The experience of a cardiac arrest is something of a mark of distinction among new paramedics. It is a notch on the belt, a necessary experience. Between preceptees, the conversation almost always centers around talk of tubes, code opportunities seized and missed. Preceptors hold their students for weeks and weeks, the ALS calls building up beneath them, full in all else but lacking the fundamental experience of a cardiac arrest. My preceptor was the same way. We need a code, we need a code.
Last week we got two.
My fellow preceptees are jealous. Two codes, two tubes, two opportunities to sample the experience and start to develop my technique. I get asked about it all the time. People clap me on the back and smile, shake my hand and punch my 9-lettered rocker, welcoming me to the brotherhood. I smile back, laugh and joke about the experience.
Thinking back about the calls though, all I remember are the mistakes.
The first code was a man in his fifties, collapsed in front of his coworkers in a large, cubicle-filled room. When we got there a first responder had already shocked the man twice with no effect, CPR was in progress. He lay there still: one eye half open the other closed, ashen gray and dead. I hesitated for a few seconds, taking in the scene. I wondered where I should go first, where I should put the big red bag and set down the monitor. Everyone was watching us, heads and curious eyes popping above the cubicle walls. The room filled with hushed silence, broken only by the rhythmic counting of first-responder CPR.
My experienced paramedic partners nudged me on, filling in the gaps as we performed each task. We got him on the monitor and saw V-Fib, shocked once with no effect and then got the line. I was opening the intubation kit when we shocked for the second time, finding the rhythm changed and organized. Fingers to the carotid find a bounding pulse as sighs of relief and clapping fill the room.
What a feeling that was.
Still more work yet though. I assemble the intubation equipment, and it seems to take forever. Stylet into the tube, find a blade, white, tight, bright, get the ETCO2 ready, the tube holder, 10cc syringe, and my stethoscope. My partners are pushing lidocane and atropine for a bradycardic post-arrest rhythm. I take a deep breath and roll the head forward into the sniffing position, insert the blade and see what I can find. The man takes a long, deep breath as his mouth is illuminated, and I watch as each muscle and flap of tissue rattles in the wind. I follow the blade backwards, into the retreating dark and underneath the floppy epiglottis. Chords cry out to me as big and white and bold as ever. I pass the tube, inflate the cuff, and send in a bagful of air. Moist condensation on the tube followed by good lung sounds and a beautiful ETCO2 waveform in the 50's.
It was at this point during my last code that my work ended. It was during my internship ride-time, and I was satisfied to simply have gotten the tube. Today, though, there was so much left to be done. The man was lying there on the ground surrounded by the debris of a halfway worked code. Wrappers and papers, EKG pads and bits of tape. Wires and tubes ran in every direction.
Together we organized the mess. We got the board under him and strapped him down, figured out an exit strategy and kept watchful eyes on the monitor. I recruited a woman who identified herself as a nurse to bag the patient, gave her careful instructions on how to mind the tube. We all worked together, struggling and groaning to get the man on the stretcher and into the ambulance. Tubes and wires cross and recross into an impossible tangle.
My preceptee asks me what I would like to do next, and I fumble for words. I've never been here before. "More leads" I say, thinking that we should watch the rhythm through a 3-lead ECG rather than the coarse paddle view. "How many more," he asks me, smiling as he probes. A light goes on above my head. Aha! Post arrest 12 lead! He nods and smiles some more. "Anything else?" Again the routine.
He nudges me through the rest of the patient's treatment. Puts me on the spot and with gentle hints I remember what it is that we are supposed to do. Lidocane is hung and I figure out the drip rate. I push versed as the man begins to buck the tube. I patch to the hospital as I attempt to catch my breath. I wonder if I would be able to do all of this if my preceptor wasnt there to remind me.
In the ED we get claps on the back and handshakes of approval. Everyone is happy to see a code-save, and the credit goes directly to my partner and I. I feel undeserving.
***
The second code was in a nursing home, a large woman found pulseless and aepnic by a surprised nurse just after lunchtime. Again, my partner and I arrived to find work had already been done. Another paramedic was working on the line as frightened nurses tried in vain to pump CPR into the huge body bouncing on the facility bed. They were bagging, too, and the patient's belly was huge. I glance at the monitor quickly only to see CPR noise, and the first paramedic on scene informs me that the rhythm is asystole.
I think of nothing other than the intubation. Again I assemble my equipment quietly at the patient's side, paying singular attention to the list of tasks that precede passing the tube. I hear the medic at the IV site announce that he got a line as I continue to ready my equipment. Gathering up all of my things, I ask the nurses to stand aside as I snap the laryngoscope open. The woman is huge and I wonder how tough the tube will be. I got the last one though, I think. I shouldnt have a problem with this one either. Hands on both sides of the head as I roll forward into the sniffing position.
A voice from the other side of the patient. "I guess I'll just go ahead and push epi and atropine then, huh."
I look up quickly, ebarrassed. "Oh, yeah," I reply. "One milligram of each please." The medic shakes his head as he goes for the drugs that he has already made ready.
Into the mouth I go with the blade. The tongue is huge and I fight it to the left, lifting and pressing forward as I try to avoid the teeth and raise mounds of tissue. The light at the end of my blade seems to smother and snuff amongst the wet masses inside. I find the epiglottis, though. Lifting as hard as I can with one hand, I am only able to see a peek of the chords. I reach for the tube and try to pass it into the spot. The tube obscures my limited view as I pass it through. My partner asks if I am in and I dont know. A bagful of air through tube and we get nothing back. No noise in the lungs, no fog in the tube, no reading on the end-tidal CO2. Gurgling in the belly.
I curse as I pull the tube back out. "One more try," I say. Nobody is doing anything as I struggle. They all watch, waiting for instructions from me that never come. Frustrated with the tube I am oblivious of everything else.
In with the blade I go again. The position of the blade is much better this time and I see the cords immediately. The tube goes in smoothly and everything checks out well. ETCO2 hovers at 10. I have no idea where I put the laryngoscope after that moment. It might as well have vanished out of my hand.
I am now aware of everything else that needs to get done, and I give feeble instructions to my partners who follow through and fill in my gaps. Everything is a mess. Worse than last time, this code is bigger, messier, heavier, longer, and more futile. I ask someone to maintain compressions as the new ACLS suggests, but it is impossible as we are moving around corners and through hallways lined with wheelchairs. Nothing seems to go right, and I'm not helping.
We do CPR on the way to the hospital, pushing another tube of epinephrine in every few minutes. I tally the number of tubes we push on a scrap of paper. The rhythm never changes even once.
In the emergency room we wipe sweat from our foreheads and give a breathless report of the futile code. The hospital staff makes a cursory effort, and the patient is pronounced dead a few minutes later.
I've gone over these patients hundreds of times in my mind, wishing that I had another chance to run through the calls. The mistakes are so obvious to me now, so plain that they stand out clearly as they nag and pester. I need to control the scene instead of focusing on the tube. I need to look at the big picture instead of zeroing in on a detail. I need to better delegate tasks and assume a leadership role. I need to remember what it is that I am supposed to do, what priority it takes, and how to practically get it done.
I realize I am new to this, but I wonder how many newbie mistakes are acceptable. I feel embarrassed for what I've missed, guilty for the things I could have done better. I need to do these calls over again.
I've made a list of things that I want to focus on next time. Hopefully I get the chance at least once more, before this precepting support structure is yanked out from beneath me and I am left alone to stand or fall. I fear that I cannot yet support my own weight, and yet the time is soon approaching that it will be required of me.
To my patients and coworkers, their families and myself: I promise that next time will be better.
Wednesday, May 30, 2007
Monday, May 21, 2007
Ones and Zeros
My preceptor keeps diligent records of my performance on his laptop computer. Spread out in sheets and boxes are the statistics of every call: IV success, percent ALS, percent BLS, airway skills, EKGs, drugs, tough calls, easy calls. The columns span to the right in seemingly endless lists, filled with binary digits designed to add objective value to my successes and failures. On secondary pages are the graphs. Pie charts lay out in colorful detail the number of times I performed certain tasks on specific patients. Lines and bars describe my hit percentage with IV sticks. My preceptor will fill in the details of each call after we finish, diligently plugging ones and zeros into the designated boxes. The graphs automatically adjust, the lines traverse up and down.
At the end of each week he prints out a report and I can see, with three digit accuracy, whether I have improved. Last week the bar graph on my IV percentage went way down. Traumas went up, along with the associated skills. A pie chart suggests that I am getting more experienced with airway maneuvers.
Still though, I wonder if he notices the things that cant be assigned ones and zeros. Looking over the report, there seems to be no value for subjective performance. No cell that captures how I remain calm and polite with the overbearing (yet uninformed) nurse, no graph describing my management and delegation of duties on scene. Nothing that makes note of how I was able to make that suicidal 9 year old laugh all the way to the hospital.
I feel like I am doing well with the things that count. I care about treating my patients well: a philosophy that I believe encompasses accurate medical care as well as comfort and compassion. I try to be mindful of those around me, politely taking reports from first responders and making requests of my help with only the urgency necessary. I know my protocols like the back of my hand, and I dont think my medicine has strayed even once from the standard of care. My first-shot IV percentage sucks, but out of almost 40 patients I can count on one hand the number of patients who I couldnt (eventually) get a line on.
I am acutely aware, though, of the things I have yet to learn. I need to get better at evaluating the whole scene, making a plan early-on, and following through. I want to get better at recognizing potential problems in advance, solving issues before they occur. (Never again will I let a patient seize on me during a 2nd floor carry down with no IV access and the Versed sealed in my pocket) I need to sharpen my ability to make the basics automatic so I can focus on the advanced. I need more time to develop a system so I can do the same thing, every time.
These are things I think about. I am my worst critic, I admit. ...But I wonder sometimes if I couldnt use a few more comments about these subjective things from another perspective. My preceptor says that I am doing fine, that his relative silence on these issues is evidence that I am performing well on my own. I am worried, though, that I am making mistakes that he doesnt see, or missing things that he does not mention.
Despite the boxes and lines, charts and graphs: I yearn for more feedback.
At the end of each week he prints out a report and I can see, with three digit accuracy, whether I have improved. Last week the bar graph on my IV percentage went way down. Traumas went up, along with the associated skills. A pie chart suggests that I am getting more experienced with airway maneuvers.
