Perceptions of pain, pt. II

From the depths of her contorted and decrepit frame, the woman screamed.

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.

Perceptions of Pain, pt. I

Pain, a subjective quality to which we are constantly trying to attribute objective value, is often a difficult symptom to fully understand. This is the first in a series of entries in which I will explore the way I have found my patients recognize their own pain, come to grips with it, and how they decide to outwardly project the experience towards the world.



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.

Ode to Mr. Jingles

A sigh of relief across all that work at this service. He is alive! He is alive!

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.

Easy

Clearly, it was an overdose. The EMTs we intercepted with said that they treated the same lady yesterday, at the same house in the same spot, with the same presentation and, likely, the same drug in her veins. The woman was hypoventillating at a rate of about eight, and her pupils were so small I had to check twice to make sure they were even there.

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.

JEMS

They made us wait.

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.

(Me on the tube)

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.

(Me on compressions)

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:

Off to EMS Today in Baltimore

I'm still furiously packing, but we leave tomorrow morning for the drive to Baltimore and the EMS Today conference. We had a really good time last year, but this time around promises something different as we will be competing in the JEMS Games. Our equipment is as ready as it is going to get, and we've practiced whenever we found time (which was almost never), but we are giving it a shot nonetheless.

Please wish us luck, and I'll be back next week to report on everything!

Demands and Distractions

Another semester of school halfway done, and I can't help from feeling like I've been here too many times before. These classes have been such a mediocre experience; sheer drudgery as I force myself to stay awake in complex lectures after 12 hours of busy days running calls in the city. I drag my feet into the classrooms each night, often still wearing my uniform, and pour myself into the desk-chair less than half ready for the important topics to follow.

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.

Delegation, and a Price Paid

Though I have found a lot of joy in the things being a paramedic has enabled me to do, I found out today that I can find equal - if not more - joy in things that I can opt not to do.

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.

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.

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.

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.

D David

A middle aged man dressed in painting gear was standing in the hallway when we reached the apartment door.

"It don't smell so good in there," he said.

It didnt. It was awful, actually. The apartment was littered with trash all over the place, stacks of empty liquor bottles, fast food containers, and halfway crushed cigarette boxes covered the floor to the point where we couldn't see the carpet. A thick stench immersed the whole area like fog, sticking to our clothes and clogging our nostrils. We couldn't find a light switch that would work, but the dingy light filtering though milky windowpanes told us more than we needed to know.

There was dark, coffee-ground looking blood everywhere. It was piled in neat circles at various points around the apartment. On the floor next to the couch, in the toilet, over the side of the bed. A firefighter warned me just as I was about to step in some that I had missed. This man had been sick - horribly, violently sick - for some time before we arrived.

We found him in the kitchen. He was on the floor, crumpled forward against the lower cabinets in a semi-crouching position, frozen there. His arms were limp at his sides, awkwardly positioned in an unnatural angle. His head was down, but tilted to the right just enough so that I could see that the entire face had turned a dark blackish blue color. His skin was a sickly greenish hue and had a puffy, wax-like appearance. The same firefighter who had warned me about the blood covered his mouth and nose, recoiling in disgust.

Our patient was dead, plainly so and had been for some time. I held my breath as I leaned in to attach the ECG stickers, pressed the power button and let the flat lines roll.

He was 46 years old.

Proof in the Pudding

It was our third dispatch for chest pain that morning, and when I heard the call I rolled my eyes anticipating more of the same. The first two were "nothing" chest pains, pleuritic at best and nonexistent at worst, my partner and I were both sick of carrying these people from their third floor apartments without elevators, huffing and puffing as our visible, exasperated breaths lingered in the winter air.

It made it worse to find that the 12 lead ECGs read normal, that the chest pains were reproducible on palpation and respiration, and that there has been a productive cough for a week and a half. Still, these people insisted that they could not walk. They complained of shortness of breath, that they felt nauseous and weakened to the point of exhaustion. They were sick, probably, but not as sick as they (or I) seemed to hope. Sometimes I wonder if these patient's wouldn't share a high five with me if the ECG paper would spit out a few millimeters of ST elevations for once. ...Throw us both a bone, make it all worth it.

