Aided with adrenaline and substances yet unknown to us, the man flexed his substantial muscles and screamed against his bounds. He let out anguished yells, cursing at all of us as we worked to hold him down. He was a big man, and we were all sweating.
My partner and I found him semi-conscious in the grass of a local park about a half hour before. He was lethargic when we walked up to him, his eyes distant and glazed over in some kind of dreamy confusion. He lay about 10 feet away from a twisted-up bicycle from which witnesses said he fell while riding through the park. They said that they knew him personally, that he is a "great guy who is always here with his family." Someone said that he had a history of seizures.
My partner glanced in my direction, and we agreed without words. I put both of my hands up towards my neck and he nodded, heading towards the ambulance for c-spine equipment and the stretcher. I did a quick assessment while I waited for the rest of the gear. No visible traumatic injuries, lung sounds clear, strong radial pulse at about 100, PEARRL. Blood sugar is 200. When my partner came back with the equipment we worked together with firefighters to roll the large man onto the board, securing his head, torso, and legs with snug straps. My partner and I bent our legs and then straightened, grunting as we lifted the massive package up to the stretcher.
In the ambulance the man began to come around. He was confused still, asking repetitive questions and often making statements that made no sense. I did my best to get a history and some background information, but the man was a poor historian at best. I got a full set of vitals, plugged in the EKG, started an IV, and told my partner we could go. The man remained confused the whole way, and despite my reassessments and double checking, I found very little that swayed me from a routine clinical impression of postictal-related altered mental status.
The man began to get a little more agitated as we rolled down the ED hallways towards the triage desk. He lifted his hands up towards the c-collar, but I was able to gently guide his hands away and talk him down. He listened to my words, agreeing momentarily but again reaching towards his restrictions a minute later. I told the triage nurse that it was probably only a matter of time before the patient lost control and ripped himself off of the board. He had that look that we have all seen before: chaos about to happen.
It did happen. About 5 minutes after getting him over the hospital bed, the patient began to lose control. Quiet requests turned into agitated demands, and then into senseless screaming. He pulled his head out of the blocks, the tape snapping and velcro ripping, all the while pulling at the backboard straps and rolling from side to side. The nurses and techs tried to calm him down, offer comforting advice through smooth tones, but the patient would hear none of it. He was on a one-way path, and would not come back. My partner and I jumped in to help, and even with our numbers, we struggled.
The doc strolled in casually, his white jacket crisp and clean, separate from the mess that was rapidly overtaking the small ED room. He asked for the story, and I told him while holding the patient down: a few brief details and a couple questions answered. He tried a round of Haldol and Ativan but it was without effect, and after another 10 minutes of fighting, the doctor casually waved his hand towards the intubation tray. The nurses, anticipating this decision, already had everything ready.
Rocuronium was sent through my IV, and within seconds, the patient was flaccid and docile. It was as if someone had found the patient's OFF button and finally decided to throw the switch, ending almost instantaneously the aggression we had been fighting for the past 20 minutes. Easy as pie, the doctor slid a miller blade into the open mouth, lifted, and passed the tube. It was good, of course. Everything was good.
I met up with the doctor later. The toxicology reports had come back, which indicated that the patient had extremely high levels of PCP in his system. It looked like the patient had smoked some of the drug before his bike ride through the park, and collapsed when the effects hit their peak. The potential trauma was still an issue, but the patient was not. He lay across the hall, silent except for the sound of the mechanical respirator performing it's windy functions.
The doctor and I discussed the drug a little bit when I made a remark about RSI. I admitted that I was glad the patient was calm with me, because I wouldn't have been able to restrain him in the ambulance if he had lost control then. The doctor was shocked to hear that we didn't have the capability to RSI patients. He stared at me, as if I were joking.
"So basically," he said, "either the patient is dead, or you are not going to get the tube?"
I admitted that this was probably the case for much of the time.
The doc sat back in his seat, thinking for a second.
"Jeez. You're right. Good thing he didn't come 'round till you got him here."
Wednesday, August 29, 2007
Thursday, August 23, 2007
Biggest Drill Ever
People who have done this before at Katrina, and others who have had experience with the military all admit that this is the way things tend to go. It was new for me, though.
Nine of us received phone calls at about 0730 on Sunday morning, just five hours after many of us got home after a long shift at the concert venue. The message was direct, but hollowed out and filled with mystery: get up, get packed, expect to leave within the next couple hours. It was chaos from the get-go, as most of us had no idea what to pack, how to pack it, and what might lie ahead. Groggily we all asked whatever questions we could muster when the phone calls came, but the supervisors calling didn't know the answers. All we know is that you are heading out today, probably soon, they said. Plan for seventeen days.
I got up and packed whatever I could think of, wondering if this was a good idea. I had already said that I would go, but this morning I wasn't quite so sure. I packed seven pairs of EMS pants with matching uniform shirts, loads of underwear, socks and various t-shirts. I remembered a rain suit and my MP3 player, a camera and the cell phone. I ran to the store quickly and bought granola bars and travel-size toiletries. When we finally got the call to go, I almost walked out of the door without my boots.
It is a scary thing to respond to a call like this. The storm had not yet hit, and none of us had any idea when, where, or how hard it would. On the TV they were showing frightening looking images of circular swirling clouds in the Atlantic ocean, arrows of potential paths swinging westward and slightly to the north, fading out in uncertainty around landfall. At the airport we huddled around together and nervously chatted about what may lay ahead. There were a few with us who had done this before, and we relied on them for whatever information we could get a hold of. As we sat and waited for our flights a few people told stories of their time at Katrina, horrible and haunting. Some of their experiences made my bones chill.
Through a layover we ended up in San Antonio Texas at about 0100, where a bus driver waited for us with a sign that read FEMA EMS DISASTER RELIEF. Stepping out of the airport was like walking into a sauna. We all staggered a bit at the heat, even at this early hour the air was saturated with thick humidity and almost hot to the touch. We weren't used to this at all.
The driver took us to a base of operations about 20 minutes away. It was obvious when we had arrived at our destination: idling ambulances lined the streets for blocks surrounding the building, which sat aglow from generator-powered overhead lights. There were hundreds of cardboard boxes filled with supplies in neat stacks at various locations outside of the building, and workers walked quickly from pile to pile with clipboards and packages like worker ants sprawling the terrain. The place was alive, and everyone was busy.
We got a quick briefing from one of our administrators, who had taken an earlier flight down. He was sweaty and looked tired already, having spent a number of hours preparing hundreds of brand new Nextel phones. Sitting back from his work for a moment, he informed us that we didn't know when we would be moving out, but it would probably be in a few hours. The main base of operations was at Kelly Air Force base, an hour away, where we would receive further instructions. Until then, he said, we should grab a spot on the floor and try and get some sleep. On the floor? It was concrete with a thin carpet, but we were exhausted. I bunched up a sweatshirt for a pillow and was asleep within minutes.
It was a consistent theme throughout our deployment that information would be both set at a premium and low in supply. From nights on the floor to travel arrangements that changed as sure as hours passed, it seemed rare that our group heard about plans that would actually occur, reliable news about the hurricane's path, or informed truth about large-scale decisions. We were all used to working small-scale: champions of the backs of our ambulances and the source of decisions to be made on scenes. The patient laid out before us in clear presentation of the problem at hand. It was strikingly clear on our first night of this deployment, though, that we would not be experiencing the familiar. Our view was instead from the bottom-up, clouded by rumor and indirect contact with the management, and while we listened and obeyed, the decisions brought down made little sense to us other than that they came from authority who presumably knew better. Uninformed, we entrusted ourselves to the greater machine and blindly did as we were told.
We were awoken twice in the middle of the night from our snoring slumber, asked to perform a few minor tasks, and then let back to bed. Later in the day we were brought to the air force base, packed 6 deep in the back of a modular ambulance along with piles of suitcases. It was sweltering hot, and we sat quietly as the loaded ambulance labored through unfamiliar streets. We all remained in good spirits though, uncomfortable but inspired by the magnitude and meaning of our presence.
