Saturday, December 6, 2008
Sunday, November 23, 2008
Organic Chemistry is a beautiful science. It is famously difficult, the “weed out” class for pre-medical students everywhere, and this semester has taught me exactly why. It is a science that requires a particular kind of continuous knowledge, applied together in the assembly of functional chemical compounds. To understand organic chemistry is to understand a particular set of tools that are used to create highly specific, exotic chemicals out of cheap and common starting materials. The process is often arduous, but the fruits of this labor are the fuels and medicines that shape our lives today. There is good reason people have put such work into developing our understanding of this science.
I have been lucky to associate some of this science with my work on the road. These studies have taught me about the importance of detail. To know a thing is to understand how and why it behaves the way it does, to understand it from every angle. This kind of scientific intimacy brings to light exactly how delicate our tools are, and how specifically they are engineered.
Above is a drawing of the chemical structure of epinephrine. These specific orientations of carbon, oxygen, nitrogen, and hydrogen might seem like unnecessary detail, but this structure holds within itself a real power. My studies have taught me how to pull that flat drawing out into three dimensional space, to give life to that compound and make it real.
That drawing above isn’t just epinephrine. It is more specific than that. The forward orientation of the hydroxyl group (the “OH” near the top) is particular to this form of the compound, and is specifically named (R)-(-)-Epineprhine, or Levo-rotary Epinephrine. This is to differentiate this particular orientation from its isomeric sister: (L)-(+)-Epinephrine (Dextro-rotary Epinephrine) in which the “OH” points in the opposite direction. See, epinephrine has a point of rotation (a point of “chirality”) that enables the molecule to exist with the same chemical formula, but slightly different three-dimensional orientations of the components. The phenomenon is called stereoisomerism, and it is more than just academics. A small change in the three dimensional shape of Epinephrine is what differentiates the biologically active from the not biologically active. Levo-rotary Epinephrine is the vaso-constricting, heart-stimulating, bronchi-dilating drug we are familiar with. Dextro-rotary Epinephrine, however, is essentially inactive. Our bodies, in all their wisdom, produce an enantiomerically-pure product: the levo-rotary epinephrine only.
Stereoisomers such as Epinphrine can be separated into their individual isomers (“enantomers,” in this case), or can be combined together into a mixture. When enantomers are combined together in equal proportions, Organic Chemistry calls the mixture a “racemic” mixture. When we give patients the drug we call “Racemic Epinephrine,” we are actually giving a combination of the active form of Epinephrine mixed with an inactive form of the same chemical compound. This technique has a blunting effect on the potency of the drug, which is the desired effect. I was surprised to learn that the technique we use at my service to perform this treatment is slightly different. We don’t technically administer “racemic” epinephrine because we don’t have dextro-rotary Epinephrine in our drug bags. Instead, we take regular levo-rotary Epinephrine and mix it with saline, achieving the same blunting effect.
The same holds true for our diabetic patients to whom we administer Dextrose. I have been asked in the past why we give dextrose to patients who are hypoglycemic. Organic and stereo chemistry provides the answer. In fact, dextrose IS glucose, just the dextro-rotary isomer of it. (Dextro-rotary + Glucose = Dextrose) The chemical compound is oriented in a specific way, like epinephrine, and it is only this orientation that is synthesized by the body to create energy. It is by convention that we call glucose created outside of the body “dextrose,” and that created inside the body “glucose.” They are both the same thing.
It is all scientific detail. Esoteric, to be sure, but the depth is there for anyone who is willing to look. For a paramedic and pre-medical student such as myself, I find the incredible complexity of these subjects fascinating. To learn about epinephrine and dextrose in this way makes me wonder about everything else we do. There are layers and layers of understanding underneath each of our drugs, underneath our procedures, policies, and practice. We do what we do out of little but faith that there exists science and understanding to provide a foundation for these treatments. We accept our protocols wholesale because we have to, as they are the assimilation of greater minds with greater perspective. To scratch the surface of this knowledge, as I have done in class, does little more than add a sense of humility and wonder for that which I do not yet understand, and to provide a motivation to move forward and learn more.
In the future, I have bigger plans for this surface than a mere scratch.
Tuesday, November 18, 2008
This neighborhood is particularly bad. Stout, two-story brick buildings are tightly clustered around an intersection of narrow, pot-holed streets. Through their iron barred vantages, these unfortunate residents overlook a scene of densely overgrown brambles, adorned with rubbish and punctuated with rusty iron poles pointing out at bent angles. Slackened laundry lines hang from a few of the poles, dipping close to the ground as if the life had been sucked right out of them. One of the ropes leads to our patient’s building, and she sits there with the door half-cocked, waving us over from down the street.
She is in a pair of neon pink pajama pants and a long white t-shirt. Against the sullen gray background of her neighborhood, the woman looks suddenly three-dimensional. Her image pops out towards us as if she had been drawn in, rack focused by an artist looking specifically for contrast. There is a smile, too, and it seems equally out of place.
“Oh thank you so much for coming,” she says. There is genuine appreciation in her voice, and warmth in character that we did not expect to hear.
“Please, follow me right up this way.”
She turns around and leads us up a darkened staircase, around to the right and into a small room. There is a single air mattress on the floor and an older TV sitting on a milk crate. On the screen is the title menu from a 101 Dalmations DVD, which plays a hushed Disney lullaby on continuous loop. A small boy of perhaps two or three years is sleeping prone on the mattress.
She’s whispering now.
“I feel so silly calling you guys, but he just fell asleep. His asthma was really bad all night. I gave him three or four puffs of his medicine but it kept coming back. It’s so scary hearing him wheeze like that, I just didn’t know what to do.”
The woman looks younger now as she tells the story. For the first time I notice that she can’t be more than eighteen or twenty years old. Despite her bright clothing and young face she looks haggard and worn out. Exhausted. At the end of her story she throws her hands up and lets them fall limply to her sides. She is wide-eyed and eager for help, looking at us searchingly for our reply.
I wonder if she honestly believes we might just pack our things and go. Perhaps we would decide she lacked merit and leave them both there in that apartment to rot.
The way she looked at us then, it seemed she was ready for anything.
Sunday, November 9, 2008
We were called last week to a small clinic for a patient who we were told had shortness of breath. The patient had undergone a procedure during which he was sedated with Propofol and placed on his left side while maintaining his own airway. When the procedure was over and the sedative discontinued, the patient complained of “a little sore throat” and some nasal congestion. At that point in time the measured oxygen saturation (SPO2) dropped from a baseline of 97% to 92% for a few minutes (then returning back to baseline). Concerned, the clinic performed a chest x-ray and thought they saw some infiltrates in the lower lobe of the left lung. They wanted this patient brought to the emergency room for evaluation and, as they put it, twenty-four hour monitoring of the oxygen saturation. They were apparently worried that the patient had aspirated during the procedure and was on the verge of some sort of pulmonary emergency. The patient, now completely without complaint having never noticed any shortness of breath with an oxygen saturation of 99% on room air, looked confused and frightened.