Still though, I wonder if he notices the things that cant be assigned ones and zeros. Looking over the report, there seems to be no value for subjective performance. No cell that captures how I remain calm and polite with the overbearing (yet uninformed) nurse, no graph describing my management and delegation of duties on scene. Nothing that makes note of how I was able to make that suicidal 9 year old laugh all the way to the hospital.
I feel like I am doing well with the things that count. I care about treating my patients well: a philosophy that I believe encompasses accurate medical care as well as comfort and compassion. I try to be mindful of those around me, politely taking reports from first responders and making requests of my help with only the urgency necessary. I know my protocols like the back of my hand, and I dont think my medicine has strayed even once from the standard of care. My first-shot IV percentage sucks, but out of almost 40 patients I can count on one hand the number of patients who I couldnt (eventually) get a line on.
I am acutely aware, though, of the things I have yet to learn. I need to get better at evaluating the whole scene, making a plan early-on, and following through. I want to get better at recognizing potential problems in advance, solving issues before they occur. (Never again will I let a patient seize on me during a 2nd floor carry down with no IV access and the Versed sealed in my pocket) I need to sharpen my ability to make the basics automatic so I can focus on the advanced. I need more time to develop a system so I can do the same thing, every time.
These are things I think about. I am my worst critic, I admit. ...But I wonder sometimes if I couldnt use a few more comments about these subjective things from another perspective. My preceptor says that I am doing fine, that his relative silence on these issues is evidence that I am performing well on my own. I am worried, though, that I am making mistakes that he doesnt see, or missing things that he does not mention.
Despite the boxes and lines, charts and graphs: I yearn for more feedback.
Thursday, May 17, 2007
Reaction
Her whole body is alive with motion.
Each muscle tremors under tremendous stress, shaking her legs and arms in a disorganized, frantic motion. The knees buckle inward as they collapse, sending the entire body to the floor, writhing and kicking along the way. Her hands grasp air tightly, clawing at nonexistant threats and tossing them to the side. Muscles strain and pull ligaments inward, flexing and relaxing in rapid succession. Her face is running, soaked with wet tears, snot, and spit. With each breath she sniffles to divert rivers from running inward. Her mouth is open and crying, loud gasps from full, stressed lungs.
On the floor writhing, spitting, yelling, flexing, praying, she quivers with life.
In the bathroom on the floor lies her mother, silent. Despite crashes and screams from the next room, the face is rock solid and devoid of expression. Her eyes are motionless as they stare towards the tiled floor.
Her skin is waxy solid, a blue-gray hue.
Each muscle tremors under tremendous stress, shaking her legs and arms in a disorganized, frantic motion. The knees buckle inward as they collapse, sending the entire body to the floor, writhing and kicking along the way. Her hands grasp air tightly, clawing at nonexistant threats and tossing them to the side. Muscles strain and pull ligaments inward, flexing and relaxing in rapid succession. Her face is running, soaked with wet tears, snot, and spit. With each breath she sniffles to divert rivers from running inward. Her mouth is open and crying, loud gasps from full, stressed lungs.
On the floor writhing, spitting, yelling, flexing, praying, she quivers with life.
In the bathroom on the floor lies her mother, silent. Despite crashes and screams from the next room, the face is rock solid and devoid of expression. Her eyes are motionless as they stare towards the tiled floor.
Her skin is waxy solid, a blue-gray hue.
Wednesday, May 9, 2007
Mistakes and Successes
I've finished my first week of precepting, and as all of you have probably noticed: I havn't posted any new entries.
It most certainly has not been for a lack of things to write about. These past six or seven shifts have been completely full with new experiences, new lessons, and new stories. Already I have done things that I never thought that I might have to do, bore witness to things I hadn't planned for. Working as a paramedic is a completely different adventure, and as of late I have found myself so overwhelmed with experience that I havn't had the time to sit back and expound on them in type.
I'm surprised by the number of mistakes that I'm making. I suppose that this should be expected, but the devil truly has been in the details. There are so many more decisions that I am responsible for, often it has been all I could do to perform BLS, control a scene, make a plan, and thrust a feeble attempt towards ALS. It is a special skill to remain organized in the face of chaos, to do things methodically so that nothing gets missed and no wires get crossed. It is most definitely a skill that I have not yet come close to mastering. I feel like I wheel each of my patients through the ER doors half-finished, always asking assessment questions in triage.
I find myself constantly hoping for a few more minutes, a moment of calm to sit back and peruse my options. In this city the hospital is always so close, looming down from a few blocks away is the promise of my patient's salvation. How long am I supposed to spend in a patient's house or in the street: assessing, tangling monitor wires and inserting needles? Time is always an issue.
With my attention focused (or spread out, perhaps) on the newness of all of this, I have made some fairly silly mistakes. I splinted the wrong wrist on a fallen motorcyclist, started an IV without spiking a bag first, forgot my oxygen bottle on a 6th floor asthma. Mistakes I would never have made as an EMT-B, but with my new responsibilities I have had trouble remembering the basics: something that I have been working hard to keep from happening.
A step back so that my next one forward is sure.
Along with failure, though, I have had some successes. The purported diabetic who I recognized as an overdose, treated, and laughed with the rest of the way to the hospital. A chest pain that I feel I managed well, offering palpable comfort to a worried old woman. While some calls have left me feeling helpless, I have been blessed with many opportunities to be the face of relief, comfort, and compassion for my patients. My preceptor seems to be reasonably pleased with my performance. He wrote in a recent evaluation sheet he feels that I am both doing well, and capable of better.
I'll make sure that he's right.
It most certainly has not been for a lack of things to write about. These past six or seven shifts have been completely full with new experiences, new lessons, and new stories. Already I have done things that I never thought that I might have to do, bore witness to things I hadn't planned for. Working as a paramedic is a completely different adventure, and as of late I have found myself so overwhelmed with experience that I havn't had the time to sit back and expound on them in type.
I'm surprised by the number of mistakes that I'm making. I suppose that this should be expected, but the devil truly has been in the details. There are so many more decisions that I am responsible for, often it has been all I could do to perform BLS, control a scene, make a plan, and thrust a feeble attempt towards ALS. It is a special skill to remain organized in the face of chaos, to do things methodically so that nothing gets missed and no wires get crossed. It is most definitely a skill that I have not yet come close to mastering. I feel like I wheel each of my patients through the ER doors half-finished, always asking assessment questions in triage.
I find myself constantly hoping for a few more minutes, a moment of calm to sit back and peruse my options. In this city the hospital is always so close, looming down from a few blocks away is the promise of my patient's salvation. How long am I supposed to spend in a patient's house or in the street: assessing, tangling monitor wires and inserting needles? Time is always an issue.
With my attention focused (or spread out, perhaps) on the newness of all of this, I have made some fairly silly mistakes. I splinted the wrong wrist on a fallen motorcyclist, started an IV without spiking a bag first, forgot my oxygen bottle on a 6th floor asthma. Mistakes I would never have made as an EMT-B, but with my new responsibilities I have had trouble remembering the basics: something that I have been working hard to keep from happening.
A step back so that my next one forward is sure.
Along with failure, though, I have had some successes. The purported diabetic who I recognized as an overdose, treated, and laughed with the rest of the way to the hospital. A chest pain that I feel I managed well, offering palpable comfort to a worried old woman. While some calls have left me feeling helpless, I have been blessed with many opportunities to be the face of relief, comfort, and compassion for my patients. My preceptor seems to be reasonably pleased with my performance. He wrote in a recent evaluation sheet he feels that I am both doing well, and capable of better.
I'll make sure that he's right.
Tuesday, May 1, 2007
Switching Seats
It was only a little baby 22 gauge, but it felt like I was pushing a garden hose through sand once I got through the skin. She winced in pain and let out a yelp, fighting the urge to pull her hand back from mine. She grits her teeth, sucking in air sharply with each motion of the needle.
No flash.
I look at the back of the hand, where I had carefully landmarked the tiny vein just a few seconds ago. It was obvious before, but now that I have inserted the sharp under her skin it has retreated to some unknown depth. It doesnt want to be found.
I try to ignore the woman's painful cries and continue my search for the elusive vessel. I use the tip of the needle like a probe, moving slightly to the left and upwards as I get closer... as I must be getting closer to the goal. Where the hell is that goddamn flash? I elect to insert more of the needle, reach farther underneath the skin. Another painful yelp from the patient. She is becoming less able to control pulling her hand back, and I almost lose the needle altogether.
"Just one more second ma'am, I've almost got it. Please try and stay still."
I dont have it though. There comes a point where - after inserting the needle and missing - careful correction becomes blind hunting and hoping. I have lost sight of where the vein was supposed to have been, and now I am sticking in the dark. I've crossed that line. One last time I move the needle upward and forward.
A splash of blood into the tiny chamber.
I wait. Sometimes the small needles take a long time to fill up the flash chamber. The lumen of the needle is very small, it takes time. Just wait a few more seconds, you'll see, it'll fill right up and the IV will be done. ...It shouldnt be taking this long, though. I must have gone right through the vein. One more tiny motion and it is confirmed as a small bulge grows on the woman's hand. Shit.
My preceptor raises an eyebrow. I've missed twice now, it's time for him to take over. I carefully climb over the monitor cables as we switch positions: me into the airway seat and him to the bench. I watch from the penalty box.
He assesses her arm, selects a location, and inserts the needle. Easy as pie, the flash chamber fills right up and the catheter slides without a hitch. The safety needle moves back and locks into position. ...The familiar clicking sound of a successful IV.
My preceptor lets out a little chuckle, smiling at me.
I'm never going to hear the end of it.
No flash.
I look at the back of the hand, where I had carefully landmarked the tiny vein just a few seconds ago. It was obvious before, but now that I have inserted the sharp under her skin it has retreated to some unknown depth. It doesnt want to be found.
I try to ignore the woman's painful cries and continue my search for the elusive vessel. I use the tip of the needle like a probe, moving slightly to the left and upwards as I get closer... as I must be getting closer to the goal. Where the hell is that goddamn flash? I elect to insert more of the needle, reach farther underneath the skin. Another painful yelp from the patient. She is becoming less able to control pulling her hand back, and I almost lose the needle altogether.
"Just one more second ma'am, I've almost got it. Please try and stay still."