We arrived on the outskirts of the base, greeted by an incredible view of ambulances that had already arrived. They stretched off in the distance to vanish points, row after row. I have never seen so many ambulances together in once place. It was difficult to appreciate the view through my camera lens, but I made an effort:
After a brief wait at the staging point, we were brought by bus to another section at the base where we were to stay. It was an extremely large multi-purpose building, expansive on the inside with carpeted concrete floors and pillars spread out in grid fashion. We were given fold-out cots and a blanket, and told to settle down where we liked. Our group picked a spot in the corner, adding a margin of privacy by stacking the cardboard cot boxes in a makeshift wall in front of us. Many others followed suit as they arrived, and in a number of hours the building was a maze of sleeping EMS workers, cots, boxes, and tables.
It was here where we spent the rest of our deployment. We were there for two days, waiting on instructions to move south that never came. FEMA supplied the some 700 EMS workers who responded with ample sleeping supplies, hygiene kits, and food. Information remained spotty and often incorrect, while rumors were constantly passed from camp to camp about what our fates might be. At night when the lights were turned down, flipped-open cell phones were visible across the room like stars as workers searched the internet and friends for updates on the storm's path. We played cards, watched DVDs on laptops, and slept as much as possible.
While we waited, the storm crept onward towards Mexico, never swinging north as so many had feared. Word was passed around about the diminishing storm categories, from five to four to three to one.
On Wednesday a large group circled around the center of the room to hear news of our dismissal. Representatives from FEMA and Texas thanked us for our response and apologized for our inconvenience, giving the official word that we could all go home. Everyone clapped, a bit disappointed for the lack of action but ready to leave.
Our group left in a caravan of ambulances at 0500, ready for the 15 hour trip from San Antonio to Gulfport MS. It must have been a sight to see our 18 ambulances rolling down the road, filled with EMTs and Paramedics unshaven and exhausted looking. We emptied our fuel tanks twice, each time gathering at truck stops and joking around, taking photos of our group in front of ambulances that used to be part of our own divisions. Some people were extremely frustrated with the situation, becoming loudly vocal about their discontent from time to time. One group from another division taped signs to the back of their ambulances reading "Lied 2" and "Corporate Puppet" in lieu of our missing license plates. Most of us rolled our eyes at the complaints, though, and the experienced members of our group commented that such frustrations were absolutely typical of large operations like this one. The time-honored military motto of "hurry up and wait" was mentioned often, and despite the frequent frustrations, most of us remained in good spirits.
Towards the end of the drive we crossed through New Orleans and the surrounding areas affected by hurricane Katrina. I had never been there before, but was shocked to see how much of the damage still lingered even as viewed from the highway. We passed countless homes that remained crushed and broken, roofs folded in and windows smashed. I rode with a medic who was in this area for the storm, and he pointed to the left and right as we drove through, talking about where the water was and what the terrain looked like then. We drove over a large overpass which he said was almost taken over completely by the onrushing waters. Looking over the now dry and damaged terrain, it was difficult to imagine the forces that caused so much wreckage.
Many of us, myself included, were at least in some small way disappointed that Hurricane Dean stayed so far south. We wanted at least a little bit of "action," and wanted to charge into broken areas and work. Seeing this destruction, though, firmly grounded us. The extent of what a hurricane can do was never palpably clear to us, and realizing what disaster was avoided, all we could do was thank god nothing like this happened again.
We took flights the next morning out of the south and back home. On the way we discussed FEMA and the response, whether we would come back on the next deployment. Just about all of us said we would. Though the hurricane did not hit US land, this was in effect the largest drill FEMA has ever conducted, and with the experience under our collective belts, we each look forward to coming back and doing it better- next time.
Nine of us received phone calls at about 0730 on Sunday morning, just five hours after many of us got home after a long shift at the concert venue. The message was direct, but hollowed out and filled with mystery: get up, get packed, expect to leave within the next couple hours. It was chaos from the get-go, as most of us had no idea what to pack, how to pack it, and what might lie ahead. Groggily we all asked whatever questions we could muster when the phone calls came, but the supervisors calling didn't know the answers. All we know is that you are heading out today, probably soon, they said. Plan for seventeen days.
I got up and packed whatever I could think of, wondering if this was a good idea. I had already said that I would go, but this morning I wasn't quite so sure. I packed seven pairs of EMS pants with matching uniform shirts, loads of underwear, socks and various t-shirts. I remembered a rain suit and my MP3 player, a camera and the cell phone. I ran to the store quickly and bought granola bars and travel-size toiletries. When we finally got the call to go, I almost walked out of the door without my boots.
It is a scary thing to respond to a call like this. The storm had not yet hit, and none of us had any idea when, where, or how hard it would. On the TV they were showing frightening looking images of circular swirling clouds in the Atlantic ocean, arrows of potential paths swinging westward and slightly to the north, fading out in uncertainty around landfall. At the airport we huddled around together and nervously chatted about what may lay ahead. There were a few with us who had done this before, and we relied on them for whatever information we could get a hold of. As we sat and waited for our flights a few people told stories of their time at Katrina, horrible and haunting. Some of their experiences made my bones chill.
Through a layover we ended up in San Antonio Texas at about 0100, where a bus driver waited for us with a sign that read FEMA EMS DISASTER RELIEF. Stepping out of the airport was like walking into a sauna. We all staggered a bit at the heat, even at this early hour the air was saturated with thick humidity and almost hot to the touch. We weren't used to this at all.
The driver took us to a base of operations about 20 minutes away. It was obvious when we had arrived at our destination: idling ambulances lined the streets for blocks surrounding the building, which sat aglow from generator-powered overhead lights. There were hundreds of cardboard boxes filled with supplies in neat stacks at various locations outside of the building, and workers walked quickly from pile to pile with clipboards and packages like worker ants sprawling the terrain. The place was alive, and everyone was busy.
We got a quick briefing from one of our administrators, who had taken an earlier flight down. He was sweaty and looked tired already, having spent a number of hours preparing hundreds of brand new Nextel phones. Sitting back from his work for a moment, he informed us that we didn't know when we would be moving out, but it would probably be in a few hours. The main base of operations was at Kelly Air Force base, an hour away, where we would receive further instructions. Until then, he said, we should grab a spot on the floor and try and get some sleep. On the floor? It was concrete with a thin carpet, but we were exhausted. I bunched up a sweatshirt for a pillow and was asleep within minutes.
It was a consistent theme throughout our deployment that information would be both set at a premium and low in supply. From nights on the floor to travel arrangements that changed as sure as hours passed, it seemed rare that our group heard about plans that would actually occur, reliable news about the hurricane's path, or informed truth about large-scale decisions. We were all used to working small-scale: champions of the backs of our ambulances and the source of decisions to be made on scenes. The patient laid out before us in clear presentation of the problem at hand. It was strikingly clear on our first night of this deployment, though, that we would not be experiencing the familiar. Our view was instead from the bottom-up, clouded by rumor and indirect contact with the management, and while we listened and obeyed, the decisions brought down made little sense to us other than that they came from authority who presumably knew better. Uninformed, we entrusted ourselves to the greater machine and blindly did as we were told.
We were awoken twice in the middle of the night from our snoring slumber, asked to perform a few minor tasks, and then let back to bed. Later in the day we were brought to the air force base, packed 6 deep in the back of a modular ambulance along with piles of suitcases. It was sweltering hot, and we sat quietly as the loaded ambulance labored through unfamiliar streets. We all remained in good spirits though, uncomfortable but inspired by the magnitude and meaning of our presence.
We arrived on the outskirts of the base, greeted by an incredible view of ambulances that had already arrived. They stretched off in the distance to vanish points, row after row. I have never seen so many ambulances together in once place. It was difficult to appreciate the view through my camera lens, but I made an effort:
After a brief wait at the staging point, we were brought by bus to another section at the base where we were to stay. It was an extremely large multi-purpose building, expansive on the inside with carpeted concrete floors and pillars spread out in grid fashion. We were given fold-out cots and a blanket, and told to settle down where we liked. Our group picked a spot in the corner, adding a margin of privacy by stacking the cardboard cot boxes in a makeshift wall in front of us. Many others followed suit as they arrived, and in a number of hours the building was a maze of sleeping EMS workers, cots, boxes, and tables.