Walking into this patient's apartment to find him writhing in bed and clutching his chest did nothing for our attitudes. This was a common presentation, learned perhaps from a cheesy medical soap opera or dramatized movie scene, the complaints of pain were over the top in almost comical fashion, unreal in both magnitude and character. Real heart attacks don't look like this.

Usually, anyways.

Keeping that caveat in mind as we are supposed to, we asked the routine questions in a routinely respectful and interested manner. Tell us the story, what the pain feels like and where it goes. Tell us if you have ever felt this before, when it started and what you were doing at the time. The questions flowed in an almost mindless manner, automatic in their practiced repetition. I listened as the answers tumbled down and collected into their respective categories, and the "not a heart attack" bin was getting full.

There was time to do an ECG while the firefighters helped set up the stair chair (it was the third floor again), so I started to attach the stickers. On the man's chest was a CABG scar, which raised an eyebrow, but we carried on:



I let out a groan. My least favorite kind of ECG: just inconclusive enough that it probably means nothing, just abnormal enough that it can't be ignored. The 12 lead ECG is one of the most objective examinations we can perform, purported to be the gold standard in isolation of cardiac injury. Still, this one waffled.

I gave the guy oxygen, nitro, and asprin, then carried him down the 2 flights of stairs with the help of fire and police officers. The trip to the hospital was uneventful as the patient described to me the remainder of his story. The nitro hadn't changed his pain at all. I performed a more detailed assessment without significant finding, started an IV, and noted stable vital signs in my chart. Routine as can be, I had a good portion of my run-form written before we arrived at the hospital.


**

The doctor looked at my pink ECG strip carefully, and then back at the patient, to the monitor, and again to my ECG strip. He looked VERY interested. Concerned, even.

I watched him with interest and a bit of fear. I wonder what it was that he saw, whether I missed something or perhaps there was a change. I followed his eyes from the strip to the monitor and to the patient, looking for something. ...I couldn't pick it out.

He dropped the paper to the floor and asked the nurse what we had for IV access, his white coat flowing back in the wind as he walked briskly to the medication cabinet. He handed to the vials to the nurse, designating dosages of each. When they changed hands I got a glimpse of their labels: Lopressor and Cardizem. He wanted them both pushed, and right away.

Hushed silence as the nurse drew up the medications.

The nurse pinched my line and pressed the drugs into the IV. The doctor nodded when it was done, staring at the ECG monitor. Still confused, I bent over to pick up my dropped ECG strip.

The man let out a weird sounding grunt, and I could see from my bent position his legs jolt upwards from their rest on the hospital bed. I stood up to see the man with a funny look on his face, at the same time intrigued and releived. The monitor was moving much more slowly now, capturing a normal sinus rhythm at 70. The doctor was smiling.

"What the...?" I started to mumble under my breath, not fully understanding what happened exactly. The doctor heard me as he walked around the stretcher, and pointed at my strip.

"It was two to one AV-flutter," he said. "Look at the rate. Do you see any P waves?"

Still off balance, I stammered about the first-degree block, and that I thought the P waves were buried because the interval was so long.

"It's a tricky one," he said, "but the proof is in the pudding. Look at him now!"

He smiled and left the room.

I stood in the same spot for a moment, staring intently at the ECG strip. It still didn't look like a flutter to me, it wasn't even that fast, I thought I could pick out some (not fluttering) atrial activity, and anyways the patient was stable...

I take pride and special interest in ECGs, but this time I just didn't see it. I tried to look harder, but was interrupted.

"Hey man."

It was the patient from his bed.

"You did a good job."

Thanks

We were at the hospital finishing up with a routine patient when I felt a tap on my shoulder. It was a large man, dressed in the yellow and black of the hospital security uniform. He towered over me, huge but in a quiet and almost meek way.

"Excuse me I'm sorry to bother you," he said, "but do you work on Saturdays?"

I was a bit taken aback, wondering what this man wanted, but I answered. Sometimes I do work on Saturdays for overtime. Not all that often, but on occasion.