I dont have it though. There comes a point where - after inserting the needle and missing - careful correction becomes blind hunting and hoping. I have lost sight of where the vein was supposed to have been, and now I am sticking in the dark. I've crossed that line. One last time I move the needle upward and forward.
A splash of blood into the tiny chamber.
I wait. Sometimes the small needles take a long time to fill up the flash chamber. The lumen of the needle is very small, it takes time. Just wait a few more seconds, you'll see, it'll fill right up and the IV will be done. ...It shouldnt be taking this long, though. I must have gone right through the vein. One more tiny motion and it is confirmed as a small bulge grows on the woman's hand. Shit.
My preceptor raises an eyebrow. I've missed twice now, it's time for him to take over. I carefully climb over the monitor cables as we switch positions: me into the airway seat and him to the bench. I watch from the penalty box.
He assesses her arm, selects a location, and inserts the needle. Easy as pie, the flash chamber fills right up and the catheter slides without a hitch. The safety needle moves back and locks into position. ...The familiar clicking sound of a successful IV.
My preceptor lets out a little chuckle, smiling at me.
I'm never going to hear the end of it.
Sunday, April 29, 2007
Decisions
It is tough to have to be the one who makes decisions.
I've spent a lot of time preparing for this, reading my protocol book and leafing through notes. All of the advice is fairly linear. Problem A gets solution B. I've spent many nights learning about solution B, memorizing dosages and routes, committing medical control orders to memory. I know all about B.
What is harder, I'm finding, is that most of the time the problem is not A. ...It is A and C. Or part of A and a little bit not A. Patients are so often a murky gray, presenting in their own fashion a disease hidden by muddled complaints which lack the clear definition laid out in my textbooks. Solution B doesn't always work if the patient is not quite A.
I knew this of course. It is one of those things they teach you on the first day, the poignant advice that carries no weight until understanding is brought to the surface through experience. "The patient hasn't read the book on how to present." Sure sure, I thought. That is what assessment is for, right? That is what we were there to learn. Problem A is characterized by these listed symptoms: you just need to be on the ball enough to know what to look for.
Even when I think I'm on the ball, though, patients keep managing to throw me curves. An outlaying complaint, something that doesnt fit. The lack of a critical symptom. The right words, the wrong presentation. It is tough to keep confidence high when treatment comes down to a judgment call, the most important information for which must come from experience that I lack. Does this patient look sick? It is often hard for me to make the decision and remain firm.
The patient is on the monitor, O2 flowing and an IV established. I've done the glucose and performed my physical assessment, obtained the history and got the complete story. Still, I'm scratching my head with indecision. I look away from the patient towards my right, where my preceptor sits. A questioning look on my face.
He is there, sunglasses on, smiling.
"These are the decisions you're going to have to make."
I've spent a lot of time preparing for this, reading my protocol book and leafing through notes. All of the advice is fairly linear. Problem A gets solution B. I've spent many nights learning about solution B, memorizing dosages and routes, committing medical control orders to memory. I know all about B.
What is harder, I'm finding, is that most of the time the problem is not A. ...It is A and C. Or part of A and a little bit not A. Patients are so often a murky gray, presenting in their own fashion a disease hidden by muddled complaints which lack the clear definition laid out in my textbooks. Solution B doesn't always work if the patient is not quite A.
I knew this of course. It is one of those things they teach you on the first day, the poignant advice that carries no weight until understanding is brought to the surface through experience. "The patient hasn't read the book on how to present." Sure sure, I thought. That is what assessment is for, right? That is what we were there to learn. Problem A is characterized by these listed symptoms: you just need to be on the ball enough to know what to look for.
Even when I think I'm on the ball, though, patients keep managing to throw me curves. An outlaying complaint, something that doesnt fit. The lack of a critical symptom. The right words, the wrong presentation. It is tough to keep confidence high when treatment comes down to a judgment call, the most important information for which must come from experience that I lack. Does this patient look sick? It is often hard for me to make the decision and remain firm.
The patient is on the monitor, O2 flowing and an IV established. I've done the glucose and performed my physical assessment, obtained the history and got the complete story. Still, I'm scratching my head with indecision. I look away from the patient towards my right, where my preceptor sits. A questioning look on my face.
He is there, sunglasses on, smiling.
"These are the decisions you're going to have to make."
Thursday, April 26, 2007
Highlighted in Purple
Two months I have waited for this, and it has finally happened.
My name is scribbled in the book now as a 3rd rider, dubbed with the honor of a purple highlight signifying me as a new preceptee. Starting only two days from now, I will unwrap the pressed nine-lettered shirts that have been hanging in the closet waiting, and present to work ready for this next step. I get to be a paramedic again.
...Or at least play the part of one.
This news has come so suddenly, the change so abrupt that I cant help but feel naked without time to prepare. I've had two months of waiting, but waiting now seems somehow different from these two days that I have before I am expected to perform. I have been begging for this, prodding my administrators and making weekly frustrated phone calls. With the anticipation of a faraway goal stripped to reveal only harsh immediacy, suddenly everything seems much less glamorous. Oh yeah, I think to myself. I'm supposed to actually remember how to do this stuff.
I have been studying my protocols casually over the past months. I carry the book with me at all times, and I try to flip through the various pages after routine calls at work. I've gone over dosages and various intricacies that elude over time, but I now feel like it has all been inadequate. I need to work harder to make sure I remember. Read this book at least a few more times over, make notes, test myself. The book is beginning to become tattered with use, the bindings bent at the corners and edges frayed, but still it seems that I find something fresh every time I reopen the pages. Some detail I glossed over last time, a chart I misread and mis-memorized.
There is fear about missing a minute detail, of course. But the greater fear is to miss something obvious. Something like oxygen or c-spine precautions. With this increased complexity I have found it difficult to remember the basics- those things that are supposed to happen without thinking. New to paramedicine, I need to pay attention to the ALS, pour my time into it to make sure everything is right. It takes my attention away from the things that are most important. I know that this is a mistake commonly made by new paramedics, and I am putting a lot of thought into trying to make sure it doesnt happen to me. Or my patients.
This weird combination of fear and excitement is exhilarating. I start on Saturday. Wish me luck.
My name is scribbled in the book now as a 3rd rider, dubbed with the honor of a purple highlight signifying me as a new preceptee. Starting only two days from now, I will unwrap the pressed nine-lettered shirts that have been hanging in the closet waiting, and present to work ready for this next step. I get to be a paramedic again.
...Or at least play the part of one.
This news has come so suddenly, the change so abrupt that I cant help but feel naked without time to prepare. I've had two months of waiting, but waiting now seems somehow different from these two days that I have before I am expected to perform. I have been begging for this, prodding my administrators and making weekly frustrated phone calls. With the anticipation of a faraway goal stripped to reveal only harsh immediacy, suddenly everything seems much less glamorous. Oh yeah, I think to myself. I'm supposed to actually remember how to do this stuff.
I have been studying my protocols casually over the past months. I carry the book with me at all times, and I try to flip through the various pages after routine calls at work. I've gone over dosages and various intricacies that elude over time, but I now feel like it has all been inadequate. I need to work harder to make sure I remember. Read this book at least a few more times over, make notes, test myself. The book is beginning to become tattered with use, the bindings bent at the corners and edges frayed, but still it seems that I find something fresh every time I reopen the pages. Some detail I glossed over last time, a chart I misread and mis-memorized.
There is fear about missing a minute detail, of course. But the greater fear is to miss something obvious. Something like oxygen or c-spine precautions. With this increased complexity I have found it difficult to remember the basics- those things that are supposed to happen without thinking. New to paramedicine, I need to pay attention to the ALS, pour my time into it to make sure everything is right. It takes my attention away from the things that are most important. I know that this is a mistake commonly made by new paramedics, and I am putting a lot of thought into trying to make sure it doesnt happen to me. Or my patients.
This weird combination of fear and excitement is exhilarating. I start on Saturday. Wish me luck.
Monday, April 23, 2007
Down 180
Hey everyone, sorry I have been slacking a little bit on the entries as of late. I have been doing a lot of really mundane stuff at work as an EMT, drudging through an impossibly high stack of BLS transfers, emergi-fers and garbage 911 calls. To be honest, I feel like I can only become so introspective, so sensitive about this kind of stuff in my blog entries before even I begin to retch. It seems like I have been dealing mostly with BLS frustration and psychs lately, both of which I have written about multiple times at length. I really need something challenging to fire me up.
Good calls, though, have been at a minimum over the past month for some reason. Our service is down something like 180 calls per week, a stagnation that has left many of us - even those who are not normally so - eager for something... anything exciting. We are all sitting in our posts, listening to the radios for the tide to change. The old guys say these kinds of things happen, periods of good calls come and go in waves. ...But it seems like it has been forever.
I did receive some good news today, though. Apparently the gates have been lifted at work over this blogging issue, and I have finally been cleared to precept by the management. The start date, as it always is, is still tentative at this point, but hopefully I should be changing to a different shirt as soon as next week.
I sure do hope the tide changes by then.
Good calls, though, have been at a minimum over the past month for some reason. Our service is down something like 180 calls per week, a stagnation that has left many of us - even those who are not normally so - eager for something... anything exciting. We are all sitting in our posts, listening to the radios for the tide to change. The old guys say these kinds of things happen, periods of good calls come and go in waves. ...But it seems like it has been forever.
I did receive some good news today, though. Apparently the gates have been lifted at work over this blogging issue, and I have finally been cleared to precept by the management. The start date, as it always is, is still tentative at this point, but hopefully I should be changing to a different shirt as soon as next week.
I sure do hope the tide changes by then.
Tuesday, April 10, 2007
Eyes
We find a young woman surrounded by firefighters and witnesses. She was walking along, they say, and then just out of the blue fell to the ground and started shaking. Her groceries are scattered across the parking lot, broken eggs and a box of cereal. She is looking upward towards us when we arrive, confusion spread thick across her face. Her brow is scrunched down, her mouth slightly open in absentminded slack. She looks at me searchingly. Her eyes ask questions she is unable to formulate, looking for answers she cant yet comprehend.
A man in his 50's grits his teeth as he sweats. His respirations are labored, deep breaths soak in through lips relaxed from fatigue. His wife pleads with him, pleads with us, but the man will not relent and admit his pain. His face is as hardened as it is ashen. Only the softness of his frightened eyes cry out, desperate for help.