It was here where we spent the rest of our deployment. We were there for two days, waiting on instructions to move south that never came. FEMA supplied the some 700 EMS workers who responded with ample sleeping supplies, hygiene kits, and food. Information remained spotty and often incorrect, while rumors were constantly passed from camp to camp about what our fates might be. At night when the lights were turned down, flipped-open cell phones were visible across the room like stars as workers searched the internet and friends for updates on the storm's path. We played cards, watched DVDs on laptops, and slept as much as possible.
While we waited, the storm crept onward towards Mexico, never swinging north as so many had feared. Word was passed around about the diminishing storm categories, from five to four to three to one.
On Wednesday a large group circled around the center of the room to hear news of our dismissal. Representatives from FEMA and Texas thanked us for our response and apologized for our inconvenience, giving the official word that we could all go home. Everyone clapped, a bit disappointed for the lack of action but ready to leave.
Our group left in a caravan of ambulances at 0500, ready for the 15 hour trip from San Antonio to Gulfport MS. It must have been a sight to see our 18 ambulances rolling down the road, filled with EMTs and Paramedics unshaven and exhausted looking. We emptied our fuel tanks twice, each time gathering at truck stops and joking around, taking photos of our group in front of ambulances that used to be part of our own divisions. Some people were extremely frustrated with the situation, becoming loudly vocal about their discontent from time to time. One group from another division taped signs to the back of their ambulances reading "Lied 2" and "Corporate Puppet" in lieu of our missing license plates. Most of us rolled our eyes at the complaints, though, and the experienced members of our group commented that such frustrations were absolutely typical of large operations like this one. The time-honored military motto of "hurry up and wait" was mentioned often, and despite the frequent frustrations, most of us remained in good spirits.
Towards the end of the drive we crossed through New Orleans and the surrounding areas affected by hurricane Katrina. I had never been there before, but was shocked to see how much of the damage still lingered even as viewed from the highway. We passed countless homes that remained crushed and broken, roofs folded in and windows smashed. I rode with a medic who was in this area for the storm, and he pointed to the left and right as we drove through, talking about where the water was and what the terrain looked like then. We drove over a large overpass which he said was almost taken over completely by the onrushing waters. Looking over the now dry and damaged terrain, it was difficult to imagine the forces that caused so much wreckage.
Many of us, myself included, were at least in some small way disappointed that Hurricane Dean stayed so far south. We wanted at least a little bit of "action," and wanted to charge into broken areas and work. Seeing this destruction, though, firmly grounded us. The extent of what a hurricane can do was never palpably clear to us, and realizing what disaster was avoided, all we could do was thank god nothing like this happened again.
We took flights the next morning out of the south and back home. On the way we discussed FEMA and the response, whether we would come back on the next deployment. Just about all of us said we would. Though the hurricane did not hit US land, this was in effect the largest drill FEMA has ever conducted, and with the experience under our collective belts, we each look forward to coming back and doing it better- next time.
Sunday, August 19, 2007
Dean
Hey folks, sorry its been a while since I've posted, but it is going to be even longer now. I got word last night several people from my company including myself are getting deployed to Texas to help out with the potential aftermath of hurricane Dean. It is still unknown whether it will actually hit Texas, or what kind of damage it will cause if it does, but FEMA is trying to get us down there ahead of time, and my flight leaves today at 3:00 for Atlanta.
I'll return with lots of photos and stories.
I'll return with lots of photos and stories.
Monday, July 30, 2007
Protocol in the Pits
In addition to the city, the company I work for has a contract with a large music venue nearby, and employees often get the opportunity to do "standbys" at the various acts that come through town. I picked up one of those shifts recently, a large rock concert consisting of multiple bands over the course of the day. Concerts like this are always a little bit crazy, packed with people fueled with alcohol and drugs, spurred along by the music into what often becomes a violent frenzy. This time was no exception.
It is a large venue, but people pack the place so tight that it is often hard to move. We carried portable radios on our shoulders turned up to maximum volume, but it was still difficult to hear the various dispatches over the guitars and yelling. Sometimes you would know to listen to the radio only because your partner had heard it by chance, and we would see eachother, head titled to the radio and hands cupping the speaker: hoping to hear. Eventually we would catch the dispatch, hearing a crackled "section 800, man down" before we would start moving.
Every response carried with it a little bit more adrenaline than usual. We pushed our ways through the crowd, yelling "move! move! make a hole!" as loud as we could. People would turn towards us with a little bit of "who do you think you are" look on their face, and then recognize, moving out of the way as quickly as possible. Sometimes people would take it upon themselves to charge ahead of us, clearing the way bully-fashion in a spontaneous effort of layman heroism. Each time they would smile at us, satisfied, and thank us for doing our job. We thanked them, too.
We carried a lot of people out of the crowds. A lot of people too drunk to stand, vomiting or passed-out, unresponsive or only slightly so. They open their eyes lazily to reveal hugely dilated pupils, often denying having a single drink all day. "Nah man," one patient slurred. "I've been straight all day. I dont drink. Much. I only had twelve." It was impressive. Beers were going for seven fifty apiece.
There was lot of trauma, too. Mosh pits would form along the edges of the cheaper seats, large circles where hyped-up fans ran around aimlessly, pushing and slamming into eachother as hard as they could. We stood and watched for a while as people would run into to the pits for 15 minutes, returning with cuts on their faces and bruises on the arms: smiling like crazy. There are unwritten rules about mosh pits, I learned. If someone falls down, everyone helps pick him up. You dont hit in the face and you dont throw punches or kicks. It is not about fighting, I was told, it's an organized expression of anger and rebellion to go along with the music. Sometimes there were fights though, and we would watch till they ended, carrying out those injured on wheelchairs or stretchers with c-spine equipment.
We were watching one of the bigger bands play when we were dispatched to another "man down" in the middle of the theater. This was probably our 10th of these dispatches, but we charged at it with energy nonetheless, pushing through the packed crowd to find our patient. We found him, in the center of a clearing of onlooking people, slumped on the ground and not moving. Two other crews, having heard the dispatch, showed up as well. We ask if anyone saw what happened, and someone stepped forward to tell us that he was crowd surfing and dropped "right on his head." He hasn't moved since.
We send someone to get the stretcher and c-spine equipment, which was stashed nearby. Someone grabs manual c-spine. I get on my knees in the muddy grass and lean down towards the patient's face, and he opens his eyes when I yell to him over the music. He seems a little lethargic, but is able to answer my questions slowly as he fights back tears. He is maybe 20 years old. His back hurts. He doesn't remember what happened. We get what information we can, and when the stretcher arrives we board and collar him, strapping him tightly to the rigid equipment. Again we push through the crowd, this time towards a waiting ambulance. On the way the patient wont open his eyes. I brush his eyelids lightly and see no response at all. My partner puts his hand on the guys chest to check for breathing, giving me a worried look. He is breathing, but completely unresponsive. We move a little faster.
We pass the patient to the waiting ambulance and we give our reports. We don't know much. We tell the story relayed from the witnesses, the patient's name and age that we got from a friend, and admit that we couldn't do very much of an assessment in there. Too loud, too chaotic. The receiving crew thanks us, hopping into the back of the ambulance to do their work. We grab their stretcher in return and head back into the crowds to find more patients.
We took out twenty-two that day.
With all the excitement and bustle of the concert, traumas run and drunks shuttled, everything seemed to settle down for the last few main acts. It was as if everyone took a deep breath and admitted that this is what they came to see, and there would be no more foolishness. We didn't take anyone else out after that point. Instead we settled down, as close to the stage as possible, and watched the last of the show.
We had great seats.