The man smiled at me, genuinely happy to hear the answer. He reached behind him and pulled out a large wallet, stuffed to capacity with photos arranged in cloudy laminate organizers. Flipping through them, he came to a picture of a young man dressed in a police uniform. The face in the picture could not have been older than 25 years, but it was firm and determined, proud and focused. The man scratched at the photo with his thumb.

"Do you recognize this boy?"

I didn't know the face, but I knew immediately who it was. A few months ago there was a terrible car crash on the highway, I remember hearing the story. A car was broken down late in the night, and officers stopped to see if they could assist. It was wet outside as it had just started raining, the roads had turned slick and drivers had not yet noticed the difference in traction. As the officers walked towards the broken down vehicle, another car came around a bend and struck this young man, throwing him a long distance up and off of the highway. He was later found by some of my coworkers, too far gone to even transport to the hospital.

I heard about it the next morning, and remember finding the story particularly haunting. Out of the blue on a normal day of work a car comes out of nowhere and that is it. Bang. He probably never even saw it coming.

The big man looked at me as I studied the photo. I wasn't sure what to say. I wasn't on the call but I knew what had happened, and it was difficult to come with the appropriate words.

"Is that the officer from the highway?" I asked.

He nodded.

"He was my son. I just wanted to find the paramedics who were there that night. I never got a chance to shake their hands, thank them and tell them that they did a good job."

His eyes were wet as he talked, holding everything back to the best of his ability as he attempted to maintain a casual conversation. He forced another smile.

"It's the two month anniversary."

I looked at the floor, sheepish and not wanting to look at the man who carried so much weight. I told him that I was sorry, that I wasn't there but I had heard about it and I could pass on the word. Again I told him I was sorry.... "for everything."

He righted himself as he tucked the large billfold into his pocket.

"Yeah...." he said, trailing off. "Thanks."

I shook his hand and he continued on his way, down the hallway to complete his work.

Sailing Rough Waters

This is a complicated job.

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

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

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

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

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

...But has he really?

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

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

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

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

On Being Sure

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Real Strength

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

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

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

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

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

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

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

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

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

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

Bad Day

A good friend of mine, also a Paramedic, commented to me the other day that he would "rather be pumping gas" than doing the job that he is doing. I feel his pain.

Frustration with this job tends to peak and trough from day to day. Though we work at different services, our feelings about where and what we do are often similar, and to be honest there are times that I too feel like I would rather be doing something as straightforward and bullshit-free as pumping gas. It is on the other side of the fence, but sometimes you have to admit: the grass is pretty green.

Gas pumpers know what to expect from their job each day. Get dressed in the uniform, come in to work, and you will be pumping gas to people who do not respect you and will treat you like garbage. So far, sounds fairly similar. The difference here is that as a gas pumper, you know and expect this reality. A gas pumper has no delusions that someone will recognize a job well done, that one tank is truly different from another, or if his disposition matters from day to day. The game plan is clear: this job is close to the bottom rung and there is no real hope of anyone believing otherwise.

Though it doesn't seem all that green over there, consider coming into work with higher expectations, but the same reality. Build up a job in your head so that you believe that it matters. Believe that hard work will pay off, that determination will lead to success and tangible benefit. ...An environment where excellence is placed on a pedestal because without excellence the job cannot properly be done. Put extra work into the job so that you believe you are capable of more than what is normally expected, present yourself as a professional deserving of respect and believe it.

...And then have someone spit in your face. Not actually spit in your face, although that has happened as well, but in a manner much more insidious. Crumple up your hard written run form. Toss your opinion to the side. Smirk when you look for a zebra, laugh when you think you may have found one. Look right through you as you as you attempt to give a report. Interrupt. Criticize harshly with incorrect information, and then carry on as if nothing happened when the truth is brought to light. Suggest that a protocol is a "guideline" when you bring up detail, and call it "protocol" when you bring up leniency. Punish good behavior and reward bad. Screw up your paycheck and expect you to suck it up with a smile. Call it a symptom of being "new" when you work hard, when you do things right. When you give a shit. Suggest that experience is a substitution for perseverance. Leave for you a mess in the ambulance, a pile of laziness and open sharps. Talk a big game about "patient care" and then behave like a police officer on scene. Listen without listening. Talk without listening. Care more about the blood than the mechanism, more about the glory than the truth. Put a premium on transfers and a damper on medicine. Believe that education does not matter. Insist that privilege be given and not earned. Hire an 18 year old with no experience to do the same job.