A retired man sits in his recliner, surveying the room slowly. He looks at me and then my partner, long and drawn out. There is no comprehension as he stares right through us. I call his name as I touch his hand, and he slowly turns his head toward me. Looking right into my eyes through halfway drawn lids, he has no expression. I explain the procedure to the face looking at me, wondering if he can still hear. Into the vein goes the clear, sticky goop and life returns to his face. I watch the man return to himself as comprehension stacks up behind his eyes. He blinks a few times, awake now. "Where did you guys come from?"
A young man in his 20's walks in through the front door, lugging a big red bag and something that looks like a television screen. He looks around the room from left to right, searching for what he has been told he will find. A voice calls and he zeros in, finding the light switch and kneeling down. He smiles and asks questions, searching through the bag for what he needs. His manner is confident, focused.
His eyes, though, betray a hint of uncertainty.
A man in his 50's grits his teeth as he sweats. His respirations are labored, deep breaths soak in through lips relaxed from fatigue. His wife pleads with him, pleads with us, but the man will not relent and admit his pain. His face is as hardened as it is ashen. Only the softness of his frightened eyes cry out, desperate for help.
A retired man sits in his recliner, surveying the room slowly. He looks at me and then my partner, long and drawn out. There is no comprehension as he stares right through us. I call his name as I touch his hand, and he slowly turns his head toward me. Looking right into my eyes through halfway drawn lids, he has no expression. I explain the procedure to the face looking at me, wondering if he can still hear. Into the vein goes the clear, sticky goop and life returns to his face. I watch the man return to himself as comprehension stacks up behind his eyes. He blinks a few times, awake now. "Where did you guys come from?"
A young man in his 20's walks in through the front door, lugging a big red bag and something that looks like a television screen. He looks around the room from left to right, searching for what he has been told he will find. A voice calls and he zeros in, finding the light switch and kneeling down. He smiles and asks questions, searching through the bag for what he needs. His manner is confident, focused.
His eyes, though, betray a hint of uncertainty.
Wednesday, April 4, 2007
A single light
The house was huge. Atop a large hill with a view so good the city taxes for it, the building was a testament to a lifetime of work. Large, spotless windows looked out over an expansive yard immaculate with a carefully arranged springtime assortment: newly budding flowers, a bubbling brook, and ornate iron wrought trimmings. The home was pristine in detail. New in condition but old in design, everything seemed to maintain a sense of timeless style.
Our dirty, diesel ambulance grumbled up the long driveway, spewing fumes and emanating a presence that, even as the driver, I felt somehow contaminated it all. We were called for a "lift-assist" only, a call so doomed to be boring that it fouled our moods and depressed our spirit. Frowning, we approached the house with our gear.
We were met at the door by an old man who was very happy to see us. Deep wrinkles on his face seemed to add volume to his smile as each crease and fold followed in turn, reaching upward as they contributed to his healthy grin. "Oh thank you for coming," he said. "Right this way. She fell on her way to the toilet and I just couldn't get her up. Just skin and bones she is, there's no meat left. She really shouldn't be walking around like that anymore."
We followed him through the house, an agonizingly slow pace as the man hobbled from one step to the next. Passing through an expansive kitchen and a luxurious living room, I marveled at the home. Absolutely beautiful. Around a few corners and down a hall, we turned right into a room lined with wood. There, on the floor, was an older woman laying face-down. She was positioned just next to the hot tub, a large marble edifice covered with more wood and leather. The tub was dry. It looked like it hadn't been used in years.
The woman had her eyes closed. She looked exhausted, her head resting on a makeshift pillow fashioned from towels pulled from hangars on the wall. Wrapped around her was an old, yellowed bathrobe. The material looked thin and fringed at the edges, a hole here and there. Although she was covered I could see that the woman was extremely thin. Ghostly thin. Just skin and bones, covered with the tattered remnants of a robe, the woman let out a small sigh as we introduced ourselves.
The man interjected immediately, apologizing for the lack of formal introduction. "She's very tired," he said. "She's been there on the floor for some time now, I just couldn't get her up. There's nothing to her, no meat on her body, but I dont have the strength anymore."
We smiled back. No problem at all. We're here to help. My partner kneeled down and touched the woman's hand. He asked about how she fell, if she remembers everything that happened and if she has any pain. The woman, seemingly mustering great effort to find the strength to do so, answers quietly. She slipped on the tiled floor. There is no pain. She doesn't have the strength anymore. "I've lost all my muscle."
We lift her up together even though one of us could have easily handled the task alone. The woman was even thinner than she looked. Like picking up a bundle of sticks. We sat her down on a chair as she sighed with relief.
The man, again. "The doctors think she has cancer. In the stomach, they say. We did a bunch of tests last week but they want us to start chemo right away. They havn't even seen the results from the tests yet!" The man's wrinkles dropped downward into a hardened frown. "How can they be sure she has cancer if the results aren't in yet?"
My partner and I both know the answer, but dont let it escape. The cancer must be that obvious, so plain to the doctor that the tests were only a formality. Look at her. Skin and bones, no meat left at all. Something is eating her away from the inside, hollowing her out. Neither of us imagine that the diagnosis was all that difficult to ascertain. The woman is deathly sick.
I ask her if she would like us to take her to the hospital. It is probably a good idea, I say. Falls are sometimes a sign of something else, and if you're feeling extra tired that might be another warning sign. How about we take you to the emergency department and have the doctors take a look at you.
The woman raises her head upward, which until now remained hung downward between her legs. Her eyes came to life as she emphatically shook her head no. "No more hospitals. I'm so sick of the hospitals. I was just there for 9 weeks, and look at me. I just want to rest." I try again in vain to get her to oblige, but she will not relent. "If you could please just help me to my bed. I'm so tired." The man agreed.
We helped her to her bed. Down the carpeted hall and left into a small room, we moved slowly as my partner and I each guided an elbow. The room was packed with personal belongings. A TV in the corner, bookshelf on the far wall. There was a small sink in the room that looked like it had been added, and a mini fridge under the bedstand. The large room was cramped with the necessities of daily living: items from every room of the house concentrated into one small space.
The woman explained. "This is where I spend most of my time now, since I've lost so much weight. I dont have the strength anymore to move from room to room, so I had all of the necessary stuff brought into here." The woman, despite an effort to project a smile, betrays a saddened frown. "No muscle on my bones anymore."
We tucked her in and brought her remotes close. Made sure she was comfortable. She thanked us profusely throughout, asking for our names and writing down the company we work for. She promised to call our bosses and sing our praises. "You boys are so nice," she said. The man knelt on the side of the bed, tucking in the covers and arranging the pillows.
We showed ourselves out. Walking through the house on our way, we noticed for the first time how empty the other rooms looked. A hot tub that hadnt been used in years, couches covered and left alone, lights off and drapes drawn. It is easy to keep things looking immaculate when you never use them anymore. A lifetime of work and success, spread out to lavish comfort and then forgotten in the face of disease. Their world shrunken down.
We coaxed our dirty ambulance back to life as it growled and spit in protest. Rumbling down the driveway, I could see the shape of the enormous house against the night sky. Only one light remained on in the entire building. A single room illuminated.
The light faded in the distance as we headed to our next call.
Our dirty, diesel ambulance grumbled up the long driveway, spewing fumes and emanating a presence that, even as the driver, I felt somehow contaminated it all. We were called for a "lift-assist" only, a call so doomed to be boring that it fouled our moods and depressed our spirit. Frowning, we approached the house with our gear.
We were met at the door by an old man who was very happy to see us. Deep wrinkles on his face seemed to add volume to his smile as each crease and fold followed in turn, reaching upward as they contributed to his healthy grin. "Oh thank you for coming," he said. "Right this way. She fell on her way to the toilet and I just couldn't get her up. Just skin and bones she is, there's no meat left. She really shouldn't be walking around like that anymore."
We followed him through the house, an agonizingly slow pace as the man hobbled from one step to the next. Passing through an expansive kitchen and a luxurious living room, I marveled at the home. Absolutely beautiful. Around a few corners and down a hall, we turned right into a room lined with wood. There, on the floor, was an older woman laying face-down. She was positioned just next to the hot tub, a large marble edifice covered with more wood and leather. The tub was dry. It looked like it hadn't been used in years.
The woman had her eyes closed. She looked exhausted, her head resting on a makeshift pillow fashioned from towels pulled from hangars on the wall. Wrapped around her was an old, yellowed bathrobe. The material looked thin and fringed at the edges, a hole here and there. Although she was covered I could see that the woman was extremely thin. Ghostly thin. Just skin and bones, covered with the tattered remnants of a robe, the woman let out a small sigh as we introduced ourselves.
The man interjected immediately, apologizing for the lack of formal introduction. "She's very tired," he said. "She's been there on the floor for some time now, I just couldn't get her up. There's nothing to her, no meat on her body, but I dont have the strength anymore."
We smiled back. No problem at all. We're here to help. My partner kneeled down and touched the woman's hand. He asked about how she fell, if she remembers everything that happened and if she has any pain. The woman, seemingly mustering great effort to find the strength to do so, answers quietly. She slipped on the tiled floor. There is no pain. She doesn't have the strength anymore. "I've lost all my muscle."
We lift her up together even though one of us could have easily handled the task alone. The woman was even thinner than she looked. Like picking up a bundle of sticks. We sat her down on a chair as she sighed with relief.
The man, again. "The doctors think she has cancer. In the stomach, they say. We did a bunch of tests last week but they want us to start chemo right away. They havn't even seen the results from the tests yet!" The man's wrinkles dropped downward into a hardened frown. "How can they be sure she has cancer if the results aren't in yet?"
My partner and I both know the answer, but dont let it escape. The cancer must be that obvious, so plain to the doctor that the tests were only a formality. Look at her. Skin and bones, no meat left at all. Something is eating her away from the inside, hollowing her out. Neither of us imagine that the diagnosis was all that difficult to ascertain. The woman is deathly sick.
I ask her if she would like us to take her to the hospital. It is probably a good idea, I say. Falls are sometimes a sign of something else, and if you're feeling extra tired that might be another warning sign. How about we take you to the emergency department and have the doctors take a look at you.