**
At the end of the shift we returned to the main office, sweaty, exhausted, and covered in mud. We exchanged stories from the day. There were a lot of amusing drunks, and angry ones too. One of my friends got punched directly in the face by a patient while he was transporting to the hospital. He said he saw stars, and then jumped on the guy with the help of another crew to restrain him.
I met up with the crew that took our crowd-surfing injury. The paramedic frowned as I asked him about it. "The guy had no neuros below the waist," he said. "The doc in the trauma room said that there was a T-9 fracture and that it looked pretty bad." The patient was intubated in the ER and taken upstairs. "They weren't sure, but the docs were pretty pessimistic that the kid would get anything back as far as motor control."
I was shocked. What? A spinal fracture with life-altering neuro damage? The kid was just one of many, a repeat of a ton of calls that we did that day: routine in both mechanism of injury and treatment provided. We did a good job protecting the spine, but only because we did that for everyone, routinely.
Retrospect is an amazing thing, but it felt good to look back and know that we all rested firmly on protocol, and followed the guidelines where they mattered most. Our treatment was solid, backed by everyday caution and routine methods. We did the right thing for this patient despite the fact that we had no idea how important those things would turn out to be. A little bit scary, but I guess that is what protocol is for.
I looked through the schedule when we got back, and signed up for another concert later in the summer. What a shift.
It is a large venue, but people pack the place so tight that it is often hard to move. We carried portable radios on our shoulders turned up to maximum volume, but it was still difficult to hear the various dispatches over the guitars and yelling. Sometimes you would know to listen to the radio only because your partner had heard it by chance, and we would see eachother, head titled to the radio and hands cupping the speaker: hoping to hear. Eventually we would catch the dispatch, hearing a crackled "section 800, man down" before we would start moving.
Every response carried with it a little bit more adrenaline than usual. We pushed our ways through the crowd, yelling "move! move! make a hole!" as loud as we could. People would turn towards us with a little bit of "who do you think you are" look on their face, and then recognize, moving out of the way as quickly as possible. Sometimes people would take it upon themselves to charge ahead of us, clearing the way bully-fashion in a spontaneous effort of layman heroism. Each time they would smile at us, satisfied, and thank us for doing our job. We thanked them, too.
We carried a lot of people out of the crowds. A lot of people too drunk to stand, vomiting or passed-out, unresponsive or only slightly so. They open their eyes lazily to reveal hugely dilated pupils, often denying having a single drink all day. "Nah man," one patient slurred. "I've been straight all day. I dont drink. Much. I only had twelve." It was impressive. Beers were going for seven fifty apiece.
There was lot of trauma, too. Mosh pits would form along the edges of the cheaper seats, large circles where hyped-up fans ran around aimlessly, pushing and slamming into eachother as hard as they could. We stood and watched for a while as people would run into to the pits for 15 minutes, returning with cuts on their faces and bruises on the arms: smiling like crazy. There are unwritten rules about mosh pits, I learned. If someone falls down, everyone helps pick him up. You dont hit in the face and you dont throw punches or kicks. It is not about fighting, I was told, it's an organized expression of anger and rebellion to go along with the music. Sometimes there were fights though, and we would watch till they ended, carrying out those injured on wheelchairs or stretchers with c-spine equipment.
We were watching one of the bigger bands play when we were dispatched to another "man down" in the middle of the theater. This was probably our 10th of these dispatches, but we charged at it with energy nonetheless, pushing through the packed crowd to find our patient. We found him, in the center of a clearing of onlooking people, slumped on the ground and not moving. Two other crews, having heard the dispatch, showed up as well. We ask if anyone saw what happened, and someone stepped forward to tell us that he was crowd surfing and dropped "right on his head." He hasn't moved since.
We send someone to get the stretcher and c-spine equipment, which was stashed nearby. Someone grabs manual c-spine. I get on my knees in the muddy grass and lean down towards the patient's face, and he opens his eyes when I yell to him over the music. He seems a little lethargic, but is able to answer my questions slowly as he fights back tears. He is maybe 20 years old. His back hurts. He doesn't remember what happened. We get what information we can, and when the stretcher arrives we board and collar him, strapping him tightly to the rigid equipment. Again we push through the crowd, this time towards a waiting ambulance. On the way the patient wont open his eyes. I brush his eyelids lightly and see no response at all. My partner puts his hand on the guys chest to check for breathing, giving me a worried look. He is breathing, but completely unresponsive. We move a little faster.
We pass the patient to the waiting ambulance and we give our reports. We don't know much. We tell the story relayed from the witnesses, the patient's name and age that we got from a friend, and admit that we couldn't do very much of an assessment in there. Too loud, too chaotic. The receiving crew thanks us, hopping into the back of the ambulance to do their work. We grab their stretcher in return and head back into the crowds to find more patients.
We took out twenty-two that day.
With all the excitement and bustle of the concert, traumas run and drunks shuttled, everything seemed to settle down for the last few main acts. It was as if everyone took a deep breath and admitted that this is what they came to see, and there would be no more foolishness. We didn't take anyone else out after that point. Instead we settled down, as close to the stage as possible, and watched the last of the show.
We had great seats.
**
At the end of the shift we returned to the main office, sweaty, exhausted, and covered in mud. We exchanged stories from the day. There were a lot of amusing drunks, and angry ones too. One of my friends got punched directly in the face by a patient while he was transporting to the hospital. He said he saw stars, and then jumped on the guy with the help of another crew to restrain him.
I met up with the crew that took our crowd-surfing injury. The paramedic frowned as I asked him about it. "The guy had no neuros below the waist," he said. "The doc in the trauma room said that there was a T-9 fracture and that it looked pretty bad." The patient was intubated in the ER and taken upstairs. "They weren't sure, but the docs were pretty pessimistic that the kid would get anything back as far as motor control."
I was shocked. What? A spinal fracture with life-altering neuro damage? The kid was just one of many, a repeat of a ton of calls that we did that day: routine in both mechanism of injury and treatment provided. We did a good job protecting the spine, but only because we did that for everyone, routinely.
Retrospect is an amazing thing, but it felt good to look back and know that we all rested firmly on protocol, and followed the guidelines where they mattered most. Our treatment was solid, backed by everyday caution and routine methods. We did the right thing for this patient despite the fact that we had no idea how important those things would turn out to be. A little bit scary, but I guess that is what protocol is for.
I looked through the schedule when we got back, and signed up for another concert later in the summer. What a shift.
Thursday, July 26, 2007
Restraint
"Second unit in, for a psych??"
My partner was incredulous. What a ridiculous call. This facility always has a ton of psychs in it, it's like a nest where they are all kept. They are always fighting with eachother, halfway trying to kill themselves, or looking for attention. To tie up two ambulances on a call like this seemed like such a waste, and we both thought about all of the better things we could have been doing on our lights + sirens response to the address. Surely someone, somewhere in the city was having a heart attack (or something!) and would be denied our help because of this.
We followed the other crew up the stairs and down the hallways, alternating between grumbles and jokes. Directed down another hallway by staff members, we could begin to hear the chaotic scene. A man lay on the floor, prone, with a knee of a police officer square in his back. Two staff members were sitting on his legs, while another tried in vain to hold the patient's head as he thrashed from side to side, screaming, crying, and spitting.
He has a history of outbursts, a staff member tells me. The paperwork read MR, and "Intermittent Explosive Disorder." He got in an altercation with another resident over the amount of cheese that was added to their midday meal, and things have been downhill since. They gave 5 of Haldol and 2 of Ativan about 40 minutes ago and it hasn't made a bit of difference.
I'll say. The room was destroyed. The pile of bodies lay in the center of the room, surrounded by a ring of chairs, tables, and lunch trays that look as if they were ejected circumferentially from some sort of uncontrolled explosion. Everyone looked a bit exhausted, and the cops, sweaty, looked at me with a hint of a pleading expression on their faces. Salvation, in the form of a paramedic. They have come to take this one away!
