Tuesday, June 2, 2009

On Being Scared

I've been spending weekends as a part time instructor at the local community college, teaching paramedic students about things I've only recently myself become passingly competent.

It's a difficult thing, to stand up there in front of the class and insist that they make decisions about spaces of gray between the black and the white. It is a wide complex tachycardia, the blood pressure is borderline and the symptoms are murky. It is a constellation of potentially unrelated complaints, presenting in unison as if on purpose to deceive. They sit there and scratch their heads, squint at the data with all their might as if the answer will present itself by force.

The next step is always to explain that there will be cases that don't fit the book. In fact, most of them wont, and the choices these students are going to make will have to be well reasoned ones, based not on algorithm or memorized protocol, but rather the larger picture of genuine comprehension. The answer isn't always to give a drug or to shock, but maybe to sit back and wait. ...Give a little bit of fluid and observe. I tell them that there is often more than one right answer, and despite the fact that the paramedic exams are largely multiple choice, working in the real world is much more often about filling in the blank.

The students stare back at me in horror, and I smile. That is precisely the right reaction.

I think it is important that all paramedics look up from their work from time to time and be terrified. There is so much out there that we don't know, a whole world that bustles around us whether we heed it or not. We are charged with making critical decisions for sick patients based on incomplete information and limited experience. It is my opinion that if you're not scared, you're not doing it right.

"I will have no man in my boat," said Starbuck, "who is not afraid of the whale." By this, he seemed to mean, not only that the most reliable and useful courage was that which arises from the fair estimation of the encountered peril, but that an utterly fearless man is a far more dangerous comrade than a coward."

Herman Mellivle, Moby Dick

Tuesday, May 26, 2009

A Reminder

I apologize for the lapse in postings, but things haven't been going so well for me lately.

My second semester of organic chemistry proved to be more demanding than I anticipated, and while I still await my final grades I know full well that they are less than what is required. To make matters worse, I was rejected from a postbaccaleurate program that would have given me opportunity to right my academic record, and my application for a preceptor position at work was also turned down. In addition I've been fighting through a slump of mundane calls in the city, two weeks ago working through thirty-two calls in a row without a single patient in need of ALS.

Frustration and disappointment have truly been the norm, and it has taken a heavy toll. Lately I have found myself questioning my willingness to continue this drive towards medical school, and feeling overcome in way that I haven't experienced in years. I have recovered from stumbles in the past, but it seems to me that my mistakes are begining to aggregate into something worse. It has taken conscious effort to keep my eyes pointed foward, and even when I do, I find that the light at the end of this tunnel remains maddingly distant.

As if on purpose though, luck has granted me a few interesting patients over the past few shifts that have helped to lift my spirits. I have found myself amazed by how my job still has this power over me: to challenge and intrigue in a perspective-changing way, to make me feel new again so that I might again experience first-hand those things that so strongly motivated me to pursue these goals.

This elderly woman suffered an unwitnessed cardiac arrest, had no immediate bystander CPR, and was being resuscitated by another paramedic by the time I had arrived. I intubated the patient, and was surprised to see my monitor print out the following:

A pretty sweet looking rhythm (considering the 10 minutes of aystole that preceeded it), and end tidal CO2 readings over 100mmHg for the duration of my care (please excuse the lapses as we had to disconnect the monitor for an especially tough carry-down). Nevertheless, the woman remained pulseless and even though we worked furiously, we simply could not get her to show any signs of life. I shook my head as we continued our rounds of drugs, CPR, and ventilations. CO2 output like that should mean this patient is viable. A rhythm like that should have pulses. Still, nothing.

I want to know why. Why was the CO2 so high for such a prolonged period? If this was a typical hypercapnia secondary to a respiratory arrest, why didn't the excess CO2 blow off as we continued to resuscitate? Should we have more aggressively hyperventilated? Why did the PEA continue happily for so long, yet refused to produce pulses? Was there mechanical activity producing an undetected hypotension? How could we have known if it was? What exactly was going on here?

I don't have the answers yet, but I am intrigued, and I will find them out. The potential to learn about something new has piqued my interest, and rendered me involved anew in a job that was begining to slip down a slope of disinterist and dispair. Just a few calls like this, and I remembered. I remember why I wanted to become a doctor, my facination with the unknown, and that thirst for new information. I remembered why I once felt so strongly that all of this work was worth it.

I remembered a reason to press through.

Wednesday, April 1, 2009

Realms of Control

Pediatric Advanced Life Support (PALS) is a two-day long course designed to teach front-line providers how to manage the very young when they become very sick. Like so much else in my training, the gritty specifics of the class are by now pretty hazy, but I do remember one thing: how to take one look at a kid and know if she is really sick.

This kid was really sick.

Even in the arms of her mother, her entire body heaved with the effort of breathing. She was profusely diaphoretic, pale, and cool in the extremities. Her lungs sounded rhonchorous, or maybe stridorous, or maybe wheezy. They definitely sounded bad. The shirt she was wearing was covered down the front with vomit from an interrupted meal, and it looked like more was on the way. Blood pressure was low. Oxygen saturation was low. Heart rate was high.

