Effective Immediately

My day with the Chief went very well. We did a few routine calls, a man who had fallen down a flight of stairs with an obvious closed tib/fib fracture, another man who's plaster ceiling had fallen down on his head while he was washing the dishes. I assessed the patients, directed other crewmembers on scene, and made treatment decisions based on my clinical impressions. I was nervous, and sweating in the 90 degree heat, but apparently avoided screwing up too badly as at the end of the shift I got a handshake and congratulations. "Do your best to kill as few people as possible," he said with a smile.

And I was done.

It seems a little odd now, after having jumped through so many hoops, filed so much paperwork, and paid all of my dues: here I am now with nothing else to do other than go out and work. What do you mean I'm cut loose to practice on my own? You mean I get to go out all by myself, with just an EMT?

I received a letter today from my Medical Control hospital:



Effective Immediately, but the feeling hasn't quite yet hit home.


My first shift as a paramedic will be tonight. 6pm till midnight or so, I am doing a quickie shift with a good friend of mine watching over a boxing event. I guess I should brush up a little on my trauma protocols?

A Final Ride

All of sudden, the day is tomorrow.

I've known for a while now that my preceptor has been just about ready set me out on my own. He has mentioned it several times, but the day was always weeks away, obscured by an unknown buffer of time. There were always a few more shifts in between then and now, a few more free lessons available for me to learn. A few more reasons to put it out of my mind.

Not anymore though. I found out this evening that tomorrow I will ride with the Chief Paramedic, my last 8 hour evaluation before I am (hopefully) cut loose to perform on my own. We will ride together for the shift, him driving and me running all of the calls. We will jump all of the good dispatches and then he will watch from the side with eyebrows raised, I imagine, as I sweat my way through each of the assessments.

I am excited for this - I have been waiting a long time for it - but right now none of it seems all that fun. My esteemed readers, please wish me luck. It could very well be that this time tomorrow, I will be out on my own.

A Potent Lesson

The man looks up at me from his bed, surrounded with the trappings of his daily life. Within reach are carefully arranged remote controls, for his bed, tv, stereo, and nurse. His pillows are arranged just-so, tucked under his legs and back in an assembly that surely took weeks of trial-and-error to get just right. Photographs of family and friends surround the bed, adorned with gifts and trinkets, flowers and balloons. He is 82 years old, relegated to bed by age and disease, chosen to stay there through consent forms clearly indicating his wishes: Do Not Recesustate, Do Not Intubate, Do Not Hospitalize.

He looks at me, sweating. I dont even get to ask what is wrong before the problem presents itself, making it's own introduction. The man's muscles flex and bend inward, all 4 extremities tightening and releasing quickly as electricity claims control for the millisecond. A shock from his implanted AICD. The man's face portrays equal amounts of annoyance and pain. "It's been happening all day," he says. "Just go ahead and get me to the hospital so they can turn this damn thing off."

Aware of the man's advance directives, I ask what it is that he would like us to do on the way. We have drugs that may help stop the shocks, I would like to give them a try if it is okay with him. Exasperated with the painful shocks, he reluctantly agrees. I explain what I would like to do, and the man waves his hand- "Do what you have to do, just make this stop."

On go the white, black, red and green wires:


Except for the jolt of electricity every 60 seconds, the man is without complaint. I ask all of the pertinent questions, perform my exam and search for more, but there doesnt seem to be much other than what is printed on the EKG paper, and the occasional flexing and arching of electricity. The blood pressure is 130/80, SPO2 99% on room air, the man is without pain or shortness of breath.

I leave the monitor on print, capturing the various outrages of the man's irritable heart:



I watched the rhythm widen and become narrow again, it's irregularity and rate alternating unpredictably, punctuated by discharges from the man's AICD and perhaps his pacemaker as well. I recognize a-fib underneath, but waver at a clear interpretation of the faster, shockable rhythm. The man sweats uncomfortably, bracing as he awaits his next scheduled shock. He asks me if we can get a move on. I call the faster rhythm a "wide complex tachycardia of unknown origin." Even though I see the rhythm narrow in places, I am nagged by occasional width, and spurred onward by the man's prodding. I am eager to provide relief, and ready to make a decision about the EKG.

I should have slowed down.

I get the man on some oxygen, and start an IV. Acutely aware of the rhythm changes, I make a decision to administer Amiodorone: 150 milligrams over 10 minutes, diluted in 100cc of normal saline. I am an expert at the tasks by this point, and the work goes quickly. It was a difficult IV, but I got it. Our buritrol was broken, but I managed. I mixed up the drug, piggybacked a line, and accurately calculated the drip rate. Like a machine.

We drip the drug in on the way to the hospital, a 10 minute trip. It is at this point that I remember the 12 lead cables. I see them in the back of the monitor as I am looking for something else, bunched up where I put them last and conspicuously unused. I recognize immediately that I should have used them earlier. I look up at the medication bag, and it is halfway gone.