I admit I don’t know much about the risks involved with laterally positioned patients under Propofol sedation. I don’t know how to read a chest x-ray and I only understand a little about what a lung infiltrate is. I have a good familiarity with pulse oximetry and clinical assessment though, and this case raised a few flags with me. I was skeptical, but the doctor told me this story with such earnest interest and concern that I couldn’t help but be impressed. He had the paperwork all ready and asked us if we were capable of monitoring the pulse oximetry while transporting this patient with the lights and sirens on. He said that he had spoken with the physician in the receiving ER and they would be anxiously awaiting our arrival. Barring what I was told and what I saw with the patient, everything about this call seemed to suggest something serious was going on. Still, there the patient sat with a weak story, no complaint, and no sign of any trouble.
I wanted to raise my eyebrows and ask a few tough questions. Are you sure the pulse ox was reading correctly? Didn’t you listen to lung sounds? Didn’t you listen to your patient? How likely is it that the shadow you saw on the chest x-ray is a physiologic change and no emergency at all? Are you sure this patient really needs to go to the EMERGENCY room? Is there something I’m missing here?
…But I couldn’t. The truth is, I don’t really know enough about any of this to be questioning a physician’s impression so directly. I am anecdotally familiar with pulse oximetry and the tendency for the sensor to slip and read low. I know that even healthy patients sometimes read low on the pulse-ox for benign reasons, but I am not sure of the exact mechanisms and science behind pathologic reductions in those same readings. Surely this physician was much more familiar, and I feel I must have some (if even blind) respect for the decisions that come from such experience and training. He must know something that I don’t. The same goes for the x-ray. Surely the radiologist understands the difference between pathologic and physiologic changes on a plain film. Who am I to question him, even if the story just doesn’t seem right?
And so we transported the patient as we were told. I sat in the back and plugged in the pulse-ox, talked with the patient and did my regular assessment. I didn’t find anything wrong with him, and the pulse ox sat at 99% for the duration of the trip. When we got to the emergency room the triage nurse rolled her eyes. She sent the lady to the waiting room.
I know a lot of medics who would have argued with the doctor. Some of them have no problem asking those pointed questions and wearing their distain for a questionable call on their sleeves. Relaying this story to an experienced medic I know, I was chastised and told to rely on my own assessment. “Did the patient look sick to you,” I was asked. When I replied that he didn’t, the answer was “Then he probably wasn’t.”
He’s right, the patient probably wasn’t sick. It was probably a bunch of trumped up nonsense arising from a cautious physician worried about iatrogenic disease and the resulting repercussions. I saw that within my first minute with these people on scene. …But I had no way of being sure. I trust my assessment and I trust my experience. I am proud of my abilities and I think I am a capable provider. Still, I know that there are sharp lines that divide what I know for sure and what I do not, and there is much more of the latter than there is of the former. If a doctor tells me his patient is sick and I don’t think he really is, would it really be prudent to follow my instincts over his? I’m not so sure.
Research after the Fact:
A pulmonary infiltrate is the filling of airspaces within the lungs with fluid, inflammatory exudates, or cells that increase the visual impression of soft tissue density on a chest x-ray. Sometimes this can be a pathologic finding, but there a is also a potential that the condition may be physiologic, where normal airspace folding and collapse creates the same visual impressions (“Atelectasis”). The left lower lobe is the most frequent location of benign atelectaisis in ICU patients. (source)
In a recent study on critical care monitoring, pulse oximetry accounted for almost half of 2525 false alarms (1). In another study looking at patients recovering from anesthesia (2), 77% of low pulse-ox alarms were false in nature. A recent survey (3) found that highly trained medical professionals may have little understanding of pulse oximetry and it's clinical application. In that survey, 30% of physicians and 93% of nurses thought that the pulse-ox measured PaO2. (It actually uses a measure of hemoglobin oxygen saturation to esimate arterial saturation, SpO2).
Tuesday, October 7, 2008
To listen to this physician speak was as much enlightening as it was humbling. I enjoy very much seeing these doctors in their zone, hooking onto a subject and going through their paces as they have been trained to do. I can see that he enjoys it, and I can see that he is at home within the language and texture of the medical literature. He reads an article with a particular flair of skepticism, as if it was up to him alone to pass judgment on the trials that have been laid before him, and with glasses at the bridge of his nose, he does. "This research does not impress me," he says, "and I'll tell you why."
We paramedics sat at this lecture like cub scouts around a campfire, wide eyed and dedicated each minute to their scoutmaster. Our physician handed down samples of his experience that we will never ourselves see. He gave us a window into the depth of knowledge that dictates our actions from the other side of the glass, and he danced a jig that we prehospital providers will never truly learn. Sitting there the other night listening to this doctor speak, the gap between us was never more clear.
It was frustrating to be so acutely aware of this divide. Working a few good calls as a paramedic has the potential to endorse hubris, and perhaps I have fallen victim to it as of late. I know ACLS pretty well, and I'm proud to say it, but a few steps back sharpens the fact that my understanding spreads not much farther than an algorithm and some light associated background. Like it or not, the expertise exhibited by this doctor the other night contrasts sharply with my own.
It motivates, though. I've got role models. These lectures give me an opportunity to keep an eye on what I am working towards. I want to speak that language, I want to understand the detail and have it ready at my command, I want to have that conversation again, informed. As frustrating as it can be to be reminded of my current limitations, it makes real and adds luster to that which - at school - I am working towards.
One semester to go.
Tuesday, September 30, 2008
There is a particular posture that can be attributed to healthcare providers of any level when confronted with these types of patients. Maybe it is anger, or disgust. Perhaps it is mistrust or simply exhaustion from all of the shit that smells the same way coming through our doors. Signs and symptoms aside, if you, your chart, or your mannerism stipulates that you are a drug abuser: you will be mistreated.
This week, I watched an ER physician withhold ventilations from an opiate overdose with a respiratory rate of six. "He shouldn't have shot up" was the justification. The kid was cyanotic and looked like shit. When the narcan went in, they slapped him in the face in order to help revive their still unresponsive patient, and when he woke up denying drugs, the doctors told him that the narcan would kill him if he wasn't honest about his drug usage.
Same day, same hospital, I brought in a patient with profound right sided weakness, obvious right side facial droop, and a blood pressure of 180/100- all an acute onset 30 minutes before our arrival at the hospital. The patient was obviously frightened, and perhaps by some lapse of judgment she let loose through her slurred speech that she had used cocaine the night before. Hearing this, the triage nurse rolled her eyes. She got a bed in the hallway and I had to make a scene at the hospital in order to get some attention for my patient.
Impose whatever judgment you will upon these ED providers, but I have personally seen these same people provide absolutely top notch care. I've witnessed them go above and beyond to provide emotional support, and I've watched as their expertise illuminated acute pathologies that only great experience and skill could have possibly recognized. I've seen these people as shining stars within their departments, and even thought to myself that if I were ever injured on the job, these are the people I would like in charge of my care.
But then again, I don't do drugs.
