Thursday, February 28, 2008

Code Snippets

I've run three cardiac arrests in the past two days. It is a staggering number for a newbie medic over such a short period, and the experiences have far from left my consciousness. These three were the first codes I have ever worked as the sole ALS provider on-scene, and there were a few moments during these calls that I would like to write down and remember. Perhaps these notes are more for myself, to read back on some day in the future. I am aware that my perspectives will change though time, but sometimes it is hard to tell which ones. Hopefully this will help:

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

Weighty Decisions

In light of the great expanse of that which I do not know, it is often hard to justify following through with any method of treatment at all.

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

Momentary Complexity

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.