We pulled the stretcher up beside the patient, and tried to devise a plan to get him onto it. We would all lift at once, each person responsible for a limb. We'll get him up and over, then bring the sheet across his torso and over his arms. The staff warns us: watch out for spitting, kicking, biting, pinching... the works. The patient is looking a little calmer now, though, so we are sure it can be done. Up and over he goes, one swift and smooth motion. He lands on the stretcher with a little bounce and smiles.
...And then he frowns. He jerks his arms suddenly and thrashes about on the stretcher, which sways dangerously from left to right. He is able to get one arm free, and starts clawing at one of the other staff members who pulls back in fear of getting hurt. Another leg free. One of the police officers grabs his shoulders and pins him down, while another attempts to regain control of the free arm. I am too close and he reaches towards me, talons out. He scratches my forehead once before I can get him back under control, drawing a bit of blood. God dammit.
We tie him down, limb by limb, but he continues to fight. He keeps finding one way or another wriggle and cause trouble: first banging his head against the metal stretcher frame, then scratching at his own skin wherever he can reach. He strains and stresses against the bounds, arching his body upward and screaming. The staff look at us with sympathy. They've been through this before, they say.
I decide to chemically restrain him. We cant transport him like this, we all agree, and he is going to hurt himself if he finds a way to manage it. I kneel down and open up my pack. Our protocols allow for 5 milligrams of Haldol combined with 2 milligrams Ativan, mixed in the same syringe and administered IM. It takes me a few minutes to draw the drugs up, and the gelatinous Ativan is giving me a little bit of trouble.
In walks the patient's doctor. He demands to know what is going on, asking for the whole story and expecting us all to stop and explain it to him. I have the staff members explain to him while I finish drawing up the drugs, but he stops me before I am able to administer them. He wants to know exactly what I am giving him, where I am giving it, and if I have called a doctor for orders. He had heard from the other nurses that the patient already got sedatives about an hour ago, and seems shocked that I would consider giving the patient another round.
"How about you just do one of Ativan," he says. "We don't want him to stop breathing, do we?"
His voice is as condescending as it is demanding, and I am a little taken aback as I sit there holding the uncapped syringe. I explain to him that I have Haldol and Ativan in the same syringe, and that this is standard procedure. I express doubt that 4 milligrams of benzodiazepine, administered IM over the course of an hour will really cause anyone of this size to stop breathing. I relent, though. How about I just give him half of the syringe. About 2.5 Haldol, 1 Ativan. The doc agrees and, in a bit of a huff, leaves the room. I feel a bit embarrassed. Taken down a notch.
In goes the drug and we wheel the patient to the ambulance. He fights and claws the whole time, screaming like a teradoctyl and searching for ways to hurt himself or others. The elevator is small, and we all press our bodies against the walls so to add the necessary free space.
In the back of the ambulance I get the patient on the monitor as best I can. The patient is tied down but he bucks and fights each of our attempts. If a wire is near his hand, he will grab and pull. I get a set of vital signs, and put the patient on end tidal capinography along with a face mask to prevent spitting. He is sinus tachy at 120 or so, pressure 130/70 and all looks well. I look at my partner, exasperated. Let's just go.
5 minutes into the transport I notice that the ETCO2 is no longer reading. The apnea alarm goes off, but a quick glance at the patient and he is obviously breathing. Must be the sensor is displaced. I lift off the face mask to readjust, and find that the patient is attempting to eat the sensor. He has it, a lot of it, in his mouth, and is pulling in more each second like a long strand of spaghetti. He is chomping and chewing, staring at me vindictively with each motion of his jaw. I grab one end of the tubing and give a tug. "Give that back! Let go!" He vehemently shakes his head, refusing with clenched teeth. He will NOT give it up. I try a little more, but I don't want to pull too hard on the tubing and break it, losing it entirely to the patient's gaping maw.
I sit back for a second, tired and sweaty as I watch him chew. The apnea alarm goes off again. Fuck this, I think. I reach into my breast pocket where I still have the drawn up meds. In go the rest. The patient lets out a yep as I sink the needle into his muscle, and at the same time I yank the mangled tubing from his mouth. Win-win.
He fights more on the rest of the trip. I sit back at the end of the bench, watching him and the monitor. I try to straighten my uniform out but it is no use. His aggressive activity wanes slowly, and by the time we arrive at the hospital he is resting comfortably, half asleep on the stretcher. He asks me for a pillow for his head and I give it to him.
We roll into the ED triage looking like we're returning from battle. Our uniforms are disheveled and sweaty, hair mussed and composure wrecked. The patient naps pleasantly on the stretcher, as comfortable and content as could be. The nurse looks at us, smirking a little. She heard our patch asking for security at the door.
"All that, for this little guy? He's sleeping like an angel!"
My partner was incredulous. What a ridiculous call. This facility always has a ton of psychs in it, it's like a nest where they are all kept. They are always fighting with eachother, halfway trying to kill themselves, or looking for attention. To tie up two ambulances on a call like this seemed like such a waste, and we both thought about all of the better things we could have been doing on our lights + sirens response to the address. Surely someone, somewhere in the city was having a heart attack (or something!) and would be denied our help because of this.
We followed the other crew up the stairs and down the hallways, alternating between grumbles and jokes. Directed down another hallway by staff members, we could begin to hear the chaotic scene. A man lay on the floor, prone, with a knee of a police officer square in his back. Two staff members were sitting on his legs, while another tried in vain to hold the patient's head as he thrashed from side to side, screaming, crying, and spitting.
He has a history of outbursts, a staff member tells me. The paperwork read MR, and "Intermittent Explosive Disorder." He got in an altercation with another resident over the amount of cheese that was added to their midday meal, and things have been downhill since. They gave 5 of Haldol and 2 of Ativan about 40 minutes ago and it hasn't made a bit of difference.
I'll say. The room was destroyed. The pile of bodies lay in the center of the room, surrounded by a ring of chairs, tables, and lunch trays that look as if they were ejected circumferentially from some sort of uncontrolled explosion. Everyone looked a bit exhausted, and the cops, sweaty, looked at me with a hint of a pleading expression on their faces. Salvation, in the form of a paramedic. They have come to take this one away!
We pulled the stretcher up beside the patient, and tried to devise a plan to get him onto it. We would all lift at once, each person responsible for a limb. We'll get him up and over, then bring the sheet across his torso and over his arms. The staff warns us: watch out for spitting, kicking, biting, pinching... the works. The patient is looking a little calmer now, though, so we are sure it can be done. Up and over he goes, one swift and smooth motion. He lands on the stretcher with a little bounce and smiles.
...And then he frowns. He jerks his arms suddenly and thrashes about on the stretcher, which sways dangerously from left to right. He is able to get one arm free, and starts clawing at one of the other staff members who pulls back in fear of getting hurt. Another leg free. One of the police officers grabs his shoulders and pins him down, while another attempts to regain control of the free arm. I am too close and he reaches towards me, talons out. He scratches my forehead once before I can get him back under control, drawing a bit of blood. God dammit.
We tie him down, limb by limb, but he continues to fight. He keeps finding one way or another wriggle and cause trouble: first banging his head against the metal stretcher frame, then scratching at his own skin wherever he can reach. He strains and stresses against the bounds, arching his body upward and screaming. The staff look at us with sympathy. They've been through this before, they say.
I decide to chemically restrain him. We cant transport him like this, we all agree, and he is going to hurt himself if he finds a way to manage it. I kneel down and open up my pack. Our protocols allow for 5 milligrams of Haldol combined with 2 milligrams Ativan, mixed in the same syringe and administered IM. It takes me a few minutes to draw the drugs up, and the gelatinous Ativan is giving me a little bit of trouble.
In walks the patient's doctor. He demands to know what is going on, asking for the whole story and expecting us all to stop and explain it to him. I have the staff members explain to him while I finish drawing up the drugs, but he stops me before I am able to administer them. He wants to know exactly what I am giving him, where I am giving it, and if I have called a doctor for orders. He had heard from the other nurses that the patient already got sedatives about an hour ago, and seems shocked that I would consider giving the patient another round.