Friday, September 12, 2008
80 year old male found seated in his recliner watching TV:
40 year old female feeling "weak" at Wal-Mart:
The nurses said this patient looked "restless." (This is the patient from Points of View):
Monday, September 8, 2008
I transferred a lady out of the hospital a few days ago after a ten day admission for a swollen foot. She was pretty old and had a complicated medical history but was cheerful nonetheless. She laughed at some of my jokes and rested while I finished up the transfer paperwork. We fluffed her pillow at the nursing home before we left. Today I passed a number 8 endotracheal tube through her vocal cords and directed CPR even as her ribs cracked under the pressure. I couldn't get an IV and had to drill an IO into her tibia. Futile, though, as despite our sweat and effort the flat lines prevailed. She looked like a different lady than I had seen just a few days prior.
Raise your eyebrows if you like, but it makes me somewhat uncomfortable when through their stories, patients become people. A symptomatic tachycardia does not demand empathy. A clonic seizure can't crush a provider's spirit. Only people can do that. Only stories with which we can identify, only smiles and conversations can have that effect.
Prudence demands that we separate the disease from the person. Insult hits much harder than injury, and I think anyone who sees these kinds of things on a daily basis needs to put barriers between these patients and themselves. My paramedic instructor had a mantra that we were advised to live by, that these are "not our emergencies." I remember feeling that the concept was somewhat cold, uncaring, and against the grain of this medical field that I saw as powered through compassion.
Today, I understand its utility.
Tuesday, September 2, 2008
The guy was having a MI and we caught it on the ECG despite a baseline altered mental status and no clear chief complaint. We treated appropriately and gave a report on the way to the hospital that got the cath lab open and waiting for us. Door to balloon time was under 15 minutes, a lifesaving success for which my partner and I proudly accept our portion of the credit.
We followed the patient right up to the cath lab and bore witness as our inferior/lateral/posterior ST segment elevations gave way to a serious occlusion of the proximal circumflex artery. It was exactly where we thought it might be, and in the darkened surgery suite, my partner and I beamed.
We got some handshakes and genuine praise from the ED doctors. They said we did an excellent job, that they wished every call went this way, and that we should keep up the good work. It was only a few kind words but it meant the world to us.
Our supervisor was waiting for us when we returned to the ambulance. He was there when we arrived with the patient, and it seems he noticed in our haste we had forgotten to secure one of the four straps that hold our patient to the stretcher. The other three where in place, but I had removed the top strap because it was causing artifact on the twelve-lead ECG.
Pulling the yellow carbon copy from his stack of citations, he handed me my notice. "You should have put the straps back together before taking the patient out of the ambulance." A written warning. Next offense I'll get suspended.
Out of the clouds, Baby Medic. Back to reality.
Wednesday, August 20, 2008
We were called for a cardiac arrest, but this man was breathing. He groaned after we moved him, and sluggishly flopped there on the bed without the energy (or will) to right himself completely. He looked exhausted. His breath was laden and heavy, his bare chest and protruding belly heaving in slow motion with clear exasperation. He smelled like liquor.
I didn't give him much time to consider his options. "Up you go," I demanded, yanking on his arm and pulling the man upright. He groaned some more as I continued to pull but it was he who relented first, and up he sat as I pulled, tipsy and top heavy coming to rest at the edge of the bed.
My flashlight in his eyes. "How much was it that you drank?" Stern and truly without compassion I wanted answers from the man. Unknowingly or not, he had instigated a dangerous lights and sirens response from across the city, inspired undue concern, and let us all down with his sluggish demeanor and potent breath. His pupils were dilated and equally reactive to light. The man tried to focus on me with the bulb in his eyes, curiously confounded. "Just five," he slurred.
I don't feel sorry for him. I don't feel compassion or energy or willingness to help. I feel exasperated, and I wear it on my sleeve. We roll him out of the apartment quickly, taking little time for comfort or care. He is a waste of our time. He is a chronic abuser, a hopeless cause, a train wreck derived from proportions of choice and circumstance. Forget the ratio whatever it may be, we don't care. Here and now he sits, drunk, and I am without inclination to delve into much more.
It is only until after the call and upon reflection that I am able to truly understand how callously we treated that man. Each step replayed in my mind, I can think of hundreds of other occasions where I would have done something different - either more slowly, cautiously, or with more care - had the patient been someone or somewhere else. ...And yet at the time, in the moment on the call, it all seemed normal. Somehow our behavior was in sync with the environment, and though out of place within our daily routine, temporarily acceptable.
...But that wasn't what bothered me most. It was the patient. Though all of this he sat still, groaning in his toxicity but nevertheless fully aware of his circumstance and the "providers" sent to rescue him from it. The expression on his face was stoic and accepting, conscious of the abuse and yet submissive.
This man was used to being treated this way.
Wednesday, July 16, 2008
Her friends who saw her fall said she landed right on her head and just "crumpled." When we got there she was sitting under a tree across the yard, holding her arm out at an odd angle that resembled some sort of zig-zag. She was pale and diaphoretic, lethargic and mumbling about the pain in her shoulder. It was obviously deformed in at two places, and probably broken in more places than that. The woman complained to me that she couldn't feel anything in her arm at all, and, laying on our backboard on the way to the hospital, asked me if I could confirm whether it was still attached. To reassure her, I told her I would take her left hand and place it on her right elbow. She could help stabilize the extremity as well as remind herself of it's presence. Taking hold of her left hand and bringing it over to her right side, the woman grabbed hold of my hand. "Thank you," she said, "thank you so much." She didn't let go. Not sure of whether she thought she had hold her own hand or was holding mine for comfort, I sat there with my arm outstretched. With only a minute until we reached the hospital I decided that either way, I'd just let her keep it.
I took care of a young boy today who was found unresponsive by firefighters inside a burning building.
They carried his limp body away from the smoke and laid him down in the grassy front yard, franticly waving to my partner and me who were standing by. As the firefighter told his account of the story, the boy began to wake up and cough, reaching out for help from his position on the ground. We scooped him up and rushed him to our stretcher, listening to lung sounds, applying oxygen, and looking for burns. The boy was fully awake now, apparently uninjured but terrified. There was another paramedic on scene who was precepting, and we decided to ride the call in together. I sat in the airway seat and helped as the new medic ran though his routine, watching quietly and helping only as necessary. The sirens were especially loud in this older ambulance, and it was hard to hear the boy's quiet answers to my few questions. I sat forward, tilting my head until my cheek was almost touching the pillow, and face to face the boy and I talked about what happened. We were close enough so that we didn't have to yell to hear eachother, and the boy seemed grateful for it. Quietly he told me that he had fallen asleep and woke up to find flames in the kitchen. When the firefighter came he was so scared he pretended to sleep, not knowing what else to do. He felt okay, he admitted to me, but was embarrassed about what had happened. Amongst the turmoil and noise of the bumpy ambulance, sirens, and a new paramedic running his routine, I think it took only a few quiet words to make this patient feel well again.
I took care of two patients today who reminded me that even "critical" calls deserve a minute's pause and consideration. These are people, not presentations. Men, not mechanism.
Its easy to forget. I'd like to thank both of my patients today for their gentle reminders.