The woman raises her head upward, which until now remained hung downward between her legs. Her eyes came to life as she emphatically shook her head no. "No more hospitals. I'm so sick of the hospitals. I was just there for 9 weeks, and look at me. I just want to rest." I try again in vain to get her to oblige, but she will not relent. "If you could please just help me to my bed. I'm so tired." The man agreed.
We helped her to her bed. Down the carpeted hall and left into a small room, we moved slowly as my partner and I each guided an elbow. The room was packed with personal belongings. A TV in the corner, bookshelf on the far wall. There was a small sink in the room that looked like it had been added, and a mini fridge under the bedstand. The large room was cramped with the necessities of daily living: items from every room of the house concentrated into one small space.
The woman explained. "This is where I spend most of my time now, since I've lost so much weight. I dont have the strength anymore to move from room to room, so I had all of the necessary stuff brought into here." The woman, despite an effort to project a smile, betrays a saddened frown. "No muscle on my bones anymore."
We tucked her in and brought her remotes close. Made sure she was comfortable. She thanked us profusely throughout, asking for our names and writing down the company we work for. She promised to call our bosses and sing our praises. "You boys are so nice," she said. The man knelt on the side of the bed, tucking in the covers and arranging the pillows.
We showed ourselves out. Walking through the house on our way, we noticed for the first time how empty the other rooms looked. A hot tub that hadnt been used in years, couches covered and left alone, lights off and drapes drawn. It is easy to keep things looking immaculate when you never use them anymore. A lifetime of work and success, spread out to lavish comfort and then forgotten in the face of disease. Their world shrunken down.
We coaxed our dirty ambulance back to life as it growled and spit in protest. Rumbling down the driveway, I could see the shape of the enormous house against the night sky. Only one light remained on in the entire building. A single room illuminated.
The light faded in the distance as we headed to our next call.
Thursday, March 22, 2007
A good conversation
Still waiting to precept, I have been passing time trying to learn by observing others.
On scene for a shortness of breath, my paramedic partner lets out a quiet sigh as we enter the patient's room. He has been here before, many times for the same complaint. The female patient is agitated at the apparent dismay of her home healthcare workers. Yelling, she chastises them for mismanagement of her medications, poor planning, and an "inedible" meal. Turning towards us, she takes a deep breath and begins to explain how difficult her breathing is. Long, elaborate sentences flow easily without a hitch: she's been short of breath all day. No-one will listen to her. She needs to see her doctor right away.
I fight the urge to roll my eyes, an effort made easier as my medic remains perfectly stable. He is focused on the patient, performing an assessment on this that I have already decided to be nonsense. I wonder what it is he sees that I dont.
I set up the stretcher and lug the gear, handing him the bits and pieces that he needs. I assist as his decisions direct our path. He speaks calmly as he describes to the patient what he is looking for. Slowly he eliminates possibilities, narrowing his impression as we get closer to the truth. She has had periods of dyspnea over the past month, transient in nature with acute onsets usually in the early afternoon. The effort and sheer annoyance of the condition, the woman says, tends to render her a little "touchy" about matters of etiquette around the house. The meal wasnt even really that bad, she admits. My partner nods and smiles, a hand over hers as he says that its OK. We'll take you to the doctor.
She smiles, and thanks us.
He rides in the back as I drive. Not because she required ALS, but because they have established a repore. Together they talk as we bounce down the street.
After the call I reassemble the equipment, puzzled. My medic walks to the back of the ambulance and lets out another sigh, louder this time and more clearly filled with annoyance.
"What bullshit was that, eh?"
I ask him why he decided to ride in the back, then, if he knew she was bullshit. Why did he entertain such nonsense? He saw the same thing I saw when we walked in the door. No increased work of breathing. Long, full sentences. Clear lung sounds and stable vitals. Still, he said, he wanted to hear her story. Maybe there was something there, maybe there wasnt.
Taking a sip from his coffee he shrugged.
"At least we had a good conversation."
On scene for a shortness of breath, my paramedic partner lets out a quiet sigh as we enter the patient's room. He has been here before, many times for the same complaint. The female patient is agitated at the apparent dismay of her home healthcare workers. Yelling, she chastises them for mismanagement of her medications, poor planning, and an "inedible" meal. Turning towards us, she takes a deep breath and begins to explain how difficult her breathing is. Long, elaborate sentences flow easily without a hitch: she's been short of breath all day. No-one will listen to her. She needs to see her doctor right away.
I fight the urge to roll my eyes, an effort made easier as my medic remains perfectly stable. He is focused on the patient, performing an assessment on this that I have already decided to be nonsense. I wonder what it is he sees that I dont.
I set up the stretcher and lug the gear, handing him the bits and pieces that he needs. I assist as his decisions direct our path. He speaks calmly as he describes to the patient what he is looking for. Slowly he eliminates possibilities, narrowing his impression as we get closer to the truth. She has had periods of dyspnea over the past month, transient in nature with acute onsets usually in the early afternoon. The effort and sheer annoyance of the condition, the woman says, tends to render her a little "touchy" about matters of etiquette around the house. The meal wasnt even really that bad, she admits. My partner nods and smiles, a hand over hers as he says that its OK. We'll take you to the doctor.
She smiles, and thanks us.
He rides in the back as I drive. Not because she required ALS, but because they have established a repore. Together they talk as we bounce down the street.
After the call I reassemble the equipment, puzzled. My medic walks to the back of the ambulance and lets out another sigh, louder this time and more clearly filled with annoyance.
"What bullshit was that, eh?"
I ask him why he decided to ride in the back, then, if he knew she was bullshit. Why did he entertain such nonsense? He saw the same thing I saw when we walked in the door. No increased work of breathing. Long, full sentences. Clear lung sounds and stable vitals. Still, he said, he wanted to hear her story. Maybe there was something there, maybe there wasnt.
Taking a sip from his coffee he shrugged.
"At least we had a good conversation."
Sunday, March 18, 2007
A problem
People are upset about this blog.
Over the past week I have been on the phone a lot, explaining both myself and the words I have written here. There are concerns about HIPAA and an upset family, unhappy administrators at work and eyebrows raised at my medical control hospital. Despite my intention, and great efforts to avoid this, it seems that I’ve caused quite a mess.
I want to be clear. I have never written about a patient or a call in a manner that I thought would enable direct identification of that person. All of the written names are pseudonyms, locations are changed (if they are mentioned at all), and I have done my best to be ambiguous, if not facetious, about demographic type details. I am familiar with the HIPAA regulations and I have taken great efforts to make sure my entries here are in accordance with them. It is my strong belief that the details I have written here cannot be used to determine the identity of any of my patients, through either direct or indirect means. These are the guidelines that I have written my entries by, and reading through the archives, I have not strayed.
Still, people are upset. There was concern that I had used a patient’s real name, a rumor spread around my school and the company where I work. My medical control hospital heard about this as well.
It is not true.
My administrators are upset about photos that I posted of an ambulance, in a compromising situation that truly looks worse than it was.
My own fault.
A family is upset about an entry that they found inflammatory.
It was not meant in that way.
Still, I owe explanations and apologies. It seems that despite my intentions, I have caused a good amount of grief for some people with this blog. Over the next few weeks I will be attending meetings, and making those apologies the best I know how. I am responsible for this blog and whatever comes out of it, and I truly am very sorry.
I use this writing for myself. I find it extremely therapeutic to compile experiences with patients and compress them into blog entries, find lessons and crystallize them into paragraphs. This is how I have learned, how I continue to make myself better. I hope that these intentions are clear through the words I have written.
Still, to cause harm with this blog would compromise all of its benefit. I will not do this if it is at the expense of others.
Please bear with me. I hope I can sort all of this out soon.
Sunday, March 11, 2007
JEMS Conference
The JEMS conference was an awesome experience. For three days I felt privileged to be surrounded by such a vast number of EMS educators and providers, to learn from them and hear their stories. I walked from class to class with my friends, an ID badge hanging from my neck identifying me as a Paramedic. I wore it proudly, turning it face-forward whenever I noticed it had turned around. I felt honored to be part of such a crowd.
Two friends and I attended classes on a huge array of subjects, ranging from difficult airway management to heart sounds, from COPD to seizures. We sat and listened as providers from around the country told their war stories and the lessons they learned, with each experience backed by science through presented research. Myths were busted as revelations were made, the truth revealed through academic rigor. It was interesting to see EMS from such a prospective. To be taken seriously. Doctors on the panels were focused towards our cause, standing ahead of the class but beside us as colleagues. It was clear to everyone there: this is how EMS is supposed to be.
I am excited to bring this feeling home with me, renewed in strength. The patient always comes first. Our actions have to be regulated through the rigor of science. We have the capability and responsibility to make ourselves better. Each of these, not lessons learned but mantras that weaved through the convention center. The message was common knowledge, both the reason and purpose of attendance. I am thrilled to be part of this.
Through the dark we drove home on Saturday night. All of us were tired from the experience, the late nights and early mornings having taken their toll. Still our conversation remained heavy with the purpose of EMS. We discussed the things we had learned, the reasons why we do this and the responsibilities we have been charged with. Exhausted, but recharged.
A quote from Biologist and Nobel laureate Jacques Monod:
In science, self-satisfaction is death. Personal self-satisfaction is the death of the scientist. Collective self-satisfaction is the death of research. It is restlessness, anxiety, dissatisfaction, agonoy of the mind that nourish science.
May we all remain dissatisfied.
***
In other news:
I am very sorry to have missed the meeting with the other bloggers on Friday night. I mixed up the times, staying later to watch the JEMS games instead of heading across the street. I was looking forward to meeting everybody, but by the time I got out everyone had already left. Sorry guys, next year I will be there.
I am still not sure when or with whom I will be precepting. Things seem to be still somewhat up in the air, and I hesitate to guess what will happen. I'll post about it when I find out.
Two friends and I attended classes on a huge array of subjects, ranging from difficult airway management to heart sounds, from COPD to seizures. We sat and listened as providers from around the country told their war stories and the lessons they learned, with each experience backed by science through presented research. Myths were busted as revelations were made, the truth revealed through academic rigor. It was interesting to see EMS from such a prospective. To be taken seriously. Doctors on the panels were focused towards our cause, standing ahead of the class but beside us as colleagues. It was clear to everyone there: this is how EMS is supposed to be.