"How about you just do one of Ativan," he says. "We don't want him to stop breathing, do we?"
His voice is as condescending as it is demanding, and I am a little taken aback as I sit there holding the uncapped syringe. I explain to him that I have Haldol and Ativan in the same syringe, and that this is standard procedure. I express doubt that 4 milligrams of benzodiazepine, administered IM over the course of an hour will really cause anyone of this size to stop breathing. I relent, though. How about I just give him half of the syringe. About 2.5 Haldol, 1 Ativan. The doc agrees and, in a bit of a huff, leaves the room. I feel a bit embarrassed. Taken down a notch.
In goes the drug and we wheel the patient to the ambulance. He fights and claws the whole time, screaming like a teradoctyl and searching for ways to hurt himself or others. The elevator is small, and we all press our bodies against the walls so to add the necessary free space.
In the back of the ambulance I get the patient on the monitor as best I can. The patient is tied down but he bucks and fights each of our attempts. If a wire is near his hand, he will grab and pull. I get a set of vital signs, and put the patient on end tidal capinography along with a face mask to prevent spitting. He is sinus tachy at 120 or so, pressure 130/70 and all looks well. I look at my partner, exasperated. Let's just go.
5 minutes into the transport I notice that the ETCO2 is no longer reading. The apnea alarm goes off, but a quick glance at the patient and he is obviously breathing. Must be the sensor is displaced. I lift off the face mask to readjust, and find that the patient is attempting to eat the sensor. He has it, a lot of it, in his mouth, and is pulling in more each second like a long strand of spaghetti. He is chomping and chewing, staring at me vindictively with each motion of his jaw. I grab one end of the tubing and give a tug. "Give that back! Let go!" He vehemently shakes his head, refusing with clenched teeth. He will NOT give it up. I try a little more, but I don't want to pull too hard on the tubing and break it, losing it entirely to the patient's gaping maw.
I sit back for a second, tired and sweaty as I watch him chew. The apnea alarm goes off again. Fuck this, I think. I reach into my breast pocket where I still have the drawn up meds. In go the rest. The patient lets out a yep as I sink the needle into his muscle, and at the same time I yank the mangled tubing from his mouth. Win-win.
He fights more on the rest of the trip. I sit back at the end of the bench, watching him and the monitor. I try to straighten my uniform out but it is no use. His aggressive activity wanes slowly, and by the time we arrive at the hospital he is resting comfortably, half asleep on the stretcher. He asks me for a pillow for his head and I give it to him.
We roll into the ED triage looking like we're returning from battle. Our uniforms are disheveled and sweaty, hair mussed and composure wrecked. The patient naps pleasantly on the stretcher, as comfortable and content as could be. The nurse looks at us, smirking a little. She heard our patch asking for security at the door.
"All that, for this little guy? He's sleeping like an angel!"
Tuesday, July 17, 2007
Justifications
In many ways I feel like a blank slate.
I've spent a lot of time in class, in clinical rotations and in the back of the ambulance. I've read thousands of pages of text on these subjects, and experienced real-life successes and failures that have left indelible marks on my character. Constant newfound knowledge makes me a new person every day, though, and each time I get dressed in my uniform I feel as if my plate is again clean: ready for another helping of experience. What will the next day bring to the table?
The same is true with my coworkers. It is very rarely left to doubt that I am the "new guy," and my opinion - if I venture to submit it - is often challenged simply because I am inexperienced. My slate is clean then, too, and a reputation is ready to be built on what choices I make and how well I am able to defend them. More than once I have had to push harder than I normally would, so that a conversation does not end on dismissive point that I am a new medic. I readily admit my inexperience, but I feel a need to stand by my choices and fiercely support them with the academic knowledge that originally inspired them. There is sometimes an understated aggression, passive in it's delivery but pointed in meaning. It is not my nature, truly, but I have felt a need lately to be my own person, and fight battles in order to establish myself as someone worth fighting with.
On scene, too. Will I be the first through the door or the second? I have become conscious lately of which end of the stretcher I stand on. I want to make sure that I am there, with eye contact, when the first responder is going to give his report. I ask the first question, and answer the patient's first as well. I have been consciously thinking about ways to maintain control on scene: the delicate balance between utility and overbearing micromanagement. I still sometimes take the submissive role by habit, though, and find myself setting up equipment when I should be doing medicine. How I handle myself on scene is part of who I will become as a paramedic, and I am often aware the choice between which habits I will choose to acquire.
I have worked a long time to earn the right to wear this patch on my shoulder. I am finding, though, that there is much more than title. Once this becomes normal, once people become used to seeing "paramedic" under my name, my reputation will again come to rest on my character, my knowledge, and how I choose to carry myself.
The title means nothing without justification for it. I have a lot to learn still, not the least of which is figuring out exactly how I will fill this uniform.
I've spent a lot of time in class, in clinical rotations and in the back of the ambulance. I've read thousands of pages of text on these subjects, and experienced real-life successes and failures that have left indelible marks on my character. Constant newfound knowledge makes me a new person every day, though, and each time I get dressed in my uniform I feel as if my plate is again clean: ready for another helping of experience. What will the next day bring to the table?
The same is true with my coworkers. It is very rarely left to doubt that I am the "new guy," and my opinion - if I venture to submit it - is often challenged simply because I am inexperienced. My slate is clean then, too, and a reputation is ready to be built on what choices I make and how well I am able to defend them. More than once I have had to push harder than I normally would, so that a conversation does not end on dismissive point that I am a new medic. I readily admit my inexperience, but I feel a need to stand by my choices and fiercely support them with the academic knowledge that originally inspired them. There is sometimes an understated aggression, passive in it's delivery but pointed in meaning. It is not my nature, truly, but I have felt a need lately to be my own person, and fight battles in order to establish myself as someone worth fighting with.
On scene, too. Will I be the first through the door or the second? I have become conscious lately of which end of the stretcher I stand on. I want to make sure that I am there, with eye contact, when the first responder is going to give his report. I ask the first question, and answer the patient's first as well. I have been consciously thinking about ways to maintain control on scene: the delicate balance between utility and overbearing micromanagement. I still sometimes take the submissive role by habit, though, and find myself setting up equipment when I should be doing medicine. How I handle myself on scene is part of who I will become as a paramedic, and I am often aware the choice between which habits I will choose to acquire.
I have worked a long time to earn the right to wear this patch on my shoulder. I am finding, though, that there is much more than title. Once this becomes normal, once people become used to seeing "paramedic" under my name, my reputation will again come to rest on my character, my knowledge, and how I choose to carry myself.
The title means nothing without justification for it. I have a lot to learn still, not the least of which is figuring out exactly how I will fill this uniform.
Thursday, July 12, 2007
Ischemic and Uninformed
The man smiles at me with that kind of nervous smile: half appreciative, half terrified. He was cordial and perfectly polite, laughing at his jokes and ours, but the sound was unnatural. Forced.
The doctor takes me aside.
"This guy has had chest pain for a week. Can you believe that? A whole week!"
The doc explains to me that the man felt a sudden onset of crushing chest pain along with shortness of breath as he attempted his normal exercise routine last Friday. Since then, he has had transient periods of dyspnea and chest "pressures," especially when he exerts himself. The doctor shows me the EKG with flipped T waves in the lateral leads. On the next page of the report are the lab results, and the Troponin levels are clearly elevated. The doc casually rattles off the rest of the man's risk factors. Smoker. Positive family history. Obese. History of hypertension. History of high cholesterol.
"We're sending him to Hospital Z," the doc says. "I think he's gonna need a stent."
We walk back to the patient's room, where my partner is getting the patient ready for the transport. The doctor chastises the man for waiting so long.
"Next time you come to the hospital right away, okay? This kind of thing can kill you. Seriously, kill you. Its not to be taken lightly. Understand?"
The man stammers, letting out a shuddering "okkkkay" as the doctor leaves the room.