Monday, June 23, 2008
There is a certain profundity that is expressed by silence in the face of screaming tragedy. Quiet has a potential to permeate the soul deeper than any cry could, hit harder than the fiercest blow. With somber sadness and a quiet reverence for a life gone in only a few seconds, my partner and I stood over the body of a woman who was alive and working at the machines only ten minutes ago. Now, her skull was gruesomely crushed, open and split onto the cold concrete. The factory, usually buzzing with activity and clanking machines, was totally shut down. The hundred or so workers who manned the iron from nine to five were frozen in their positions, standing in awe. Their smudged faces peeked out from yellow hardhats, betraying a contorted mixture of disbelief, shock, awe, fear, and sadness. Silently, we all stared at the result of an accident that brought the entire factory, and this woman’s young life, to an abrupt halt.
She was assisting on a large iron press, we were told in whisper. The machine exerts several tons of pressure, and through some miscommunication or some other horrific lapse, this woman was caught underneath it on a downward stroke. The result was the worst traumatic injury I have ever seen: a crushed skull and brain matter spread out in a fanning pattern. The face was an unrecognizable mash, attached loosely to a body that lay lifeless in an awkward, contorted position. We didn’t even check a pulse. There was no point.
We conducted our business under our breaths, passing word to the police officers that the patient would be presumed dead having sustained injuries incompatible with life. Firefighters wordlessly began surrounding the workstation with a large opaque tarp, shielding the entire area from the tearing eyes of her coworkers and friends. I was able to get demographic information from some of the factory management, and then quietly made my escape back to the ambulance.
My partner and I stowed our gear and climbed back into the truck. Looking at each other from driver’s seat to passenger, we couldn’t come up with anything other to say than “holy shit.” Silently, we drove back to the ambulance bay.
I’ve been to the scenes of many recent deaths. Car accidents, shootings, various cardiac arrests. Outside of health facilities there seems always to be some distraught family member or friend, loudly exclaiming their grief in either cry or yell. It used to bother me to see the faces of these anguished people, and it was usually with them – not the patient – that I empathized. For some reason or another I don’t usually find myself sympathizing with the dead. They’re gone, and in most cases there seems to be plenty of grieving going on anyways.
…But not this call. It was deathly quiet. The silence was so thick that it had to be managed, considered as its own passive obstacle like knee-high sand. We waded into that factory though oppressive quiet and took in a scene that few should have to bear witness to. We saw a hundred hard-hatted faces, watching and silent as if they were waiting for the woman to take her next breath and spring from that contortion. It was a frozen moment of time, lasting an hour, where consideration and re-consideration of events past left little room for outward emotion or cry. It was unreal.
We were brought in to talk with our supervisors who worried whether we were okay. They were extremely accommodating, asking if there was anything we wanted or needed. They said they knew that the scene was pretty gruesome, that it is tough for anybody to see a body so mangled and dead like that.
But it wasn’t the gore. It was the quiet. Seeing that person lying there frozen where she last moved herself was an extremely powerful experience that I don’t think I will soon be rid of. It was as if the clock stopped immediately after that machine banged downward, and though the area surrounding that small space shuffled and blurred in the background, our dead patient remained in sharp focus, preserved in powerful tragedy on the precipice of comprehension.
…And all we could manage to say was “holy shit.”
Tuesday, June 17, 2008
Monday, June 9, 2008
Nevertheless I thought I'd ride with him to the hospital instead of driving. Maybe he could use a little fluid I thought, or perhaps some medication to control his nausea and make him a little more comfortable. I hadn't teched a call all day and my own boredom probably played as much a role in this decision as any particular sign or symptom. What the hell, right?
The twelve-lead ECG was full of noise from the bumpy ride despite my best efforts, and there was a bundle branch block that further obscured the view. What I could see, though, were some ST depressions in the V5 and V6. They were maybe a two millimeters or so, and I had my doubts that they were much more than a reflection of all else that was wrong on that strip.
Besides, I have been down this road before. ST depressions in a few leads, inverted T waves, small elevations: they get scoffed at in the ED. Especially without a really good story, these minimal, inconclusive ECG changes often bring nothing more than eye rolls and a condescending pat on the back. "We'll look into it, good job." I've heard it many times before.
The hospital flipped out. The nurse's eyes widened when she saw my strip, pointing at the tiny ST depressions as if they were tombstones from the widowmaker itself. She rallied all her resources, worked the patient up and yelled for the doctor who came quick-stepping into the room as I shrank farther towards the corner. Right about this time the patient's family arrived at the patient's room. I had met them earlier at the patient's home and before I left I told them not to worry, that I would take care, and that they should drive safe. We left the driveway without lights or sirens, and I thought I had made a calming impression on the otherwise edgy and nervous relatives.
So much for that. They sensed the tension and the doctor wasn't helping. "The ECG does not look good at all," she said. "I don't like it one bit." The doctor explained the next few steps in quazi-technical jargon that whipped the family right up into a frothy frenzy, and in just a few minutes I wanted nothing more than to make a quiet escape to review the strips again for myself.
They looked the same as they had earlier. Just a few minimal changes. The same stuff that I've brought in plenty of times before and been disregarded and tossed aside. "Oh, that's cute," they'd infer. "Look how thorough the medic is trying to be." I squinted at the paper and looked as hard as my eyes and education could decipher. Nothing impressive. Not even close, really.
A little bit of experience has raised my index of suspicion for acute coronary syndrome to perhaps a ridiculous level. It seems when I print off twelve leads these days, the patient better have huge ST elevations and the most convincing story I've ever heard if I am going to truly consider ACS with any seriousness. T wave inversion? Hah. ST depression? Yeah right. Don't get me wrong, I'll pass the asprin and nitro out like I am supposed to, but as far as actually believing the patient? As far as being willing to present this to the ED as a heart attack? Not on your life. Doctors simply do not want to hear a paramedic's evaluation of the minute. Its cath lab or shut up about it.
But not this time.
Monday, June 2, 2008
My patient is dead. He is spread out on the cot, naked and surrounded by nurses and doctors performing CPR, looking over my cardiac strips, pushing drugs, yelling out commands. The scene is organized chaos, but my focus is set upon just one person there, at the head of the stretcher.
Its the doctor saying that my tube is in the esophagus.
The feeling of fear and shame was so intense, so immediate and powerful that I still remember it with utmost clarity today. Surely any paramedic who has been in a similar position can sympathize. I was taken by surprise, having run this cardiac arrest for more than thirty minutes to the best of my ability, exhausted from the effort and glad to turn over care to the emergency department, only to hear this.
The doctor ordered an intubation kit and the nurses scrambled to comply. I caught a few eyebrow-cocked glances from those in the room. An unrecognized esophageal intubation is probably one of the worst things a paramedic could possibly do, and there I was, helpless in front of my jury, waiting for the verdict from a white-coat at my patient's head. My god I didn't know what to do. My blood ran cold and I just stood there, my mouth half open and staring at the scene as it unfolded. What the hell do you mean my tube isn't in??
The doctor put the laryngoscope in the patient's mouth and almost immediately made the claim again. "Yup," he said, "It's in the stomach." I remember the words exactly.
He asked for another tube with an outstretched hand and a nurse quickly complied. With my tube still in it's place, the doctor directed his new tube slowly, deliberately. It bent upward. He tried again, and again. Each time the tube would contort out of place and resist forward motion. He tried moving the blade around, lifting higher and harder. No luck.