I am excited to bring this feeling home with me, renewed in strength. The patient always comes first. Our actions have to be regulated through the rigor of science. We have the capability and responsibility to make ourselves better. Each of these, not lessons learned but mantras that weaved through the convention center. The message was common knowledge, both the reason and purpose of attendance. I am thrilled to be part of this.
Through the dark we drove home on Saturday night. All of us were tired from the experience, the late nights and early mornings having taken their toll. Still our conversation remained heavy with the purpose of EMS. We discussed the things we had learned, the reasons why we do this and the responsibilities we have been charged with. Exhausted, but recharged.
A quote from Biologist and Nobel laureate Jacques Monod:
In science, self-satisfaction is death. Personal self-satisfaction is the death of the scientist. Collective self-satisfaction is the death of research. It is restlessness, anxiety, dissatisfaction, agonoy of the mind that nourish science.
May we all remain dissatisfied.
***
In other news:
I am very sorry to have missed the meeting with the other bloggers on Friday night. I mixed up the times, staying later to watch the JEMS games instead of heading across the street. I was looking forward to meeting everybody, but by the time I got out everyone had already left. Sorry guys, next year I will be there.
I am still not sure when or with whom I will be precepting. Things seem to be still somewhat up in the air, and I hesitate to guess what will happen. I'll post about it when I find out.
Sunday, March 4, 2007
Precepting II
On the phone with one of our administrators the other day, he informed me that there was a "problem." The voice was ominous sounding, followed by a long period of silence. I had worried this might happen. Due to a number of circumstances within the company, my assigned preceptor has changed. No longer will I be precepting with Mr. Canning.
I hesitate to say that I am disappointed. My newly assigned preceptor is also a long-time paramedic, and a knowledgeable man for sure. I look forward to learning as much as possible with him, and I am sure that our experiences will be both interesting and fruitful. I will be precepting in the city now, instead of mostly in a nearby suburban town as I would have with Canning. This is good. I think.
Still though, I admit that I was a bit excited to precept with Canning. A published preceptor, a man well respected throughout our system and beyond: interested in EMS beyond the immediate and eager to teach. Even the blogging would be an experience, with our two sites mirroring each other in student/teacher fashion. That would have been really cool. I am happy to be given the opportunity to precept with my company, but it is a shame that I missed this chance.
Those of you who know me and are familiar with our system are probably smirking at my careful wording here. I am doing my best to take care and not complain. I dont want to come off to my readers, or especially my administrators, as ungrateful for this opportunity. There are many people who did not pass through the system as quickly as I did, lots of preceptees who have had to wait a long time. I am happy to be starting so soon. I am glad I got a good preceptor. I am aware that this engagement is only for a few months, a mere moment compared to a future of paramedicine. On a wide enough scope, this is a hiccup that shouldn't matter at all.
I know all that, but even still, It would have been very cool.
****
The schedule has been mostly set. I will not start this week (as I am going to the JEMS EMS conference in Baltimore), but the week after on Wednesday the 14th. I look forward to it.
I hesitate to say that I am disappointed. My newly assigned preceptor is also a long-time paramedic, and a knowledgeable man for sure. I look forward to learning as much as possible with him, and I am sure that our experiences will be both interesting and fruitful. I will be precepting in the city now, instead of mostly in a nearby suburban town as I would have with Canning. This is good. I think.
Still though, I admit that I was a bit excited to precept with Canning. A published preceptor, a man well respected throughout our system and beyond: interested in EMS beyond the immediate and eager to teach. Even the blogging would be an experience, with our two sites mirroring each other in student/teacher fashion. That would have been really cool. I am happy to be given the opportunity to precept with my company, but it is a shame that I missed this chance.
Those of you who know me and are familiar with our system are probably smirking at my careful wording here. I am doing my best to take care and not complain. I dont want to come off to my readers, or especially my administrators, as ungrateful for this opportunity. There are many people who did not pass through the system as quickly as I did, lots of preceptees who have had to wait a long time. I am happy to be starting so soon. I am glad I got a good preceptor. I am aware that this engagement is only for a few months, a mere moment compared to a future of paramedicine. On a wide enough scope, this is a hiccup that shouldn't matter at all.
I know all that, but even still, It would have been very cool.
****
The schedule has been mostly set. I will not start this week (as I am going to the JEMS EMS conference in Baltimore), but the week after on Wednesday the 14th. I look forward to it.
Monday, February 26, 2007
Precepting
According to my certifications, the powers that be, and the paperwork: I am ready for precepting.
I met with the boss this afternoon in his office and sat while he looked over my credentials, eying expiration dates and perusing all that is necessary. I am but one detail short, something that within reason should be taken care-of over the next few days. Assuming everything goes according to plan, I should be presenting for work as a precepting paramedic early next week. My preceptor? None other than Peter Canning.
The past few weeks I have been able to busy myself with the task working and hoop-jumping that “getting ready to precept” entails. Filing forms, photocopying certifications, taking the local protocol exam. All of it, completed in record time as my excitement to put on a paramedic rocker increased. Bolstered with the confidence of first-time exam passes, and spurred onward by a drive to finish before other potential preceptees, I have forgotten to take the time to think about what I was setting myself up for. Today, with the forms filed and the “go ahead” nod only days away: I remember what it was like to be nervous.
The feeling is familiar. Walking into my first day during my internship I felt the same way: confident on paper, knots in my stomach. At least then I was less familiar with what I didn’t know. Today, with 54 internship patients under my belt and additional months of working as an “informed EMT-B,” the gap between what I am used to, and what will be expected of me seems increasingly vast. It has been easy these past few months to simply drive the ambulance and critique ALS through the rearview mirror. My paramedic partners at work have been awesome, most allowing my input into the assessment, my opinion into the decisions. Still, the work was easy. No pressure to be right, no weight on my shoulders if I was wrong. With the red-tape impeding my precepting cut, I no longer feel the comforting buffer between myself and the clinical decisions that I will have to make. Assuming everything goes to plan, next week it will be all me, and it is scary as hell.
I should do fine. I know what I need to know, I’ve studied the protocols and reviewed the details. As much as I am able to, and as far as I can tell, my brain is ready.
My knotted stomach, though, has yet to catch up.
Sunday, February 18, 2007
Pedi Arrest
My partner and I raced northbound for the confirmed cardiac arrest. The phone rings and I answer, its a friend in another ambulance who has been listening to the fire radios. "It's a kid," he says. "2 years old."
We're on scene a few minutes later, finding the address already saturated with police officers and firefighters waving franticly as they yell and point the way. We park and grab our gear, just the monitor and the ALS bag. No need for a stretcher to carry a 2 year old.
We find our patient by following the sounds of an anguished mother's screams. She is upstairs, getting dressed as she cries, her hair still wet from the shower she took while her baby stopped breathing. Later we would learn that 15 minutes ago she put her child down for a nap and decided to take the opportunity to shower. Walking in afterwards to check on the crib, she found that her child would not wake up.
The 2 year old was on the wooden floor surrounded by giant firefighters in dirty yellow jackets. Arms outstretched and mouth slightly open, she looked positively motionless. Absolutely still. Her skin was an ashen gray, only a memory of warmth remained.
We dropped the gear and got on our knees to work. I ripped the bag open and found a pediatric sized BVM, throwing it to one of the firefighters to set up. My partner confirmed there was no pulse and the patient was not breathing, quickly reaching for the intubation kit. We work smoothly despite the tremor in our voices as we call out commands. Get that oxygen in here. We need the suction. Find out how long she's been down.
The room is so small.
On the monitor is an apparent v-fib that to our dismay smooths out to asystole when all hands pull away from the lifeless body. Get back to work, my partner says. Good CPR. We try for the tube and the patient vomits. The mother is still screaming from the hallway outside, the room feeling smaller by the minute. My partner looks at the monitor, then back at me. "We need to just go."
We scoop up the baby in our arms and rush back to the ambulance. Behind us is a trail of firefighters and police, each grabbing a piece of equipment as they follow in toe. My partner gives CPR with two fingers and delivers ventilations as she climbs down stairs, over snow banks, and into the back of the ambulance. Another crew and a paramedic supervisor are there to help.
We do what we can. The ride to the hospital is harsh but fast, the three of us supporting ourselves against the stretcher while we give CPR and work on the airway. The baby is still ashen gray and motionless except for its lifeless jostling against the city streets. We're at the hospital within three minutes, and they are ready for us.
Room four! Room four!" They yell as we rush the stretcher down the hallways of the emergency department. Shocked patients, sitting upwards in their beds, forget their own troubles for a moment to see what all the commotion is about. Inside the brightly lit emergency room, doctors and nurses await us next to a hospital cot. We give a report and the patient is theirs. New pairs of hands with fresh gloves reach downward towards the gray child.
***
We all gather around the parked ambulances in the hospital loading dock. Each provider handles the call in their own way. Some tell jokes, some are silent. More than one person turned away with reddened eyes, tasking themselves with cleanup chores in order to keep busy. Just leave me alone for a few, they say.
Our supervisor walks from person to person, shaking hands and speaking softly. You did a good job, he said. The best we could have done. He asks if there is anything he can do, anything we need. Take your time, he says. You guys come first.
Back in the emergency department, they get pulses back. The pressure remains stable with vasopressors running into multiple IV lines. Warm air is pumped into the child's lungs via a respirator machine programmed to compensate for a gross metabolic acidosis. The pupils remain fixed and nonreactive to light.
Hearing the news, my partner's jaw tightens. She doesn’t say a word. I'm not sure what to say either. We head back to the office to clean up and restock, attempt to refresh ourselves. Our supervisor is more than accommodating. Anything we need, he offers again.
My partner insists that we go back out onto the road to finish the day. She'd rather work, she says.
We go through the motions of the rest of our shift, trying to talk about something else.
We're on scene a few minutes later, finding the address already saturated with police officers and firefighters waving franticly as they yell and point the way. We park and grab our gear, just the monitor and the ALS bag. No need for a stretcher to carry a 2 year old.
We find our patient by following the sounds of an anguished mother's screams. She is upstairs, getting dressed as she cries, her hair still wet from the shower she took while her baby stopped breathing. Later we would learn that 15 minutes ago she put her child down for a nap and decided to take the opportunity to shower. Walking in afterwards to check on the crib, she found that her child would not wake up.