I smile at the man, hoping to ease the tension. "Let's get ya all unhooked here so we can get you on our equipment." I make jokes about the wires. There are too many, too long. They're just for show, to be honest. The man cracks another nervous laugh but it is plain that he is preoccupied and afraid. I cant blame him. Textbook presentation for cardiac disease, EKG changes, and elevated enzymes? Its a scary picture.
We hook up our gear and roll the man into the back of the ambulance. I burn off a quick 12 lead for our records.
The man watches me as I read over the EKG. He clears his throat and asks me how it looks. I explain that it seems pretty much the same as the EKG they did in the emergency room.
"You've still got a little bit of an issue on the left side of your heart here, but it doesn't look too bad just yet."
The man seems to be clinging to my every word as he looks at me with wide eyes, and I pause for a moment.
"Have they explained any of this to you?"
The man put his head down.
"Not really. They're so busy in there I didn't want to trouble the doctor with too many questions. Everything was moving so quickly. They said that they're going to try and open up an artery or something?"
I am amazed. How is it that a man could come in to an emergency department, be found to have a serious cardiac issue, and wait till he was on his way to surgery before he begins to understand what is happening? The man sat patiently in that department for at least an hour, sitting quietly through the tests and exams, as EKG wires were plugged together and discussions between doctors occurred just out of earshot. All the while, in the dark.
He picked up on the tone, though, and it wasn't good. He tells me that more than once he was spoken to about "coming to the emergency room earlier," and that he shouldn't have waited a week. He knew that there was something wrong with his heart, but not exactly what, where, what it means, or what exactly could be done about it.
I lean forward from the bench and show him the pink printout. I point to the lines on the paper, explaining that some are going down when they should be going up. I pull out his old EKGs from the file so he can compare, explaining the difference between ischemia and infarct in layman's terms. "Its almost as if your heart is short of breath, and is getting bruised up because of it," I explain. "...But the danger is that it can get worse, to the point where it cant be helped." We talk about vessels closing and opening, about supply and demand.
He asks me questions. Lots of them.
"If a part of my heart dies, will it grow back?"
"Does this mean that I wont be able to get up and do things anymore?"
"What are they going to do to me at the Hospital? Will I be awake the whole time?"
"Is any of my heart already dead?"
I answer each question in turn, using basic language that I hope the man fully understands. He clarifies what he doesn't, and listens intently to my replies. We spend the entire trip to the hospital talking about cardiac physiology, treatment modalities, and prognosis. I exhaust my knowledge upon him, and when I get to the end, I remind him to ask his doctor when we get to the hospital.
I tell the man: this is your heart, and these are your decisions. You have a right to know about what is going on, and nobody can do anything without your permission. Do not be afraid to ask questions. Insist that you are informed, and advocate for yourself as much as you are able to. It may not seem like it, but you are in charge.
I left the man on his new ED bed with a firm handshake, and he thanked me with an emphasis that echoed through me for the rest of the week. I truly made a difference in this man's day, helping him through a difficult time with academic knowledge, patience, and a caring tone.
It was easily the most satisfying thing that I've done as a paramedic so far.
The doctor takes me aside.
"This guy has had chest pain for a week. Can you believe that? A whole week!"
The doc explains to me that the man felt a sudden onset of crushing chest pain along with shortness of breath as he attempted his normal exercise routine last Friday. Since then, he has had transient periods of dyspnea and chest "pressures," especially when he exerts himself. The doctor shows me the EKG with flipped T waves in the lateral leads. On the next page of the report are the lab results, and the Troponin levels are clearly elevated. The doc casually rattles off the rest of the man's risk factors. Smoker. Positive family history. Obese. History of hypertension. History of high cholesterol.
"We're sending him to Hospital Z," the doc says. "I think he's gonna need a stent."
We walk back to the patient's room, where my partner is getting the patient ready for the transport. The doctor chastises the man for waiting so long.
"Next time you come to the hospital right away, okay? This kind of thing can kill you. Seriously, kill you. Its not to be taken lightly. Understand?"
The man stammers, letting out a shuddering "okkkkay" as the doctor leaves the room.
I smile at the man, hoping to ease the tension. "Let's get ya all unhooked here so we can get you on our equipment." I make jokes about the wires. There are too many, too long. They're just for show, to be honest. The man cracks another nervous laugh but it is plain that he is preoccupied and afraid. I cant blame him. Textbook presentation for cardiac disease, EKG changes, and elevated enzymes? Its a scary picture.
We hook up our gear and roll the man into the back of the ambulance. I burn off a quick 12 lead for our records.
The man watches me as I read over the EKG. He clears his throat and asks me how it looks. I explain that it seems pretty much the same as the EKG they did in the emergency room.
"You've still got a little bit of an issue on the left side of your heart here, but it doesn't look too bad just yet."
The man seems to be clinging to my every word as he looks at me with wide eyes, and I pause for a moment.
"Have they explained any of this to you?"
The man put his head down.
"Not really. They're so busy in there I didn't want to trouble the doctor with too many questions. Everything was moving so quickly. They said that they're going to try and open up an artery or something?"
I am amazed. How is it that a man could come in to an emergency department, be found to have a serious cardiac issue, and wait till he was on his way to surgery before he begins to understand what is happening? The man sat patiently in that department for at least an hour, sitting quietly through the tests and exams, as EKG wires were plugged together and discussions between doctors occurred just out of earshot. All the while, in the dark.
He picked up on the tone, though, and it wasn't good. He tells me that more than once he was spoken to about "coming to the emergency room earlier," and that he shouldn't have waited a week. He knew that there was something wrong with his heart, but not exactly what, where, what it means, or what exactly could be done about it.
I lean forward from the bench and show him the pink printout. I point to the lines on the paper, explaining that some are going down when they should be going up. I pull out his old EKGs from the file so he can compare, explaining the difference between ischemia and infarct in layman's terms. "Its almost as if your heart is short of breath, and is getting bruised up because of it," I explain. "...But the danger is that it can get worse, to the point where it cant be helped." We talk about vessels closing and opening, about supply and demand.
He asks me questions. Lots of them.
"If a part of my heart dies, will it grow back?"
"Does this mean that I wont be able to get up and do things anymore?"
"What are they going to do to me at the Hospital? Will I be awake the whole time?"
"Is any of my heart already dead?"
I answer each question in turn, using basic language that I hope the man fully understands. He clarifies what he doesn't, and listens intently to my replies. We spend the entire trip to the hospital talking about cardiac physiology, treatment modalities, and prognosis. I exhaust my knowledge upon him, and when I get to the end, I remind him to ask his doctor when we get to the hospital.
I tell the man: this is your heart, and these are your decisions. You have a right to know about what is going on, and nobody can do anything without your permission. Do not be afraid to ask questions. Insist that you are informed, and advocate for yourself as much as you are able to. It may not seem like it, but you are in charge.
I left the man on his new ED bed with a firm handshake, and he thanked me with an emphasis that echoed through me for the rest of the week. I truly made a difference in this man's day, helping him through a difficult time with academic knowledge, patience, and a caring tone.
It was easily the most satisfying thing that I've done as a paramedic so far.
Sunday, July 8, 2007
Tachy
Dispatch asked us to intercept with a BLS unit south of our location. They were headed towards us out of a quiet nearby town, and asked for paramedic help as soon as they saw their patient.
He was 45 years old, racked with disease for years that seemed to count double their time. The man looked 80, easialy. He was unresponsive with a glascow coma scale of 4, gaining only one point for his occasional incomprehensible moans. His body remained slack, absolutely still despite whatever stimuli we could deliver. I rubbed his sternum hard with my knuckles. Nothing.
Despite his calm demeanor, though, his body was a cataclysm of active turmoil. His respiratory rate was just shy of 50 breaths per minute, his heart counting 190 beats in the same time. None of us could get a blood pressure manually, and the automated machine spit "NIBP Timeout" back at me over and over again. I thought I could find a radial pulse, but maybe it was nothing. The pulse oximeter refused to read, and end-tidal CO2 returned a measly 10 mmHg.