I stared at my monitor printout. It listed the end-tidal CO2, which showed readings in the high teens and twenties for the entire trip. I remember listening to the lung sounds and hearing them clearly. Positive in both lungs, negative over the epigastrium. I SAW the tube pass through the cords, and it fogged up with my first few squeezes of the BVM. The patient's stomach remained perfectly flat for thirty minutes of bagging through that tube, and I re-checked the position at least three times on the way into the ER. God dammit, I was sure about that tube.
...But the doctor continued to insist that it wasn't in. He went back with his laryngoscope and dug harder, peering into the mouth from only a few inches away, squinting his eyes and contorting his face. The tube continued to bend on each of his attempts.
A nurse tapped me on the shoulder and I almost jumped. I was so focused on the events at hand, I didn't pay attention to anything else going on in the room. Now it was the doctor getting the half-cocked looks, and the nurse tapping on my shoulder whispered in my ear. "Don't worry about it," she said, "thats a good tube."
It was. It took the doctor a few more tries before he gave up, pronounced the patient dead, and signed my paperwork acknowledging that I had a good tube. He never said a word to me about it and carried on with whatever else he had to do.
Exhausted, relieved, and trembling, I found a quiet corner to write my run form. Its amazing how quickly things can turn around on you with this job.
Wednesday, May 21, 2008
Those complicated calls - the ones where we are forced to make tough decisions or recognize an elusive pathology - those are diamonds in the rough. They happen so infrequently that news of them spread far and wide, across our service and beyond as tales of so-and-so's call permeates distance and time. If someone gets a good call, even in this city, you can bet that most will have heard about it by day's end. It seems sometimes that truly challenging calls are so rare, that when they do occur we find ourselves so surprised and unpracticed that we might be glad to get through it all without making an idiotic mistake. My last entry on this blog might serve as case in point.
And yet those calls are the reason why so many of us decided to do this job. I hope I have convinced my readers by this time that I have a genuine interest in medicine and that I do my best to learn from each and every patient, but I must admit that I too do what I can to seek out those elusive diamonds in the rough. I want to be challenged. I want the excitement and pressure of the unfamiliar. I want to be able to say that I've been there before. I want to respond to the side of a patient for whom a special skill or talent might mean the difference between better and worse. Who doesn't, right?
...But the mundane. Oh, the mundane. It is almost suffocating in it's volume. Paralyzing in it's persistence. My days are absolutely filled with it, and I find myself sometimes in the backs of ambulances, plugging away at the routine ALS as if my job could be performed by a machine. We get dispatched to calls like a short order cook during lunch rush. Chronic back pain. Hand swelling. Car crash and everyone is out walking around. We trudge through it for twelve hour shifts, heads high only for the hope that one of these might turn out to surprise, to challenge or intrigue. There are a lot of disappointments.
I would like to know how those who have been doing this job for a long time are able to withstand the mundane. Do they no longer live for the exciting calls? Are they content to relax in the routine, or have they a way to find interest in the subtleties that I may perhaps miss in my eagerness for something new?
Am I missing something?
Monday, May 5, 2008
Not a regular every-day kind of mistake, but a critical one. It was something we've been taught from the beginning. Basic, and yet in the heat of the moment of a call wrecked with the unfamiliar and quick decisions, I forgot. And really, there was nothing more than that. I simply forgot.
What I should have done now appears impossibly clear. The benefit of time and conscious reflection has forced those decisions outward for inspection, starkly naked and illuminated in the harsh light of all that only now seems heartbreakingly obvious. I'd slap my forehead if the expression wouldn't so drastically underestimate the seriousness of my own omission. This time it was real, and it counted.
I suppose on a large enough scale, I can afford myself the opportunity to sit back and comment that these kinds of mistakes are unavoidable. We are put in a tough spot, us paramedics. Forced to deal with undifferentiated patients in unfamiliar environments, pressured by time and the sheer inadequacy of our own knowledge, day after day we blindly toss ourselves from scene to scene and patient to patient. As the census numbers climb, a statistician would probably conclude that the opportunity for error climbs as well. The probability most likely doubles with the inexperienced, and increases exponentially as the patients become more and more complex. ...And even though my rationalizing mind would like to point out such explanations, I still find myself looking back on those few minutes with great regret and dismay. I'm new. It was a tough call. But even still, I should have known better.
It brings to mind the oft-tossed around concept of "good paramedics" and "bad paramedics." There are a few at my service who are categorized as at the extremes of each definition, either through rumor or - in some cases - as the result of a few isolated incidents. We hear stories passed around all the time of so-and-so having made a terrible mistake, or another medic making a great call. Each of these stories, most likely taken well out of context, contribute directly to the reputations of people who - I know - work very hard to keep themselves upright against the constantly changing winds of EMS and the patients we find. With all that we are subjected to, I cant imagine that anyone is able to completely keep his head down, maintain an even keel and avoid the extremes. The big mistakes will happen. A stroke of luck sometimes swings our way. And all the while we do our best to maintain. A good paramedic, I imagine, is able to weather the storms at least as well as he rides the highest waves.
And so, as is the usual procedure after an experience such as this, I return to the work of weathering the storm. Not that I caught any real trouble for my mistakes, but there is most certainly a battle that I need to fight with myself. Even experiences like these can prove beneficial if I refuse to let mistakes become the focus, but it doesn't come without a fight. I will most definitely learn from this. I just hope in the meantime that nobody thinks I'm a bad paramedic.
Tuesday, April 22, 2008
Every time I touched her she would shriek in some unintelligible manner, her tone wavering and exhausted as the last bit of her breath was forced to the effort. She was a mess. 89 years old and more co-morbidities than I had time to count, the dialysis staff where we found her told me that she "needs to just die." ...But for some reason, she wouldn't. Not a DNR, not four times a week hemodialysis, not cancer, not massive systemic infections would finish her off. Instead, she sat there in her chairs and stretchers, writhing in pain and suffering through every minute.
Her family calmy watched from the waiting room. This happens all the time, they say, but they don't want to give her too many pain medications because she "isn't herself" when she's on them. They've been cutting her oxycodone pills in half with a butter knife at home and feeding them to this woman slowly, as they deemed necessary. I stared at them in horror as they relayed the story.
The woman had advanced dementia. She was weak beyond helping herself and wasting away in a slow, agonizing manner. What personality this woman once had seemed to be long gone, or recessed so deep as to never be recovered. In front of me was a bag of bones, a writhing shell of a person who once was. If there was any consciousness within that body, and if it had any sense at all, it was probably pushing from the inside desperately trying to escape as soon as possible.
...But the pain was real. It had to be. She yelled so loudly when we moved her that the nurses had to apologize to the rest of the patients in the facility. It was a harsh, agonizing cry, and even though it was technically unintelligible it somehow, through seeming urgency or subconsciously perceived texture, spoke clearly to all who heard.
Let me go, it said. Let me go.
Thursday, April 17, 2008
Dispatched for the "possible heart attack," I arrive to find a tall, strong man in his 40's chatting with a police officer. He is walking around the small doctor's office, refusing to sit down and ignoring the nurse's increasingly frustrated attempts to apply a nasal cannula. "I'm fine," he insists, "I'm fine."
