Friday, November 30, 2007

Sailing Rough Waters

This is a complicated job.

There is a lot to pay attention to. Nuances that must be noticed in proper respect, concurrent details that need to be handled adeptly and smoothly. There is a significant amount of academic knowledge necessary, coupled with a standard of dexterity and physical skill that must be mastered for proper control. There is a social aspect as well: a smooth tone of voice and calm demeanor that experienced medics develop, employed judiciously to an extremely diverse population of patients. The role is one of leadership, of proper resource control and group dynamics. Coupled with a constantly changing work environment, it is important to learn how to adapt quickly, ride the waves and keep the course true.

These challenges were patently obvious to me as a medic student, as I'm sure they are to anyone experiencing this job for the first time. To be faced with these responsibilities all at once is an incredibly frightening prospect, one that is handled to varying degrees of success by those that make the attempt. It is a difficult thing to face all that must be done, to do so under the stress of a medical emergency and the ultimate knowledge that the buck stops at you.

The other side of the coin comes with slowly encroaching senses of calm and competence. I have been on my own for almost 6 months now, and though my body occasionally runs cold with fear at the presentation of something unknown, I have slowly been finding a groove in which I am capable of running. Most of the calls we run are routine, and I am starting to handle them in an almost lethargic manner, robotic in my repeated assessment and treatment. I am calm on scene, expressionless in a practiced manner of unsurprise and experience. I ask the same questions, run though the same routines, and expect little else. The routine has become just that, and I dare say with this limited experience: easy.

It is a sharp change from my first few months as a paramedic student riding 3rd on foreign ambulances, unsteady and nervous as I wobbled my way through repeated assessments under watchful instructor eyes. I remember taking manual blood pressures, placing the scope in my ears and feeling grateful for a few more seconds to think about what I was going to do next while the needle turned downward through the numbers. I was on edge all the time, nervous and thinking a mile a minute. I had to be, I was being watched and assesed. Criticized and reviewed.

I wonder sometimes, running these lethargic calls of routine low priority, if despite my nerves and mistakes back then, perhaps I was a bit more thorough. When you are a student, chest pain is never muscular in origin. Cold symptoms are zebras in hiding, and tucked deep behind every omission was the critical point. Students are exhaustive in their approach, over-the-top in a way that now might generate a smirk from a more experienced provider. It is newb-ish to remain unsatisfied in the face of the routine, while the rugged and seasoned medic is tranquil as he sits with the same patient, content in all that he has supposedly assimilated.

...But has he really?

I have come to grips with the immensity of this job by riding the waves from peak to peak. I keep the course smooth by handling rough waters with a steady hand, calm as I approach a patient wholesale: sick or not sick. Still, I wonder if sometimes the student might have it right, his boat riding wildly over all over the place, jostling and twisting unsteadily while at the same time experiencing everything that the patient has to offer. My demeanor is much more low-key these days, and as I coolly peruse the patient and his host of complaints I feel like I look more experienced. Thinking back, though, I have found myself now omitting things that I might have stressed when I was back in school. I roll my eyes at complaints more, blow more things off than I used to.

The assumption is that my experience and knowledge thus far has afforded me the ability to understand patient presentation so well that it is no longer conscious thought. ...That I am able to assimilate a host of factors at once in rapid succession, assemble them together, and come to the correct decisions without much fanfare. This is the standard that they set in medic school, and the goal of my repeated trainings and research.

I want to remind myself, though, that a calm demeanor does not mean that I have reached the point. I still make mistakes. I still miss obvious things from time to time. Despite the fact that I am starting to feel more competent on scene, I need to remain fervent in my efforts and unsatisfied in my assessment. I have not been around long enough to be calm, and I should probably sacrifice myself to a few more smirks if it means that I am more thorough in the end.

Call me new, but I want to get this right.

Tuesday, November 13, 2007

On Being Sure

My eyes must have been as wide as saucers as I looked at the strip. Though I have seen EKGs like these during my training and passed between friends at work, I had yet to have a patient capable of printing anything like this.

We were called for the "possible heart," and though the patient was without complaint and looking fine, the nurses pulled me aside and told me that he had a MI a few weeks ago with emergent angiocath and two stents placed. They were drawing a routine troponin today and got a reading of 7.65. Extremely high, and coupled with the significant cardiac history and ECG changes, I was absolutely sure this was the real thing.