On go the six black wires:



The rate is still fast, but nothing else is the same. It was as if I had wiped away a dirty window and looked again, amazed with a new vision- unobstructed and clear as day. This rhythm is not wide at all. It is narrow, irregular, fast. It is a-fib. Any day of the week, a-fib.

I stare at the strip, drained. The Amiodorone is almost all of the way in now, and while the drug is far from the wrong one (it may still help), it should not have been my first choice. A-fib like this gets calcium channel blockers, not general antidysrhythmics. Mine was an appropriate treatment still, but a less effective one - and something that I will have to explain to the doctor who will surely ask why I made such a decision.

The patient, unaware, rests comfortably. I look up from the EKG paper as he touches my knee. "Thank you," he says. "This is much better." His heart rate has come down slightly, to about 150, and the AICD has stopped shocking. The diaphoresis is gone. I tell him he is welcome, grateful for his relief.

In the ED the doctor does ask me why I chose Amiodorone. He looks over the strips quickly as he moves between charts. "That looks like a-fib or flutter. Pretty fast, too." I offer a weak explanation that the rhythm appeared wide at times, and that I felt that this drug was a safe call considering the varied morphologies. He shrugs, and says okay. At least he's not getting shocked anymore. I shrink back away and try to disappear.

Paramedic friends of mine say that I'm too hard on myself. I should have done a 12 lead first - especially on a stable patient like this one - but they pat me on the back and tell me I still did well. It's hard, they all say, to make these determinations quickly, in the back of the ambulance surrounded by the chaos of a patient in pain and buried under a mountain of other tasks that must be done at the same time. "Dont overthink these things," one medic tells me. "Just next time make sure you get that 12 and you'll be right on."

Still though, I'm angry with myself. I was eager to get to the treatment, moving too quickly for a necessary second glance at the rhythm. It was embarrassing to come into the emergency department, to give reports to doctors that I respect, fully knowing that I didnt quite do the right thing and, worse, that the cause of the problem was an omitted step. These kinds of mistakes can turn out well, like they did this time, or they can be deadly. It is a scary thing, and I really need to be more careful. This was no benign error.

This is something I will not soon forget. I feel strongly that the resilience of this kind of lesson is equal in proportion to the amount of danger the inciting mistake imposes. This was a small omission which could have posed a significant danger to a different patient. The importance of such an opportunity to learn consequence-free is not lost on me, and I will make great efforts to make sure that the memory sticks. I will squeeze this for what it is worth.

I overheard a new medic the other day, worried about his upcoming ride-time as a new preceptee. He was nervous, explaining that he hoped he didnt "make too many mistakes." To the contrary, I think. May he make lots of mistakes. Let them pile up underneath him, build up his experience and stick with his memory. May his errors remain free from serious consequence, but packed full of value, so that next time the choices will be clear and ready.

I am new. I will continue to make mistakes. I cannot hope that they will not happen, only that when they do I am able to claim from them the fruit of experience, and pass the benefit to my next patient.

I will be better next time.

New Paramedic and Aspiring Doctor

I wrote in my last entry that I hadn't thought about medicine over my vacation. That isnt quite true.

While becoming a paramedic has dominated my thoughts these past few months, I often find myself looking back on it all- angry that I've let the greater goal slip from consciousness. I still want to go to medical school, to take my education further and move onward. Paramedicine is seductively interesting, though, and snares me each day with its excitement, newness, and promise of more. There remains a fantastic depth to this work that I am far from understanding, and yet the sum of it all is assumed - by my other mind - to be shallow at it's end. With so much new to me, I am supposed to prepare for the point at which it will no longer suffice.

I've found it incredibly difficult to put that effort forward, with each daily experience tingling with challenge and intrigue. I love the work. I learn something new every day, meet different people and experience scenes that I can barely translate to type. How could this ever come up short?

It will, though. I am tenacious enough for this kind of knowledge, eager enough about medicine that I can see myself stretching my capabilities out to their limits. I will continue to read, explore, and learn. I will become better, more experienced, more adept. At some point, I think, there will come a time when I want more. More medicine, more knowledge, more freedom, more money, more everything. Despite all of my excitement about paramedicine, that feeling is still there. Nagging.

Nothing is easy, though. I need to take a full time position at work, so that I can get health coverage and a regular paycheck. At the same time, I still have to take a year each of Chemistry and Organic Chemistry so that I can prepare for the MCATs and eventually apply to school. The two do not necessarily jive well. I am last on the seniority list at work, relegated to the last - least desirable - shift at work, which may or may not coincide with the lecture and lab classes I need to schedule. Fees at the college approach $1500 per 4-credit class, of which I need to take 2 per semester in order to finish within a reasonable time. Money is tight, time is worse. ...And all along, the siren song of EMS maintains it's relentless tug. Even after all of that: the idea of medical school scares the shit out of me.

And yet I remain firm. This needs to get done. I will put my head down, work my shifts, learn my lessons. Stay sharp and keep my eye focused on where I am headed.

Cruising

I thought I'd explain why I havn't posted in a few days.