The doctor pulls me aside, rolling her eyes a bit as she shuts the door between us and the patient. "I don't care what he says," she tells me, "he's got something going on." The man came to the clinic because he has been waking up in the middle of the night drenched in sweat, short of breath with an "aching" feeling in the crook of his left elbow. At some point he admitted to some nausea as well, and the ECG taken today showed some mild ST elevations in the anterior leads. "After he realized that this might not be a simple sweating problem, he clammed right up," the doctor told me.
She was right about the clamming up. In fact the man was positively evasive when I tried to do my assessment. He would respond to specific questions with general answers, refusing to make eye contact at any point. When I asked him if he had any chest pain he replied "Well, yeah, I get pain all the time. Like when I work out, or if I fall down." He was probably one of the toughest patients that I've had to interview in a long while, and I was surprised to find that someone would so effectively try to sabotage his own care. I've heard of denial before, but there is usually a point where people - out of fear or whatever else - finally open up. This man simply would not, and we spent the ride to the hospital in tense discussion as I asked - and re-asked - each question.
The man was visibly shaken as we rolled him through the hissing doors at the emergency room entrance. His voice trembled as I asked him for his registration information, and despite my efforts to help him relax, his hands remained gripped tightly to the stretcher rails. We transferred his care to the hospital staff, and he released his grip from the stretcher only once: to shake my hand.
"I'm fine, but thank you," he says.
Monday, April 14, 2008
It was an arduous journey no doubt. Months he was laid up, rendered alone to the cold with little more to comfort than that which he had prepared for himself in advance; our little friend was not seen for quite some time. Some feared him dead, some wondered if he had traveled far away for more hospitable climates, but there were those who maintained hope all the while. Though the cold, though his forlorn absence, though every unfinished nut, there remained a burning light of hope between us over the smothering, snowy months. He would return, we knew it, and there would be much rejoicing.
...And today, he did. Perched at the entrance to the Emergency Room doors today I found Mr. Jingles himself. A bit skinnier, a bit worse for wear, but alive nonetheless. Ready for another glorious summer of midday snacks and social sessions with the local EMT's, our mascot accepted a welcome back buffet of barbecue-flavored sunflower seeds and regaled us of winter months past.
Wise Mr. Jingles, many patients you have seen bustled past your doors. Here's to another season of summery survival.
Thursday, April 3, 2008
The call was so easy, so routine that I relaxed more than I normally would. We didn't move slowly, but certainly didn't rush. We where deliberate with our actions, and didn't make any mistakes. Nothing got tangled, nothing got in the way. One of the EMTs managed the airway with a bag-valve mask and an OPA, while the rest of us walked on the side of the stretcher towards the ambulance. Everyone, having been there before, was completely calm and comforted in the transparency of the situation. She'll be up in no time, a little vitamin N and we'll be cooking with gas.
We were right. 0.8 milligrams in the muscle, and then 0.8 more though the line and she was breathing well on her own, satting at 100% with just a nonrebreather mask and dreamily enjoying the ride to the hospital. It was the perfect amount of Narcan: that sweet spot between respiratory function and a pleasant patient. We hit a bullseye.
One might imagine that at this point I would, as I have many times before, launch into a lengthy discussion about the perils of overconfidence. ...Perhaps this patient might turn out to have something else going on, some terribly elusive pathology that I might've missed weren't it for some stroke of luck or moment of brilliance. I could write about myself being embarrassed by the hospital staff for a simple mistake, or relieved by a close call and reeling from the experience. All of these things have happened before, and it would be easy to weave these experiences into this story to make the point that I have made many times before.
Not this patient, though. Nope. She looked like an overdose, she presented like an overdose, and - lo and behold - she was an overdose. The drug worked, and all was well.
Sometimes its really nice to have things cut so cleanly. I probably can't expect the same from my next patient - and part of that is what I love about this job - but every once in a while, it ain't so bad to catch an easy touchdown.
Tuesday, April 1, 2008
For almost 2 hours we sat with sweaty palms playing board games in the sequester room waiting for our turn. It was probably the most disinterested I'd ever been in Monopoly, but I couldn't help from thinking my way though the scenarios they'd told us we would be confronted with. A HAZMAT identification, difficult airway, ACLS resuscitation, c-spine and carry. Each step would be individually scrutinized, points attached and pitfalls set in place. We needed to get the airway established within four minutes from the start, and that included time to identify the hazard, climb through and obstacle, and get all our equipment through.
In time, though, the buzzer went off and we went through our motions. The hazard was quick, next throwing ourselves up and through the obstacle, back down onto our knees for the airway. It was calm and easy for only a minute, and then things started to get difficult. The air from the bag valve mask wasn't going in, and despite abdominal thrusts and even direct laryngoscopy, we couldn't find the obstruction. We tried to pass a tube but there were no lung sounds still, even though the positioning seemed good from the view, we couldn't hear a thing. Aware of the ticking clock, we yanked our scopes from our ears and questioned the judges.
"Are we supposed to be hearing lung sounds on the dummy if the tube is good?"
"You hear what you hear," they answered flatly.
I looked one more time with the laryngoscope, desperately checking the tube one more time as our last few seconds ticked away. All I could see, though, was mannequin skin. I repositioned the blade slightly more anterior, lifting higher and forcing a larger view. There it was. A little plastic baggy filled with some yellow material. My partner handed me the magills and I pulled it out, but even then I knew that we were sunk. Four minutes had more than elapsed, and though we were able to establish a patent airway, we were dead in the water.
The next stage, the patient resuscitation, didn't go well either. We like to say that we are used to stress on the job, that we are practiced in dealing with unusual circumstances, but this situation seemed to push us back to our heels. It was a VT arrest on a simulation mannequin, and though we got our IV line, pushed drugs, and did good CPR like we were supposed to, we did it all sloppily. It felt a mess.
Aware of the judges over our shoulders, we messed up things that we never would have otherwise. We made simple mistakes and forgot the order of things. After a bradycardic return of spontaneous circulation, we decided to try atropine first instead of pacing. Because we deviated from the established ACLS algorithm, we weren't released from the station until we realized our mistake, and pacing brought the blood pressure back to acceptable levels. More time wasted, more mistakes made.
Exhausted from the stress and the extended resuscitation, we strapped the 175lb dummy to a long spine board and performed the physical tasks required of us. We pulled it through a tunnel, up and over some stairs, and strapped everything down to the stretcher. Into the ambulance we went, and a honk from the horn indicated we were done.
We each flipped off our gloves, let out a sigh of relief, and collected our equipment.
The fact was already clear to us, but it wasn't until two days later into the conference did we find out that we were disqualified. I'm still not sure exactly which station we were knocked out for (JEMS is sending an evaluation in the mail), but the news was far from a surprise. We learned quite a bit, though, and the competition was great fun. This was the first time we had ever done anything like this, and -rationalizing afterwards - we all agreed that it was inexperience with the format that surely caused our errors. True or not, each of us learned some lessons that we will take home with us, and, next year, we will be a different team. JEMS Games: we will be back!
