. They're so busy in there I didn't want to trouble the doctor with too many questions. Everything was moving so quickly. They said that they're going to try and open up an artery or something?"

I am amazed. How is it that a man could come in to an emergency department, be found to have a serious cardiac issue, and wait till he was on his way to surgery before he begins to understand what is happening? The man sat patiently in that department for at least an hour, sitting quietly through the tests and exams, as EKG wires were plugged together and discussions between doctors occurred just out of earshot. All the while, in the dark.

He picked up on the tone, though, and it wasn't good. He tells me that more than once he was spoken to about "coming to the emergency room earlier," and that he shouldn't have waited a week. He knew that there was something wrong with his heart, but not exactly what, where, what it means, or what exactly could be done about it.

I lean forward from the bench and show him the pink printout. I point to the lines on the paper, explaining that some are going down when they should be going up. I pull out his old EKGs from the file so he can compare, explaining the difference between ischemia and infarct in layman's terms. "Its almost as if your heart is short of breath, and is getting bruised up because of it," I explain. "...But the danger is that it can get worse, to the point where it cant be helped." We talk about vessels closing and opening, about supply and demand.

He asks me questions. Lots of them.

"If a part of my heart dies, will it grow back?"

"Does this mean that I wont be able to get up and do things anymore?"

"What are they going to do to me at the Hospital? Will I be awake the whole time?"

"Is any of my heart already dead?"

I answer each question in turn, using basic language that I hope the man fully understands. He clarifies what he doesn't, and listens intently to my replies. We spend the entire trip to the hospital talking about cardiac physiology, treatment modalities, and prognosis. I exhaust my knowledge upon him, and when I get to the end, I remind him to ask his doctor when we get to the hospital.

I tell the man: this is your heart, and these are your decisions. You have a right to know about what is going on, and nobody can do anything without your permission. Do not be afraid to ask questions. Insist that you are informed, and advocate for yourself as much as you are able to. It may not seem like it, but you are in charge.

I left the man on his new ED bed with a firm handshake, and he thanked me with an emphasis that echoed through me for the rest of the week. I truly made a difference in this man's day, helping him through a difficult time with academic knowledge, patience, and a caring tone.

It was easily the most satisfying thing that I've done as a paramedic so far.

Sunday, July 8, 2007


Dispatch asked us to intercept with a BLS unit south of our location. They were headed towards us out of a quiet nearby town, and asked for paramedic help as soon as they saw their patient.

He was 45 years old, racked with disease for years that seemed to count double their time. The man looked 80, easialy. He was unresponsive with a glascow coma scale of 4, gaining only one point for his occasional incomprehensible moans. His body remained slack, absolutely still despite whatever stimuli we could deliver. I rubbed his sternum hard with my knuckles. Nothing.

Despite his calm demeanor, though, his body was a cataclysm of active turmoil. His respiratory rate was just shy of 50 breaths per minute, his heart counting 190 beats in the same time. None of us could get a blood pressure manually, and the automated machine spit "NIBP Timeout" back at me over and over again. I thought I could find a radial pulse, but maybe it was nothing. The pulse oximeter refused to read, and end-tidal CO2 returned a measly 10 mmHg.

I ask as many questions as I can think of, rapid fire as I try to get a sense of the story. The patient has a history of brain abscesses and has been declining over the past few weeks. The family told the EMTs that this has been his baseline mental status for the past week, and that they called 911 only because it seemed he was having trouble breathing. I am struck by the story. Unresponsive like this for a week? Really?

I get the EMTs to insert an oral airway and start assisting the man's breathing with a bag-valve mask while I do the rest of my assessment. The eyes have a dysconjugate gaze to the upper left, and pupils are sluggish to react at about 3 millimeters. Lung sounds are with bilateral rhonchi, but filling up adequately with each squeeze of the BVM's bag. The skin is warm and pink at the core but mottled and slightly cyanotic towards the extremities. Blood sugar is 146. A rapid trauma assessment is without significant finding. On goes the checklist while I start an IV. I plug together the monitor cables and get these in reply:

The man is in shock, crashing in front of my eyes but I cant pinpoint an exact cause. The eyes and mental status suggest a neuro event, although the vital signs defy the textbook Cushing's triad. ...And the family says the mental status is baseline. The 12 lead shows a significant tachycardia, and generalized ischemia across the man's heart. The blood pressure is too low to read. Sepsis? PE? I dont know.

I get the patent in trendelenburg and open up the IV, reviewing my options. I think about intubation, but we are 5 minutes from the hospital and the man is biting on the OPA. I dont think I have time, and the BVM has been pretty effective. Full, equal lung sounds and the end tidal CO2 is slowly coming back up as the EMT controls the man's runaway tachypenia.