Currently I am aboard a cruise ship, sailing in the Atlantic Ocean towards our next destination in Bermuda. This is a 7 day cruise, and we have already made stops at 2 islands in the Bahamas, spent time on the beach lounging and playing volleyball as we sipped on icy red beverages. It is a much needed break from the 70 hour weeks I have been working in the city, although I look forward to returning on Monday, refreshed and conspiciously tanned.

I have thought very little about EMS or medicine over these days, and I think I'd like to keep it that way. The internet here is very expensive anyways ($0.75 per minute), so I will delay writing further until I return.

To my friends back in the city: would you mind texting me your home addresses? I have something to send, and cant use my phone without huge ship-to-shore charges.

See you all on Monday!

The Front Seat

My preceptor was out on vacation today, so I spent the day doing calls with my EMT-I partner, swapping every other call as technician and driver. It was something of a nice change: to sit in the front of the ambulance again where the AC blows cold and windows surround every view. It feels like a long time that I have been locked in the back of the truck, relegated to the uncomfortable seat and stuffy atmosphere, removed from conversation and left to my own thoughts.

I was reminded again of the experience of driving. Priority 1 to a call, flicking the sirens and blaring the horn. Talking trash about drivers who freeze or do the wrong thing when we come racing their way. It all seems to add to the experience, and I hadnt realized how much I missed it until I got the chance to remember it today. I like to quickly switch the "wail" siren on and off through intersections, creating my own - custom - wah wah wah sound for all to heed. Some people like to use the air horns constantly, blaring for long, drawn out tones as we slip through traffic. I like to use it sparingly, though, saving the obnoxious blast for only those who do something really stupid, or are about to hit our ambulance. I like to keep something in reserve so that I have a "next level" if the situation requires.

My partner drove to a call today, a particularly long distance across town on a priority 1-- his favorite kind of response. He settled into the seat and gripped the wheel tightly with his left hand as the right worked the siren and horn. He is aggressive behind the wheel, moving his body to the left and to the right as if cornering on a tightly wound motorcycle. Our heavy ambulance tilted and swayed in turn. By the time we got on scene we could smell the hot brakes, a potent acrid odor that satisfied my partner in affirmation of a well-driven response. He could barely wipe the smile off of his face. The experience of responses like these are somewhat less enjoyable on days when I am trapped in the back of the ambulance, arms and legs spread out in four points of contact as I attempt to anticipate the next pitch and roll of the lurching vehicle. Today, though, I was in the front.

I got to drive slowly, too. On the way to the hospital with a patient in back, I had the chance to talk with family members or friends who came along for the ride. On one call we took along a friend of a patient, a nurse for 15 years who suffered through the experience of becoming her friend's healthcare provider for the 10 minutes before we arrived. It was horrible, she said. She couldnt separate herself from the situation, become the objective observer that the job really required. Several times she would stop mid-sentence, to turn around over her shoulder and, worried, check that her friend was "still doing okay" in the back. She turned forward, catching my eye each time with something of an embarrassed look: as if she wasnt supposed to behave in such an emotional manner as a "professional provider." She apologized and I told her not to worry.

It was a nice break. Tomorrow I am back in the rear of the truck, my preceptor returning to supervise me on another day's worth of calls. We are hoping for a "good medical," maybe a CHF or a profound MI. I haven't had a chance to use our new CPAP devices yet, either.

I look forward to learning something new.

Survival to Discharge

I found out today that my "code-save" from the other day actually was a code save. A paramedic student doing a rotation in the CICU caught up with me, excited to tell the story of a man who was wheeled in with tubes and wires, wrecked and posturing, only to walk out - under his own power and without neuro deficits - 6 days later.

It boosted my whole week, thats for sure. I wonder if some day I will bump into him walking on the street or in line at a store, a vague recgonition as, yes, that's the guy I helped resuscitate. I wonder if it would be prudent to say anything to him, if that oppertunity were to ever arise. What would I say? What could I expect him to say?

I probably wouldnt say anything.

I got around to digitizing (in my own halfway manner) the strips from that call. With the good news in mind, I thought I'd post them. A story told by EKGs. (You can click on any one of these to get a more detailed view)







I skipped a few to make the story a little more succinct, but please rest assured that there do indeed exist strips with regular 3 leads, and a perfect square-like capinography output overshooting first in the 60's, then coming to rest around 40. The tube was good the whole time, I made damn sure of that.

**

In other good news, I got word from my preceptor that he is "about ready to kick me out," meaning release me from my preceptorship and set me off on my own. We need to schedule a day when I can ride along with one of the company's administrators, to be evaluated and checked just one last time before I am allowed to practice without supervision. I am acutely aware of how much I have yet to learn, but even still I am eager to be given leave to make my own decisions. Peter Canning's preceptee is in a similar position, and she confided in me the other day that she might "never feel like [she has] learned enough," but the time is soon approaching where she is "going to have to learn on her own."

Both of us are just about ready to be cut loose, free to make our own mistakes, pick ourselves up, and learn our own lessons.

Two Codes

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.

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.

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.

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.

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.

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."

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.

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.

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 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.

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."

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.

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.