I have taken care of a few critical patients thus far during my time as a paramedic, but the occasion still makes me extremely nervous. The urgency set me off balance a little bit, and though I remembered clearly what it was that I was supposed to do, I felt a slight tremor in my voice and a constant nagging pressure of excitement that pushed me right out of my comfort zone. The stress stressed me.

The nurses took a really long time with the paperwork and I snapped harshly at them. I told them flatly that they needed to hurry up because this patient's heart was wasting as we spoke. I criticized that the paperwork should have been done before we got there, or at least assembled during the 5 or 6 minutes we were getting the patient ready and taking the ECG. I wasn't over the top, but I was most certainly rude and they glared back as they handed me the necessary papers. Without apology we rushed off.

In the ambulance on the way to the hospital with the lights flashing, I reassessed. The patient was without complaint, which I thought was odd, but he also had a history of dementia and had a baseline confused mental status. Besides, I thought, plenty of people feel the "pain" of AMI in odd ways: the absence of discomfort amongst all of the other evidence surely mattered very little. It nagged me though, and added to my stress. I asked myself if there was anything I missing, assessed repeatedly, and took several copies of the ECG. All signs pointed to AMI, and though this presentation is foreign to me in the flesh, I was pretty sure I knew what I was dealing with.

I gave a radio patch to the hospital, forgetting that this was not one of the facilities that allowed EMS to activate the cath-lab from the field. When I mentioned the prospect into the microphone, the answer back was confused. They asked me if I was calling for nitro and asprin orders, which I told them I had already given to the patient. Why the hell would I need to call for those meds anyways, I thought to myself. Stress continued to build.

At the hospital, the triage nurses kept us in queue for much longer than I was expecting. Usually they will usher critical patients right through into the trauma rooms for immediate evaluation, but this time they wanted me to linger as they completed the lengthy registration process. They asked me for the patient's social security number, his entire medical history, meds, and allergies. They took the time to print out an identification bracelet, and attach it to the patient's wrist. I showed the nurses the EKG and told them the story, but they seemed somehow unimpressed. They sent us, frustrated, stressed, and confused, to a low-acuity section of the Emergency Department. When he told us, I unknowingly made a disgusted face to the nurse that my partner laughed about later. "You should have seen your expression," he said.

The story was no different with the nurses in the patient's room, who silently listened to my report and without fanfare helped us transfer the patient to his hospital bed. They thanked me and walked out of the room, as if I had just brought them an earache or hangnail.

Again I re-studied the ECG and rehearsed the patient's story. There must be something I am not getting here, I thought to myself. I needed to know, and decided to talk directly to the doctor. She was busy but I interrupted as politely as I could, showing her the ECG and telling the story as thoroughly as possible. She stopped me when I mentioned the recent cardiac surgery, her eyebrows raised with suspicion. "Yeah," I said, "the cardiac history is pretty significant, which is why I was so suspicious this is an MI..."

The doctor swung around in her chair and typed a few things into a nearby computer. She came up with the patient's discharge ECG following the surgery, which looked exactly the same as the ones I had taken not 15 minutes earlier. She let out a sigh of relief. "It's nothing," she said. "Just residual ST elevations." She explained that some patients retain their ST elevations following cardiac surgery, sometimes for weeks after they have left the operating room. Troponin levels are also notorious for remaining high for lengthy periods afterwards. I didn't do anything wrong, she said, admitting that paramedics need to treat "as if," but in the light of this evidence it is clear that the patient is not having a heart attack.

It was news to me, and my heart sunk as I thought about how I had behaved throughout the call. I was stressed and rude, nervous and assertive. I remember reading in class that ST elevation marked the acute phase of a MI, but new knowledge had surfaced to prove that sometimes incorrect, and my face was red as I snuck back to the ambulance to write my report.

We have learned a lot of things as absolutes in school which have turned out be not quite so in real life. There is so much in medicine that relies on the "not always" caveat, often I am frustrated by the inconsistency and struggle to find footholds amongst endlessly shifting ground. A MI will not always present with pain. An altered diabetic's sugar will not always be low. Sometimes patients with critical conditions will display them, sometimes they wont. It is incredibly difficult to tell the truth sometimes, often it is best to conclude that we truly have no idea what is actually happening, and admit that transport to the hospital is the only viable solution.