Looking at the patient, and the monitor, I feel that I need to do something about the heart rate. The hypotension could very well be related to the tachycardia, and while it is possible that the heart rate could be compensatory for some unseen hypovolemia or otherwise, I doubt it. I remember from ACLS that heart rates over 150 are very rarely compensatory, and still, at this rate cardiac refilling time must be seriously hindering effective output.

We are 3 minutes from the hospital and I draw up adenosine. 6 milligrams, and a 10 cc normal saline flush behind it. I push print on the monitor and flush both syringes through the line. As we come to a stop in the ambulance bay I stare intently at the monitor.

No change whatsoever.

In the hospital they listen to my story with raised eyebrows. They are skeptical about the family's story too, but accept what I have to give them. The man is paralyzed and intubated, bloods drawn and x-rays taken. The team converges around the man, working intently as they pass lines and instructions to eachother. The man codes. Four times, resuscitated each time with jolts of electricity as I write my run form. When I return with paperwork the team is sweaty and tired. Empty boxes of epinephrine litter the floor. They are mixing up an epinephrine drip to maintain the blood pressure, and the doctors are calling more doctors to discuss what could possibly be wrong. Nobody knows yet.


It was a good call in many ways. There was a lot to do in a short amount of time, a complicated story to assimilate and an important treatment decision to make. It was a job to remain calm and focused, to get things right and make sure I didnt miss anything important.

I ran through the call with some of my coworkers, and there are always raised eyebrows around the time that I mention the adenosine. I know. I knew it then, too, but I felt that I had to do something about that heart rate in the face of the rest of the patient's presentation: and I stand firm that there was value in the choice both as a treatment and as a diagnostic tool. If it worked, great. If it didnt, a pathology eliminated.

I may or may not have been right. Maybe the heart rate was actually a compensating effort. Perhaps the rate was completely unrelated to the rest of the presentation. Maybe I should have focused instead on doing something else. I dont know, and as far as I've heard thus far- neither do the doctors. It is a little frustrating to not know, to remain in the dark after such a fervent effort.

I did my best though, and I stand by my decisions. In work where often nothing is certain, and choices must be made quickly and accurately based on experience and talent: I think that counts for something.

Sunday, July 1, 2007

Planet Paramedic

I feel like a different person. I am acutely aware of the new patch on my shoulder, yes, but there is more than that. I have done a lot of this before. Routine clinical practice in school, calls on my ride-time internship, more calls while precepting. All of them, experiences designed to bolster my confidence and add wisdom to my choices, but still: sitting in the front of the ambulance - the paramedic with an EMT at my side - I feel like I am in a new and strange place.

The feeling strikes me as contrast to those Peter Canning expressed in his most recent blog entry. He writes how things havnt seemed to "stand out" lately, that he could write about some of the things he has seen, but he has been there before- written about it and now considers it old news. He's met a lot of amusing patients, seen the good medicals, and was there for the big traumas. ...And yet the experiences no longer seem to stimulate as much as they once did. Peter is experienced. Stable.

I sure as hell cant say that for myself. I've seen a total of 4 patients so far in my career as a cut-loose paramedic, and each one has seemed so important, so groundbreaking, that I really had a hard time choosing what I wanted to write about.

It isnt as if I have had all great calls, either. A seizing, ex IV drug abusing hypoglycemic who woke up after 3 tough IV attempts and an amp of D50, a deformed ankle, female weakness x 6 days, and a drunk. I went through my routines with each patient, assessed, treated, and even downgraded one of them-- but the experiences were so fresh and new. I was shocked to watch a first responding firefighter glance at our patches and then come to me to give his report. It was such an odd experience to act as the final word on scene. We're going to stay here and take a look. We're going to get going as soon as we can. The words came out of my mouth, not for the first time but with newfound impact. I was in charge of the scene, and people listened. Maybe they have no idea how new I am, that this is my first day and that behind my sunglasses, my eyes probably betray this overwhelming uncertainty.

I hung tough though. Played it cool and, I think, made the right choices for these first four patients. Even the routine feels new these days though, and I worry how I will fare when something really tough, some zebra comes along and forces me to make a decision. I hope I make the right choices and, even more, I hope I dont have to make those until I can get a little more experience under my belt. This job seems to favor trial by fire, though, so I doubt it.

Things sure are different here on planet paramedic.


I left my last entry with the news that my first shift would be with a friend, standing-by at a boxing event. So it was, although we didnt get any patients. We did, however, get awesome seats to a pretty good show:

Cant complain about that!