It is painful to look around and see people who used to be like me. People who were once excited with this job, who looked at it as if it were a branch of medicine and not a path to a paycheck. People who let the above paragraph become them. It would be unfair to say that everyone is like this, but I can write with absolute certainty that the percentage is far too high.

It is enough to suck a person in. Like a black hole of overwhelming gravity, the could-be realities of this work are hard to avoid as we spin around the edge from day to day.

I love this job. But I'm glad I'm getting the hell out.

Potato Chips

Called for the allergic reaction, I am greeted at the door by a small child. He looks at me sheepishly, kicking his right leg nervously and looking at the ground. He hands me a scrunched up piece of paper and without making eye contact says "mommy told me to give you this."

I unfold the note and read it at the doorstep.



I tell the child to lead me to his mommy, and he does. Around the corner and up the stairs we find a woman sitting on the floor in the bathroom. Her face is extremely swollen, puffy and bloated. She has a thin body, but her head looks as if it belongs to someone else entirely. Looking up at me from the floor she is alert and anxious, wheezing with each breath.

I drop the red bag on the floor and pull out the yellow pack. Without words we we are at work, my partner is setting up the oxygen equipment. I draw up the epinephrine and push it into the woman's arm.

Her relief is almost immediate.

**

On the way to the hospital, priority two, the woman looks at me with a profoundly thinner face. She is still thanking me, thanking me, thanking me. Her lung sounds are full and clear, skin with a little redness but otherwise in good condition.

Potato chips. She had never eaten that brand before, and likely never will again.

"I shouldn't be eating those greasy things anyways," she says.

Tuesdays and Thursdays

The calls keep rolling in, and as I gain experience with this job and start to begin to feel like I can perhaps have an inking of comfort with what I do, I have been subjecting myself every other day to a completely different experience: school.

Tuesdays and Thursdays are school days. I am on campus all day, in the lecture hall and the lab studying Chemistry and Physics. The material is foreign to me with it's dizzying array of equations, formulae, and mathematical logic- starkly different from the Monday, Wednesdays, and Fridays I spend in the fronts and backs of ambulances. The two efforts seem to require different parts of my brain. Half of the days I think how I have been trained, with what information I have gleaned from experience on the subjects of signs and symptoms. The other days, I have to warp and contort myself around concepts that I have never seen before, about math that I barely recollect in orientations that I struggle to comprehend. I hate the math. I have never been very good at it, and to do well in these subjects means to grind my way through mountains of practice problems, gritting my teeth as I calculate, erase, and re-calculate solutions.

Mastery is coming with time, but the work is harder because of my distaste for it. It took a lot of effort to learn what I know as a paramedic also, but the struggle was eased by my interest. I always kept my medic book open a little longer than required, spurred onward by a thirst for the knowledge. With this science I am taking, though, I am always glad to have finished: slamming the book covers closed with a definite thump. It is a hoop to jump through, and as of late I am becoming more entwined with the idea that I am being tested not on my scientific ability, but on my determination. This work comes easy for some, but for most of us I have come to believe that it is simply a matter of pressing forward, putting the work in even when it is nothing other than horrible drudgery. Those that rise from the dust of this pre-medical schedule do so because they are hardened warriors: eyes fixed towards a goal, mouth hardened, hands calloused. "Throw at us what you will," they say. "We're coming anyways."

My days in the ambulance test me as well, but I have come to find the time as a relief. I am glad to have this experience, this window into medicine that shines enough light into the tunnel so that I can do for a little while longer without sight of the end. The challenges I face as a Paramedic are exciting, tasty glimpses into a bounty that lays ahead. They are tantalizing, and with each patient I leave in the hands of a higher level of care my determination grows. I still groan when it comes time to do my schoolwork, my stomach aches and I loathe every minute, but I will not give up.

My eyes are fixed.