The 2 year old was on the wooden floor surrounded by giant firefighters in dirty yellow jackets. Arms outstretched and mouth slightly open, she looked positively motionless. Absolutely still. Her skin was an ashen gray, only a memory of warmth remained.
We dropped the gear and got on our knees to work. I ripped the bag open and found a pediatric sized BVM, throwing it to one of the firefighters to set up. My partner confirmed there was no pulse and the patient was not breathing, quickly reaching for the intubation kit. We work smoothly despite the tremor in our voices as we call out commands. Get that oxygen in here. We need the suction. Find out how long she's been down.
The room is so small.
On the monitor is an apparent v-fib that to our dismay smooths out to asystole when all hands pull away from the lifeless body. Get back to work, my partner says. Good CPR. We try for the tube and the patient vomits. The mother is still screaming from the hallway outside, the room feeling smaller by the minute. My partner looks at the monitor, then back at me. "We need to just go."
We scoop up the baby in our arms and rush back to the ambulance. Behind us is a trail of firefighters and police, each grabbing a piece of equipment as they follow in toe. My partner gives CPR with two fingers and delivers ventilations as she climbs down stairs, over snow banks, and into the back of the ambulance. Another crew and a paramedic supervisor are there to help.
We do what we can. The ride to the hospital is harsh but fast, the three of us supporting ourselves against the stretcher while we give CPR and work on the airway. The baby is still ashen gray and motionless except for its lifeless jostling against the city streets. We're at the hospital within three minutes, and they are ready for us.
Room four! Room four!" They yell as we rush the stretcher down the hallways of the emergency department. Shocked patients, sitting upwards in their beds, forget their own troubles for a moment to see what all the commotion is about. Inside the brightly lit emergency room, doctors and nurses await us next to a hospital cot. We give a report and the patient is theirs. New pairs of hands with fresh gloves reach downward towards the gray child.
***
We all gather around the parked ambulances in the hospital loading dock. Each provider handles the call in their own way. Some tell jokes, some are silent. More than one person turned away with reddened eyes, tasking themselves with cleanup chores in order to keep busy. Just leave me alone for a few, they say.
Our supervisor walks from person to person, shaking hands and speaking softly. You did a good job, he said. The best we could have done. He asks if there is anything he can do, anything we need. Take your time, he says. You guys come first.
Back in the emergency department, they get pulses back. The pressure remains stable with vasopressors running into multiple IV lines. Warm air is pumped into the child's lungs via a respirator machine programmed to compensate for a gross metabolic acidosis. The pupils remain fixed and nonreactive to light.
Hearing the news, my partner's jaw tightens. She doesn’t say a word. I'm not sure what to say either. We head back to the office to clean up and restock, attempt to refresh ourselves. Our supervisor is more than accommodating. Anything we need, he offers again.
My partner insists that we go back out onto the road to finish the day. She'd rather work, she says.
We go through the motions of the rest of our shift, trying to talk about something else.
Sunday, February 4, 2007
Medical School
At some point there will have to come a time where my caring for patients will have to be substituted for a drive to learn how to care for patients.
Medical school has always been the goal. In the background, mostly, over the past year of paramedic training - but the ultimate goal nonetheless. My motivation to become a paramedic was derived out of a desire to care for patients, to obtain the opportunity to touch them with my own hands and listen to their complaints. The experience has been extremely visceral: a realistic up-front endeavor into the "realities" of medicine that I couldn’t possibly have imagined beforehand. Each day I ride in the back of ambulances, granted the chance to experience these people, bear witness to emotion and - once in a while - do something about it. Despite all of the work that this requires, the genuine strength and depth of knowledge that truly is necessary, this is fun for me.
I don’t mean to sell paramedicine short. How could I, I'm not even a medic yet. Still though, I am constantly nagged by a part of my brain that forces upon me the memory that, yes, this is supposed to be a building block. The bulk that is "Medical Training" still lies ahead of me, a great mass of the unknown that it only illuminated in part by my endeavors in EMS. There is so much more that I could learn. So much more to experience. Medical school provides the opportunity to take that next step: the realization of all that yet remains a mystery. There, I think to myself, they can teach me how to really take care of patients.
All the while, though, I remain fascinated by ambulance work. These patients, and the treatments which I am able to provide for them, make me happy. I ride on calls each day, observing or even myself making a difference in people's lives. We in the ambulance see patients at the moment of their weaknesses and are gifted with an opportunity to lend strength, medical treatment and a calm voice. The feeling is intoxicating.
Medical school is a grounded and sure-fire pathway to excellence. I could have the opportunity to know more, do more, and -- it is assumed -- get more from my patients. The chance requires dedication, though, and a willingness to lash myself to the mast of science and resist the siren call of this visceral EMS experience. I need to give up what I enjoy to obtain something that I think - only through secondhand experience - will give me more in return.
Ostensibly, medical school provides an opportunity for better. ...But I wonder, how much of what I love will I have to give up in hopes that what comes out on the other end will surpass it.
I'm still not sure what to do.
Medical school has always been the goal. In the background, mostly, over the past year of paramedic training - but the ultimate goal nonetheless. My motivation to become a paramedic was derived out of a desire to care for patients, to obtain the opportunity to touch them with my own hands and listen to their complaints. The experience has been extremely visceral: a realistic up-front endeavor into the "realities" of medicine that I couldn’t possibly have imagined beforehand. Each day I ride in the back of ambulances, granted the chance to experience these people, bear witness to emotion and - once in a while - do something about it. Despite all of the work that this requires, the genuine strength and depth of knowledge that truly is necessary, this is fun for me.
I don’t mean to sell paramedicine short. How could I, I'm not even a medic yet. Still though, I am constantly nagged by a part of my brain that forces upon me the memory that, yes, this is supposed to be a building block. The bulk that is "Medical Training" still lies ahead of me, a great mass of the unknown that it only illuminated in part by my endeavors in EMS. There is so much more that I could learn. So much more to experience. Medical school provides the opportunity to take that next step: the realization of all that yet remains a mystery. There, I think to myself, they can teach me how to really take care of patients.
All the while, though, I remain fascinated by ambulance work. These patients, and the treatments which I am able to provide for them, make me happy. I ride on calls each day, observing or even myself making a difference in people's lives. We in the ambulance see patients at the moment of their weaknesses and are gifted with an opportunity to lend strength, medical treatment and a calm voice. The feeling is intoxicating.
Medical school is a grounded and sure-fire pathway to excellence. I could have the opportunity to know more, do more, and -- it is assumed -- get more from my patients. The chance requires dedication, though, and a willingness to lash myself to the mast of science and resist the siren call of this visceral EMS experience. I need to give up what I enjoy to obtain something that I think - only through secondhand experience - will give me more in return.
Ostensibly, medical school provides an opportunity for better. ...But I wonder, how much of what I love will I have to give up in hopes that what comes out on the other end will surpass it.
I'm still not sure what to do.
Saturday, February 3, 2007
HB
One of our older medics told me a story the other day. He confided in me that he and his partner, over the past year or so, have been involved in a special relationship with a local homeless man who calls himself "Homeless Bob," or HB for short.
The relationship began out of curiosity and boredom. One morning at the beginning of their shift, this medic decided to leave a few dollars and a note, partially hidden in an especially downtrodden part of town. The note read something along the lines of "Take this money as a gift, but please write me back." The drop-spot was a small red shopping basket, hidden among overgrown weeds, trash, and worn away concrete barriers.
Checking the basket every few days, this medic eventually found the money gone and a note - as requested - in return. It was written in sloppy handwriting, uneven lettering scribbled onto a tattered shred of paper. The writer expressed sincere thanks for this unexpected generosity, and praised god for his luck upon finding it.
Homeless Bob continued to write back for an entire year, each time finding some money or gift in the red plastic basket. The conversations grew more frequent, and gifts between the two increased in value. One morning after reading about complaints of sore feet, the ambulance crew left the man a set of workboots, and a warm work suit. Another time a sleeping bag was left. Homeless Bob began to make specific requests for gifts. He asked for money for a bus ticket, since his feet were too sore to walk. He asked for money for clothing or food, some trinket or another. The request was always for cash money, not for objects. Homeless Bob argued that he could "get things cheaper" than the ambulance crew would, so that their money would not go to waste.
The crew would return to the "drop spot" several times a day, checking for new communications. It was the their first stop in the morning. They would sit in a nearby parking lot when posting in the area, from time to time rushing off to help others on 911 calls and then immediately returning. This was their location, their project, their contribution. They were making a difference in this man's life.
One day Homeless Bob communicated that he was interested in traveling to meet some family who lived a distance away. He requested money for a motor scooter, which he said would enable him to get around town as he needed, as well as visit his family as he pleased. Seven hundred dollars, he said, would cover it. They left the money. ..And a little more, for a helmet, gloves, and jacket.
That was the last time they heard from Homeless Bob.
Musing about the experience, this old time medic reclined in his seat. He admitted to me that many times he thought he was crazy leaving all of this money for a man who would probably spend it on alcohol and drugs, waste it instead of seizing the opportunity to better himself. With each letter, though, he felt reenergized in the cause, convinced that the effort they were making truly did have a profoundly positive effect on this man's life. He described the experience as something amazing. Separate from the satisfaction he finds at his job with medical successes, he was able to provide for someone on his own accord: not out of a work obligation, or expectation based on the standard of care. The notes and gifts they left in that basket, he said, were his own choice. ...And from that, he found great satisfaction.
We returned to the drop spot later that day and found the red basket. It was empty, overturned and surrounded by the destruction of a forgotten part of town. The medic sighed as he looked around the area. This is exactly how he found the basket, over a year ago. Not a thing had changed.
The relationship began out of curiosity and boredom. One morning at the beginning of their shift, this medic decided to leave a few dollars and a note, partially hidden in an especially downtrodden part of town. The note read something along the lines of "Take this money as a gift, but please write me back." The drop-spot was a small red shopping basket, hidden among overgrown weeds, trash, and worn away concrete barriers.
Checking the basket every few days, this medic eventually found the money gone and a note - as requested - in return. It was written in sloppy handwriting, uneven lettering scribbled onto a tattered shred of paper. The writer expressed sincere thanks for this unexpected generosity, and praised god for his luck upon finding it.