The rest of the conference was a great time. We attended a whole lot of lectures, some of which were absolutely phenomenal. The electrolyte talk by Corey Slovis was one of the best, and Bob Page, as usual, did not disappoint. A "Street Doc" Q&A session lead by Bryan Bledsoe got us asking some good questions and getting some good answers. All in all, like last year, I feel that I am returning back to my hometown better prepared to do my job well. That alone makes it all worth it.
Some photos I took from the JEMS Games finals:
Monday, March 24, 2008
Please wish us luck, and I'll be back next week to report on everything!
Tuesday, March 18, 2008
Though I sometimes find interest in the concepts discussed in class, more often than not I have trouble shifting gears between work and school. Just a few hours before I took this seat I was sweating in a dim hallway, pulling the weight of an obese man in congestive heart failure down three flights of stairs as I struggled to balance my treatment regimen with the pressure of a true emergency. Now here I sit as an elderly man in a chalk-stained tweed sportcoat dryly lays out the principles of chemical equilibrium to a hushed classroom. Bound up in my job and the impression it makes on me, it is becoming increasingly difficult to find hands free to do well with almost anything else. All the while, relentless school marches towards the increasingly complex, demanding more time that doesn't exist, more energy that I never had, and more effort than I have ever had to put out.
It now seems little wonder to me that EMS has become a trap for so many. To break out of this is to strain and pull, consistently, against an almost overwhelming lure of the presently interesting and financially stable. ...All traded for classes that really are no fun, demand an incredible price, and promise nothing but a chance at more.
Much more, though. Supposedly.
Things have not been good lately. The classes are getting tougher and more demanding. Work continues to distract from that which should matter most. I think there is going to have to come a time where I will be forced to cut loose from this job so that I may take my shot at something bigger.
Otherwise, I fear, I may never move on.
Monday, March 10, 2008
We were dispatched for the "sick call," which was updated as we were halfway there to an ominous sounding "diarrhea, use caution." No further explanation other than that. My partner and I looked at each other with wide eyes, each betraying some deep-rooted fear arising from an inkling of what this call might have in store. This can't be good.
We arrived to find firefighters already on scene, clustered around the outside of the building and doubled over, arms covering their noses and gagging. At first it looked as if they were playing it up, exaggerating in some sort of juvenile stunt, but as we approached closer it became clear that their faces were serious and solemn. One of them walked slowly to my window as I rolled it down. "Just follow the trail," he said. "...And you'd better put your masks on."
With our courage up and masks on, we entered the building.
Down the dimly lit hallway there was a long path of feces on the floor. The amount was staggering in both the distance it traveled and the magnitude in which it did so, brown clumps and streaks pointed the way towards some yet unknown horror. We scrunched our noses under our masks, recoiling at the growing odor as we walked slowly on each side of the droppings. The path lead all the way down the hallway, around a corner and into an open apartment door. Reluctantly, we followed.
It was everywhere. On the walls, on the floor. On the toaster oven and everything else that was strewn about on the floor. The small room was in ruins, stifling in the thickness of it's presence and odor, we coughed and gagged through our green masks as we struggled to (and not to) take it all in. There was an old man, skin and bones, disheveled and wild in an almost ghoulish way, emerging from the depth of the mess. He was ragged and limping, his hair standing up straight as if terrified and struggling to escape their roots. A castaway on an island of filth, the man seemed to reign king over his own detritus, and he growled unintelligibly when we attempted to communicate with him.
Though it didn't appear as if the man was in any apparent distress, it was clear that we would have to remove him from the apartment and let the police lock it up until both parties could be washed clean. It was a simple social-services call, and we had a job to do. Barefooted, the man trudged through his apartment, pacing in wild, erratic circles as he shook his fist in protest. He, too, was caked with the foul stuff.
Somehow we were able to coax him onto our stretcher, and with extra blankets galore, we insulated him from the rest of us. "Let's make you really comfortable, sir," I said as I piled more blankets on.
Back down the hallway and up towards the fresh air, I smiled quietly at my partner. She glared back at me, and through our faces were partly covered by the masks the messages were clear: "You're going to BLS this one aren't you," she said with terrified eyes. I said nothing, but continued to smile.
At the ambulance we got a set of vital signs, avoiding and isolating the filth as best we could. They were stable. The man was without complaint save anger at his extraction. Slowly I crept backwards out of the ambulance, into the daylight and away from the increasingly foul-smelling patient compartment. "Let me know if you need anything," I said to my partner, winking. She glared at me some more as I closed the door.
The ride to the hospital was pleasant as I listened to the radio with the window down. The wind in my hair and a good song playing, I tapped the steering wheel to the beat and whistled the tune.
For those of you who will undoubtedly consider me rude for passing this call to my partner, let it be known that I was not without suffering of my own. While attempting to get the patient on the stretcher and carefully trying to avoid contaminating ourselves, my glasses became dislodged from my head and fell to the floor. Though I grabbed them up right away, they came in contact with a particularly dirty area of the carpet and became spoiled almost immediately. They were only $3.99 from a gas station, but I had these glasses for some time and they had served me well. Contaminated as they were, I just couldn't feel right putting them on my face again.
And so they were laid to rest in the biohazard bin:
RIP, my trusty shades.
Thursday, February 28, 2008
1. The man being held in a seated position by his franticly hopeful family, aunts and uncles who were completely oblivious as to the gravity of the situation. He had a dead look about him, a point that became more clear to everyone when you asked the family to lay him down and he smacked hollowly to the tile floor. They had no clue. Asystole.
2. Pupils fixed and dilated. Flat lines. Twenty minutes of ACLS on a kitchen floor with firefighters groaning and sweating through the work. You rolled your sleeves up because the effort and proximity of the room made everything seem stuffy and hot, but it was a message too: let's get to work, I'm ready.
3. Thirty-nine years old, the family said, and they thought she was alive this morning but they couldn't be sure. Someone thought they heard her get up and make coffee. "The lady deserves a chance at that age," the doctor said over the radio after refusing your request to discontinue resuscitation. "Bring her on in."
4. Frozen to the ground with the weather in the teens. No idea how long she has been laying there but it has been a while because all her clothes have become solid and crinkly around her iced-up flesh. A reluctant jaw and a lucky tube, an 18 gauge in the wrist. Protocol says we can't give drugs without orders?
5. The words coming out of your own mouth to a family not expecting any such thing: "Ma'am, his heart has stopped and we are doing everything we can to get it going again." Never having thought of practicing this phrase, considering ahead of time how to deal with these words. I hope it didn't sound too hurried or callous, too revealing of the situation's hopelessness.
6. How did the wires get this tangled? Do we have all the sharps? Knotted end-tidal CO2 lines and and the top of the ET tube coming off with the BVM. Feeling like the equipment needs to be reigned in as much as the patient. How do you keep this organized?
7. Delegation gone right. Partner getting a great line as the tube slides in. CPR from the firefighter, all in sync. The way it's supposed to be. Now what?