The specifics don't matter. This child was seriously ill with a condition that remained beyond my control. Despite all of my training, the giant red bag that I carry on my back, the uniform, the lights and the sirens, the definitive answer for right here, right now, was to scoop the kid up and run to the hospital.

It is a difficult thing to explain to a terrified family. I told them that I didn't know what was wrong with their child, but I was sure she was quite unwell. I explained that things are likely to get worse if we can't get her to the hospital quickly, and we need to get moving right away. Don't worry about finding her a jacket, don't worry about her shoes. Let's go.

The family looked at me, shocked. Can't I do something? I'm not sure exactly what it was they envisioned me doing in their living room, but certainly it was more than to tell them their child was sick. And even though we had fancy looking tools: the cardiac monitor, end tidal CO2 waveform capinography, intravenous fluids and oxygen bottles, the truth was out. All of our training and experience, tools and protocols were nothing but fluff. They were along for the ride, as we were, against an uncontrollable pathology and a random outcome that only the hospital on the hill could really make sense of.

So off we went, down the road above the speed limit with the lights and sirens doing their noisy work. I went though my routine as I was trained, knowing that the efforts would land without much effect. And though it upset me to remain unable to offer any definitive treatment, it helped all of us to know that something, anything, was being done. The hospital was only ten minutes away.

The doctors converged on the supine patient, a ring of white coats bending forward to look over the similarly colored child. They attached monitors and took assays of varying types through the cluster of work. They called resources in from across the hospital, pulled out the stops, and brought experience and reason to bear. It was more than forty minutes before one of them stepped out of the room to talk with the frightened parents.

"Ms. Reynolds," they said, "we're not quite sure exactly what the problem is yet, but we know your child is very ill."

Monday, February 9, 2009

Trauma is Easy

People like to say that compared to complex medical calls, trauma is easy. Just backboard, Oxygen, and bang in an IV, they say. Still, it has been these trauma calls that have been tripping me up lately.

Its about scene control. These patients aren't supine in their nursing home beds with a neatly-printed medical history and medication lists at the ready. There are no nurses with the story, no recent diagnosis to help with the case. Instead we find these patients twisted up in their cars, drunken on the sidewalk or combative on the ground. Taking care of these people isn't simply about their medical problems, but also (sometimes even more so), about resolving the issue at hand. A combative, drunken man dressed in four snowcoats who needs to be exposed and backboarded provides a unique challenge, and I've found myself more than a few times at a loss what to do next.

A man drove through an intersection and T-boned another car at a high rate of speed. When we get there we notice immediately that both cars have significant damage, but only the occupants of the second car are on scene. They tell us that the man who hit them ran down the street, taking with him a small child who was also in the car. A few minutes later the police find the man, and call us over to evaluate him. He is about 30 years old, not making any sense, and gripping a two year old girl tightly to his chest. His left leg is severely deformed with an open tib-fib fracture. How he made it two blocks away from the accident on that leg, we may never know. We can't communicate with the guy. He is either altered, drunk, or doesn't speak english. ...Likely some combination of all three. He won't let go of the little girl, who is now screaming in terror and burying her face in the man's chest. This man's car is destroyed, with intrusion damage into the passenger compartment and windshield starring. We need him backboarded and to the trauma room, but he doesn't seem to understand and he won't let go of that child.

How long do we work with him? How hard do we try to coax the child away from his arms? Do we just pull the two apart and hold the man down as he struggles to get his child back? What is the best for both patients?

I wasn't sure.

Sunday, January 4, 2009

Arbitrary Medicine

I brought a patient to the hospital today who was clearly having a stroke. The Cincinnati Scale was a three out of a possible three and the family was hysterical over the dramatic change that their loved one had experienced over such a short period. They wiped their eyes clear and tried to concentrate when I asked them when this man was last seen in his normal state. It was at lunch, they think. Yes, at exactly twelve twenty they brought him a ham sandwich and everything seemed fine at the time. It wasn't until four hours later that they found him slumped over in his armchair with that terrible slackened look in his face.

My heart sank as I heard the story. A possible four hours since the onset of symptoms puts this patient right around the cutoff point for a clot-busting therapy that might otherwise have made all the difference. At three hours the doctors might have made an exception, or allowed the desperate and emotional family to overpower a general clinical guideline. ...But not at four. The window of opportunity had closed and what was done, was done.

I had the patient's wife sign my paperwork after I transferred care to the hospital staff. She looked at me and gave a genuine thanks for the work I had done. Her eyes welled up as she spoke, and I could tell it took not a small amount of strength for this woman to maintain her composure. She didn't quite understand what had happened to her husband or what events had transpired that would dictate his foreseeable future, but she seemed to know enough.

The difference of an hour. I wondered later what damage it would have done if I had asked the family to perhaps reconsider what time they recalled giving this man his lunch. They had no clue what repercussions such a seemingly mundane detail might have, but I knew. I sat there and listened to it. I wrote it down on my notepad.

The TPA might never have done any good. It would in all likelihood have been a fruitless, expensive, and emotionally taxing exercise that ended with the same (or worse) end. Still, I wonder what the family would have thought if they knew the whole story. ...If they knew how close they came to the potential for a different future.

Something tells me they would have wanted to know.