Homeless Bob continued to write back for an entire year, each time finding some money or gift in the red plastic basket. The conversations grew more frequent, and gifts between the two increased in value. One morning after reading about complaints of sore feet, the ambulance crew left the man a set of workboots, and a warm work suit. Another time a sleeping bag was left. Homeless Bob began to make specific requests for gifts. He asked for money for a bus ticket, since his feet were too sore to walk. He asked for money for clothing or food, some trinket or another. The request was always for cash money, not for objects. Homeless Bob argued that he could "get things cheaper" than the ambulance crew would, so that their money would not go to waste.
The crew would return to the "drop spot" several times a day, checking for new communications. It was the their first stop in the morning. They would sit in a nearby parking lot when posting in the area, from time to time rushing off to help others on 911 calls and then immediately returning. This was their location, their project, their contribution. They were making a difference in this man's life.
One day Homeless Bob communicated that he was interested in traveling to meet some family who lived a distance away. He requested money for a motor scooter, which he said would enable him to get around town as he needed, as well as visit his family as he pleased. Seven hundred dollars, he said, would cover it. They left the money. ..And a little more, for a helmet, gloves, and jacket.
That was the last time they heard from Homeless Bob.
Musing about the experience, this old time medic reclined in his seat. He admitted to me that many times he thought he was crazy leaving all of this money for a man who would probably spend it on alcohol and drugs, waste it instead of seizing the opportunity to better himself. With each letter, though, he felt reenergized in the cause, convinced that the effort they were making truly did have a profoundly positive effect on this man's life. He described the experience as something amazing. Separate from the satisfaction he finds at his job with medical successes, he was able to provide for someone on his own accord: not out of a work obligation, or expectation based on the standard of care. The notes and gifts they left in that basket, he said, were his own choice. ...And from that, he found great satisfaction.
We returned to the drop spot later that day and found the red basket. It was empty, overturned and surrounded by the destruction of a forgotten part of town. The medic sighed as he looked around the area. This is exactly how he found the basket, over a year ago. Not a thing had changed.
Monday, January 29, 2007
Psych
I took care of a man today who, according to the convenience store owners where he was found, "went totally crazy." When we got there he was on the floor, writhing like a fish out of water as eleven police officers stood over him catching their breath. He was handcuffed and lying face down, screaming as he struggled against his bounds. He covered his posterior with his hand, madly swatting away some invisible insult. "He's raping me," the man screamed. "Why are you letting him do this to me?"
When we flipped him over and onto the stretcher he hardly seemed to notice. His face ran with tears, his mouth wide open in anguished cry. Every once in a while he would catch my eye and plead with me that I make "this guy" stop. I tried to ask him what happened, what was going on. Looking into his eyes I tried to offer him a way out, a softness beyond the hell that he endured. He looked right through me. His reality was too much for him to bear, too potent to ignore.
I did my best to perform an assessment. He had a strong, regular radial pulse at about 134, his skin hot and diaphoretic. His lung sounds seemed to be clear between screams. I did a rapid trauma assessment and found nothing. PEARRL. Unable to obtain a medical history, meds, or allergies. I wasn't even sure I had his first name right. I tried to give some nasal cannula oxygen, but the man kept shaking his head whenever I got close, screaming with rapidly depleting energy and fighting the best he could. I resigned myself to simply trying to calm him down, which didnt work either.
Patients like this are not uncommon in the city. They get into the back of the ambulances - willing or, sometimes, unwilling - and refuse to budge. We do routine assessments, going through the motions to be thorough, knowing all the while that we cant really touch these people. The barriers are too high, the insults are too deep. They look at us with the eyes of experience, tired of the same questions. Most have done this before and seen failure, their pockets filled with medications and crisis intervention business cards. Again we both try.
Its easy to burn out on these patients. Perceived futility is an especially hot ember. I'm not sure how long-term, adept clinicians handle this. Do they relax in the system, mindlessly going through the motions in efforts to provide for these patients another halfway opportunity? ...Or are they convinced of the value of these interventions, actually believing that people this far gone can truly be helped?
Which method is the best for the patient? Which is more healthy for the provider?
On our way to the hospital I sat in the airway seat, behind the patient. I didnt want him to look at me, ask me for help I couldnt give. I spoke to him from out of his view. "Calm down buddy. Try to relax. We're taking you to the hospital, we'll get you some help."
When we flipped him over and onto the stretcher he hardly seemed to notice. His face ran with tears, his mouth wide open in anguished cry. Every once in a while he would catch my eye and plead with me that I make "this guy" stop. I tried to ask him what happened, what was going on. Looking into his eyes I tried to offer him a way out, a softness beyond the hell that he endured. He looked right through me. His reality was too much for him to bear, too potent to ignore.
I did my best to perform an assessment. He had a strong, regular radial pulse at about 134, his skin hot and diaphoretic. His lung sounds seemed to be clear between screams. I did a rapid trauma assessment and found nothing. PEARRL. Unable to obtain a medical history, meds, or allergies. I wasn't even sure I had his first name right. I tried to give some nasal cannula oxygen, but the man kept shaking his head whenever I got close, screaming with rapidly depleting energy and fighting the best he could. I resigned myself to simply trying to calm him down, which didnt work either.
Patients like this are not uncommon in the city. They get into the back of the ambulances - willing or, sometimes, unwilling - and refuse to budge. We do routine assessments, going through the motions to be thorough, knowing all the while that we cant really touch these people. The barriers are too high, the insults are too deep. They look at us with the eyes of experience, tired of the same questions. Most have done this before and seen failure, their pockets filled with medications and crisis intervention business cards. Again we both try.
Its easy to burn out on these patients. Perceived futility is an especially hot ember. I'm not sure how long-term, adept clinicians handle this. Do they relax in the system, mindlessly going through the motions in efforts to provide for these patients another halfway opportunity? ...Or are they convinced of the value of these interventions, actually believing that people this far gone can truly be helped?
Which method is the best for the patient? Which is more healthy for the provider?
On our way to the hospital I sat in the airway seat, behind the patient. I didnt want him to look at me, ask me for help I couldnt give. I spoke to him from out of his view. "Calm down buddy. Try to relax. We're taking you to the hospital, we'll get you some help."
Tuesday, January 23, 2007
Patron
New Hampshire was bitterly cold. We stayed in dorms on a fire training campus the night before the exam, alone in the lecture halls as we studied our respective examination stations and played cards. The freezing wind battered the windows with blustery sprays of whipped up snow, but we remained warm inside. Three of us, surrounded by the expansive emptiness of rooms waiting to be filled the next morning, huddled over our note cards.
The rooms were full by 7:45, a half hour before the exams were scheduled to begin. Awake with bleary eyes we listened to the nervous chatter of other students waiting to be tested. All wondered how tough the examiners would be, how in-depth the evaluations would get. One student asked me if I could remember the maintenance infusion for Magnesium Sulfate, and I did. He shook his head, frowning. "I really hope they dont ask me about that. I'm never going to remember."
My friends and I, reinforced by practice and tempered by experience, were able to remain calm. It takes something away from the threat of the exam to have been there once, failed, and come back for a second try. Lessons learned through the experience of failure have been those that I remember most clearly during my ride-time internship, and today - with similar lessons learned - I felt prepared. Ready.
Dynamic Cardiology was never easier. Asystole, V-Fib, Asystole, PEA, and out. I cycled through my ACLS, remembering each step, finding time to recall detail that I left out on my first time through the exam. I was ready for infusion rates with fancy dosages, but the need never came. Halfway through an explanation of my last treatment the proctor smiled and asked me to stop. "You're making this too complicated." she said, "Get out of here, have fun being a Paramedic." I left the room with a huge grin on my face. Another proctor standing in the hall laughed at my smile. "Went well, eh?"
My friends had similar experiences, each of them letting out sighs of relief as we met up after the examinations. Fisties and handshakes all around, smiles and congratulations. I bought a bottle of an expensive liquor at the New Hampshire state package store on the trip up, and we all shared a shot in our dorm room before we left. Holding the glasses up high we toasted to the end of exams, the beginning of a new experience.
The liquor went down smooth, warming our stomachs. A delightful contrast - and welcome end - to our cold New Hampshire winter.
***
With both the practical and written exams passed and behind me, I am now a Nationally Registered Paramedic. I next have to apply for my state license, a process that people before me say could take weeks to months. I continue to work my job as an EMT, hoping for the former. Next hurdle to overcome will be precepting.
The rooms were full by 7:45, a half hour before the exams were scheduled to begin. Awake with bleary eyes we listened to the nervous chatter of other students waiting to be tested. All wondered how tough the examiners would be, how in-depth the evaluations would get. One student asked me if I could remember the maintenance infusion for Magnesium Sulfate, and I did. He shook his head, frowning. "I really hope they dont ask me about that. I'm never going to remember."
My friends and I, reinforced by practice and tempered by experience, were able to remain calm. It takes something away from the threat of the exam to have been there once, failed, and come back for a second try. Lessons learned through the experience of failure have been those that I remember most clearly during my ride-time internship, and today - with similar lessons learned - I felt prepared. Ready.
Dynamic Cardiology was never easier. Asystole, V-Fib, Asystole, PEA, and out. I cycled through my ACLS, remembering each step, finding time to recall detail that I left out on my first time through the exam. I was ready for infusion rates with fancy dosages, but the need never came. Halfway through an explanation of my last treatment the proctor smiled and asked me to stop. "You're making this too complicated." she said, "Get out of here, have fun being a Paramedic." I left the room with a huge grin on my face. Another proctor standing in the hall laughed at my smile. "Went well, eh?"
My friends had similar experiences, each of them letting out sighs of relief as we met up after the examinations. Fisties and handshakes all around, smiles and congratulations. I bought a bottle of an expensive liquor at the New Hampshire state package store on the trip up, and we all shared a shot in our dorm room before we left. Holding the glasses up high we toasted to the end of exams, the beginning of a new experience.
The liquor went down smooth, warming our stomachs. A delightful contrast - and welcome end - to our cold New Hampshire winter.
***
With both the practical and written exams passed and behind me, I am now a Nationally Registered Paramedic. I next have to apply for my state license, a process that people before me say could take weeks to months. I continue to work my job as an EMT, hoping for the former. Next hurdle to overcome will be precepting.
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