Such consistent uncertainty makes it difficult to remain assertive about our decisions and advocate for our patients as strongly as we would like. I am embarrassed that I was rude to the nurses, but at the same time I defend the choice as important to the patient's welfare. For every story like this there is another about a paramedic's urgency buying his patient a critically necessary and life-saving evaluation. We have limited tools, limited knowledge, experience, and education. There is an incredible wealth of what we do not know, and yet we must sometimes stand firm and make a decision, baring ourselves completely for either important discovery or embarrassing ridicule.

Handicapped, we find our way through the dim light by grasping to that which matters most: the welfare of our patient.

Friday, November 9, 2007

Real Strength

Sometimes it is easy to forget what color our uniform is. It is a lighter shade, of a different material, and carries different insignia. We wear pants that have pockets in very different places, designed that way to accommodate the starkly different gear we must carry and use. On my leg is not a baton and leather gloves but rather a small penlight and a pair of trauma shears. My gloves are baby blue and nitrile.

We dress differently from police officers because we are not to be confused with them. Though our occupations may both be loosely considered of the "public service" department, our duties and skills are enough so that our work may be thought of as mutually exclusive. We do not arrest, bully, or enforce. We have very little to do with the law other than those we must abide by, and our concern of illegal activity truly ends at that which may be considered medically relevant. We work side by side with them, help each other out when we can: but we are not police officers.

And yet our identities are so often confused, even amongst ourselves. I overheard a crew the other day, laughing and bragging between themselves about the manner in which they physically confronted an abusive patient. The man was drunk and violent, spitting venom to the best of his faculties and swinging his arms in a whiskey-induced rage. The crew was proud to say that they handled him swiftly and with the efficiency of a trained force. One EMT grabbed the left arm while the other grabbed the right, and the man was quickly removed from his footing and brought down hard onto his back. He was restrained with a knee in his chest as the ambulance crew tied him down and sniped with comments of their own. The man was antagonizing the crew, and they were proud to say that they didn't take any shit. He got one chance and then down he went, they said.

The story is exhilarating. Fun to tell and fun to listen to, it brings to mind a sense of the "street tough" mentality that many urban EMS'ers aspire to. The story goes that we must be tough, we must remain firm and hard in the face of antagonism. To be compassionate is to be weak, and to give too many chances invites further insult. Subscribers to this attitude wear their choices for all to see. Sleeves are rolled up high and at the bicep. There is often an EMS badge, and leather gloves tucked into the back pocket ready for use. They walk differently, talk differently, and - as it must be - think differently about what this job is about.

But we are not police officers. Though I am hardly on my own an authority on the standard of our practice, I think many would concede the point that our approach is on the outset markedly softer. We don't demand answers but request them. Often we will listen instead of talk. We work hard on our facial expressions so that they do not falter even at the most ridiculous scenario, at the most embarrassing confession. We are worthy of trust because we are steadfast in our compassion, free from judgment, and always, always willing to help. Such is the purpose we serve.

The attitude of the quasi police officer EMS worker is one of boisterous ego. These people are proud to admit that they do not take attitude from their patients, that they elicit their answers by demand and exude an authority of medical necessity. They are the bosses of their ambulances, and will do with their patients what they like. The patient is in their care, and must submit in the name of proper medical care. I have watched this happen. Patients getting bullied around in the back of ambulances, forced with the power of supposed medical urgency and relegated to submit to unnecessary brutish and judgmental attitude. These patients sit on the stretcher, scared and submissive. The EMS worker sits on the bench, proud of his job and convinced of his importance.

Strength does not derive from the volume of our voices. Authority does not come from the issuance of a demand. Our "street cred" will not be determined by our ability to tackle a patient to the ground. No, real strength, real ability is much less flashy. It happens quietly, in conversation between a medical professional and a frightened patient. It happens when a provider will sacrifice for the benefit of those in need. When he fights off his frustration, quells his qualms with the unpleasant.

As often as I have witnessed brutish behavior in the backs of ambulances, I have also seen incredible feats of strength in quiet and uncelebrated patient assessments. Providers willing to forgo their immediate ego for the greater good, listen to an entire story and speak calmly despite an escalating situation. People willing to elicit transports to the hospital by leveraging their own humility, admitting to a lack of knowledge and ability in order to make clear the importance of seeing a doctor. People who sacrifice everything that they have so that the patient will get the best chance at what is available.

This is real strength. Though it may go unnoticed by so many, hidden and overwhelmed by the stories and tales told by the loud and flashy, it is important to know that those who are very good at this job are often also very quiet. Mildly they will accept their victories and walk without a word past the opportunity to boast.

Self assured and confident in the knowledge of their own success, they wait for their next call.