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.


Kari said...

If it makes you feel any better, you're in good company: I too just barely scraped through my second semester of orgo. Even though I doubled my hours working in the ER--something that usually reminds me why I'm doing a post-bacc--watching my GPA plummet made me question whether I was really meant to do this.

Some days I'd go to work sure that I needed to pick a different career. But I can't tell you the number of residents, fellows and attendings who told me about their long road to medical school. My favorite ER attending got straight Cs in orgo and was told by her adviser to "consider a different career path." A pulmonary critical care fellow had to take the MCAT three times before he got above a 27. Another ER attending applied six years in a row until he finally got in; now he's the academic director of the EM program at my hospital's medical school.

If you want this, which I think you do, don't let anything--not a bad grade in orgo, not a rejection from a post-bacc program--stop you from reaching your goals. The medical community needs more people like you.

I'm glad you remembered. Don't forget again. :)

Shaggy said...

I took Ochem 1 and 2 last summer. As accelerated classes and working two jobs, I found it most tortuous. I literally went days without sleep, practically ODing on caffeine pills. And the worst thing of all, I have seem to forgotten most of what I learned, or tried to learn. Stick with it! I have many residents tell me they did worse in O-Chem than in medical school.

Herbie said...

My guess is that she was retaining. I've intubated asthmatics with EtCO2 readings at 99 mmHg.

As for medical school, don't give up the good fight. Setbacks are going to happen; how you come out of them define what kind of person you are.

medicblog999 said...

I wish I had the courage to go to medical school earlier in my life. Don't get me wrong, I LOVE being a paramedic, but I often wonder, what if......
I'm sure you will do absolutely fine, it's going to be really hard, but imagine the satisfaction when you come out the other side.
Whatever happens, at least you have gone for it!
And we will all be here, reading how you get on too. Should be quite a journey!!

Anonymous said...

Just thinking out loud here but isn’t that a 3rd degree heart block. Disassociation could prevent pulse, pacing may help. Not sure that I would think of that while bouncing down the streets with lights and siren but that’s what jumps at me in the quiet of my den and computer.

Unrelated, but I had a status epilepticus patient today with a ETCO2 of 104, RR=44, O2 sat of 99 on 15 LPM. After seizing for 10 minutes, despite copious versed, I’m sure she was retaining. Seems like a similar effect.

Just thoughts, not really answers.

Docwannabe said...

Don't fret, I'm applying this summer, the applying process alone seems like a killer. And studying for the MCATs, what a blast! Coming from a family of many doctors I can say this: medicine is far from a pretty and glorious profession as people may think it is like on TV. Actually its probably one of the worst professions to get into if you want to ever actually enjoy your life and family. Or my family members are just workaholics, that could be it too :) I don't know why I'm hooked to medicine knowing all the tough times that lay ahead, but honestly I can't see myself doing anything else. Good luck, just take it one step at at time.

Adam Thompson, EMT-P said...

Interesting case. I would imagine that the respiratory acidotic output is in someway a compensation for a metabolic PH condition. Maybe this patient overdosed. We are unsure of the initial pulseless rhythm or cause, right?

Either way, you are right to think that the ETCO2 levels should have comedown after your advanced airway with supplemental O2. I'm interested to know if bicarb was administered and if a profound amount of NS was infused.

Air leaks, such as uncuffed tube, may result in persistent hypercapnea, but not at those levels.

I'll try to find the answer for ya.