8. A sigh of relief when it's done. Fisties from the rest of the team. Thank you's, good job's, and you-did-all-you-could's
9. The knowledge that there will be many more to come, and that I will have the benefit of these to reflect upon.
Monday, February 11, 2008
When faced with a complex patient who is in the least sense stable, who could stand the ride to the hospital in relative good health without printing flat lines, more and more it seems that the answer for the questioning paramedic should be to do nothing. Old wisdom says that it is better to spend time with the non-invasive, with the safe and comfortable until more skilled hands take charge of the real decisions. The fancy drugs? Leave them. The risky procedure? It can wait.
See, in the loosest sense we are technically allowed to perform a large list of interventions. Our drug bags are fairly extensive, stocked with fairly complex and fancy solutions about which we understand only a small portion. We are granted surgical procedures which many of us - even the brave with many years of experience - have never or only once attempted. We are able to stop and start heart rhythms in the right patient on our whims, and every paramedic knows: the decisions are not always obvious.
That was the attraction, though. Murky gray patients in discomfort or teetering on the edge of something worse, supine on my stretcher and I, a paramedic, with the ability to do something about it. Yes I can intubate a patient in cardiac arrest, push epinephrine through their flattened veins and heroically demand all to stand clear while the electricity flows... but what I really wanted, what I really looked forward to was to take a patient who was almost worse. ...A patient that I could see circling the drain and then - by the strength of my notice and power of my appointed abilities - reverse the course. Epinephrine for a bad allergic reaction. Magnesium Sulfate for severe asthma. A dysrhythmic for a tachycardia. These are the interventions that make the differences, that require knowledge and skill and ability and all of those things attribuited to the provider who is truly good at what he does.
These are weighty decisions, though, and there is a reason why they are made only by the experienced and able. It is too easy to swing wide, to notice what there is not and power-over in an unnecessarily aggressive treatment. Equally there remains potential to undertreat, exaggerate permissiveness to an unhealthy degree. In these cases especially, as much as there is the capability to reverse sickness, used incorrectly these treatments have a special potency to accelerate certain doom. Here lies at once the ability to do immediate good, living right alongside - as neighbors - a potential to cause disastrous harm. It is a delicate and discerning touch that knows the difference between too much and too little, a rare mind that weighs the evidence in proper perspective and always hits center with each decision.
From the view of this still-new paramedic, it seems increasingly clear that given all that there is, it is best to remain conservative. ...Even if it is not what I think is best for the patient, recent experiences are teaching that it is better to hang back for a few minutes; observe instead of reaching for the boxes and bags. Retrospect teaches that it is far easier to justify an omission than an act, simpler to explain the why-not than the why.
Nagging, though, is the patient. Better for him or better for me? Even in full awareness of my ignorance compared to the depth of medical knowledge, in plain view of my inexperience and lack of education: the supine patient will ask for help.
Monday, February 4, 2008
I recognized the rhythm as soon as the monitor started displaying it, and smiled to myself in anticipation of a job well done. This was rapid atrial fibrillation and I knew exactly how to handle it. The algorithm was clear in my memory, it's dosages and considerations familiar to me as if I had handled a case like this yesterday.
...I hadn't though. This was the first time I've seen it in "real life," and though all of my academic confidence there remained just a twinge of unease.
As a whole, the woman was stable. Her blood pressure was in the low 100's, her mental status at baseline. She complained of chest pains and said that she has been feeling "weak" and "uneasy" since earlier this morning. When I started asking her about her medical history, she mentioned the a-fib and a recent ablation surgery to rid herself of it. She was on daily Coumadin and a beta blocker. It was pretty clear-cut.
My partner and I did the basics. We put the woman on some oxygen, started an IV, and obtained a 12 lead ECG. There was no evidence of WPW. I ran through assessment techniques that I had performed hundreds of times before, and we spoke in easy tones with our nervous patient, easing and relaxing the situation until her stress was gone.
Zero point two five milligrams per kilogram was the dose for Cardizem, I remembered it clearly. I got the patient's weight, converted to kilograms, calculated the dose, drew up the proper amount, and slowly pushed the medication through the IV line. My first time with Cardizem, but the mechanics of the task were routine and I knew enough to say that I had been there before. No problem. Together the patient and I watched the monitor for changes, and like magic:
There it was. Still a-fib, but a much more satisfactory rate. Beautiful.
I remembered the next line in the algorhythm too: start a maintenance infusion. The dose was 10-15 milligrams per hour, a slow drip as prophylaxis against the rhythm returning. My paramedic instructor had always made a big deal about dysrhythmic maintenance infusions, drilling the point home on exams and quizzes so that we would never forget. It was an important step, often neglected in the ambulance but not this time: I was going to do it.
The math, though, oh the math. I was lost. Between talking with the patient, monitoring my equipment, and obtaining reassessment information, I found it impossible to calculate the proper drip-rate with the supplies that I had on board. The smallest saline bag I had on hand was 500mL, and there was only 25 milligrams of Cardizem left for the infusion. I shot the medication into the bag, and sat there on the bench with a faraway look in my eyes as I mixed it. I was good at these in medic school with pen, paper, and calculator. ...But now, sitting in the back of the moving ambulance with a patient and a bag in my hand, my brain froze over and slowed to a crawl. I tried the math a few times on my notepad and failed, cursing quietly under my breath.
I knew approximately what it was that needed to get done. The patient needed about half of what was in the bag over an hour's time: 12.5 milligrams per hour. I hung the assembly and piggybacked the line, setting a drip rate at "about" what I thought would drain within that time. I watched it carefully as we drove to the hospital, adjusting it slightly after 50cc's had flowed. Practically, the rate was just about correct. Academically, though, I had no idea what exact drip-rate the patient was getting. It made me extremely nervous. I imagined showing up to the hospital and being questioned on my assembly, the concentration and what infusion rate I had chosen. I could recite "about" what it was, but remained terrified that the ED staff would question the specifics. What do you mean you started a medication infusion and you don't know what the drip-rate is? I imagined I would stammer and sweat, standing there in the harsh ED lights looking not only ridiculous, but incompetent.
I tried over and over with the math, but with the distractions and the increasing stress as we approached the hospital, I just could not do it. I had no calculator, and the numbers were starting to blur into meaninglessness. We arrived at the hospital before I was ready, and without anything else to do, I decided to just lock the IV line and head in to the ED.
The ED staff didn't seem to care much at all about my drip. The pulled the piggybacked bag off of my main IV line and tossed it to the side. They assessed the patient on their own, barely listening to my report and only glancing at my ECG strips. Never once did they ask me at all what infusion rate I had administered my patient. Hearing the story, the doctor smiled at me and told me I "fixed her," patting me on the back. I nodded and backed slowly out of the room.
The drip rate calculation took me less than 30 seconds as I sat at a desk writing my report. I immediately recognized the mistake I was making earlier, and shook my head in wonder of how I could have messed it all up. Simple. It really was simple.
I made simple, rookie mistake because I was flustered with a new situation and new procedure. With all of the routine ALS that I have been doing lately, satisfaction with my performance of the familiar was beginning to inspire an unearned confidence. The experience was a sobering one, bringing me back to the ground after so many months of remaining largely unchallenged. No matter how much I think I've learned, experiences like this have been reminding me that this job has the potential to surprise at any moment. ...Without warning exposing a weakness in harsh, bright light.
Baby Medic, you'd better stay sharp.