I ask as many questions as I can think of, rapid fire as I try to get a sense of the story. The patient has a history of brain abscesses and has been declining over the past few weeks. The family told the EMTs that this has been his baseline mental status for the past week, and that they called 911 only because it seemed he was having trouble breathing. I am struck by the story. Unresponsive like this for a week? Really?
I get the EMTs to insert an oral airway and start assisting the man's breathing with a bag-valve mask while I do the rest of my assessment. The eyes have a dysconjugate gaze to the upper left, and pupils are sluggish to react at about 3 millimeters. Lung sounds are with bilateral rhonchi, but filling up adequately with each squeeze of the BVM's bag. The skin is warm and pink at the core but mottled and slightly cyanotic towards the extremities. Blood sugar is 146. A rapid trauma assessment is without significant finding. On goes the checklist while I start an IV. I plug together the monitor cables and get these in reply:
The man is in shock, crashing in front of my eyes but I cant pinpoint an exact cause. The eyes and mental status suggest a neuro event, although the vital signs defy the textbook Cushing's triad. ...And the family says the mental status is baseline. The 12 lead shows a significant tachycardia, and generalized ischemia across the man's heart. The blood pressure is too low to read. Sepsis? PE? I dont know.
I get the patent in trendelenburg and open up the IV, reviewing my options. I think about intubation, but we are 5 minutes from the hospital and the man is biting on the OPA. I dont think I have time, and the BVM has been pretty effective. Full, equal lung sounds and the end tidal CO2 is slowly coming back up as the EMT controls the man's runaway tachypenia.
Looking at the patient, and the monitor, I feel that I need to do something about the heart rate. The hypotension could very well be related to the tachycardia, and while it is possible that the heart rate could be compensatory for some unseen hypovolemia or otherwise, I doubt it. I remember from ACLS that heart rates over 150 are very rarely compensatory, and still, at this rate cardiac refilling time must be seriously hindering effective output.
We are 3 minutes from the hospital and I draw up adenosine. 6 milligrams, and a 10 cc normal saline flush behind it. I push print on the monitor and flush both syringes through the line. As we come to a stop in the ambulance bay I stare intently at the monitor.
No change whatsoever.
In the hospital they listen to my story with raised eyebrows. They are skeptical about the family's story too, but accept what I have to give them. The man is paralyzed and intubated, bloods drawn and x-rays taken. The team converges around the man, working intently as they pass lines and instructions to eachother. The man codes. Four times, resuscitated each time with jolts of electricity as I write my run form. When I return with paperwork the team is sweaty and tired. Empty boxes of epinephrine litter the floor. They are mixing up an epinephrine drip to maintain the blood pressure, and the doctors are calling more doctors to discuss what could possibly be wrong. Nobody knows yet.
**
It was a good call in many ways. There was a lot to do in a short amount of time, a complicated story to assimilate and an important treatment decision to make. It was a job to remain calm and focused, to get things right and make sure I didnt miss anything important.
I ran through the call with some of my coworkers, and there are always raised eyebrows around the time that I mention the adenosine. I know. I knew it then, too, but I felt that I had to do something about that heart rate in the face of the rest of the patient's presentation: and I stand firm that there was value in the choice both as a treatment and as a diagnostic tool. If it worked, great. If it didnt, a pathology eliminated.
I may or may not have been right. Maybe the heart rate was actually a compensating effort. Perhaps the rate was completely unrelated to the rest of the presentation. Maybe I should have focused instead on doing something else. I dont know, and as far as I've heard thus far- neither do the doctors. It is a little frustrating to not know, to remain in the dark after such a fervent effort.
I did my best though, and I stand by my decisions. In work where often nothing is certain, and choices must be made quickly and accurately based on experience and talent: I think that counts for something.
He was 45 years old, racked with disease for years that seemed to count double their time. The man looked 80, easialy. He was unresponsive with a glascow coma scale of 4, gaining only one point for his occasional incomprehensible moans. His body remained slack, absolutely still despite whatever stimuli we could deliver. I rubbed his sternum hard with my knuckles. Nothing.
Despite his calm demeanor, though, his body was a cataclysm of active turmoil. His respiratory rate was just shy of 50 breaths per minute, his heart counting 190 beats in the same time. None of us could get a blood pressure manually, and the automated machine spit "NIBP Timeout" back at me over and over again. I thought I could find a radial pulse, but maybe it was nothing. The pulse oximeter refused to read, and end-tidal CO2 returned a measly 10 mmHg.
I ask as many questions as I can think of, rapid fire as I try to get a sense of the story. The patient has a history of brain abscesses and has been declining over the past few weeks. The family told the EMTs that this has been his baseline mental status for the past week, and that they called 911 only because it seemed he was having trouble breathing. I am struck by the story. Unresponsive like this for a week? Really?
I get the EMTs to insert an oral airway and start assisting the man's breathing with a bag-valve mask while I do the rest of my assessment. The eyes have a dysconjugate gaze to the upper left, and pupils are sluggish to react at about 3 millimeters. Lung sounds are with bilateral rhonchi, but filling up adequately with each squeeze of the BVM's bag. The skin is warm and pink at the core but mottled and slightly cyanotic towards the extremities. Blood sugar is 146. A rapid trauma assessment is without significant finding. On goes the checklist while I start an IV. I plug together the monitor cables and get these in reply:
The man is in shock, crashing in front of my eyes but I cant pinpoint an exact cause. The eyes and mental status suggest a neuro event, although the vital signs defy the textbook Cushing's triad. ...And the family says the mental status is baseline. The 12 lead shows a significant tachycardia, and generalized ischemia across the man's heart. The blood pressure is too low to read. Sepsis? PE? I dont know.
I get the patent in trendelenburg and open up the IV, reviewing my options. I think about intubation, but we are 5 minutes from the hospital and the man is biting on the OPA. I dont think I have time, and the BVM has been pretty effective. Full, equal lung sounds and the end tidal CO2 is slowly coming back up as the EMT controls the man's runaway tachypenia.
Looking at the patient, and the monitor, I feel that I need to do something about the heart rate. The hypotension could very well be related to the tachycardia, and while it is possible that the heart rate could be compensatory for some unseen hypovolemia or otherwise, I doubt it. I remember from ACLS that heart rates over 150 are very rarely compensatory, and still, at this rate cardiac refilling time must be seriously hindering effective output.
We are 3 minutes from the hospital and I draw up adenosine. 6 milligrams, and a 10 cc normal saline flush behind it. I push print on the monitor and flush both syringes through the line. As we come to a stop in the ambulance bay I stare intently at the monitor.
No change whatsoever.
In the hospital they listen to my story with raised eyebrows. They are skeptical about the family's story too, but accept what I have to give them. The man is paralyzed and intubated, bloods drawn and x-rays taken. The team converges around the man, working intently as they pass lines and instructions to eachother. The man codes. Four times, resuscitated each time with jolts of electricity as I write my run form. When I return with paperwork the team is sweaty and tired. Empty boxes of epinephrine litter the floor. They are mixing up an epinephrine drip to maintain the blood pressure, and the doctors are calling more doctors to discuss what could possibly be wrong. Nobody knows yet.
**
It was a good call in many ways. There was a lot to do in a short amount of time, a complicated story to assimilate and an important treatment decision to make. It was a job to remain calm and focused, to get things right and make sure I didnt miss anything important.
I ran through the call with some of my coworkers, and there are always raised eyebrows around the time that I mention the adenosine. I know. I knew it then, too, but I felt that I had to do something about that heart rate in the face of the rest of the patient's presentation: and I stand firm that there was value in the choice both as a treatment and as a diagnostic tool. If it worked, great. If it didnt, a pathology eliminated.
I may or may not have been right. Maybe the heart rate was actually a compensating effort. Perhaps the rate was completely unrelated to the rest of the presentation. Maybe I should have focused instead on doing something else. I dont know, and as far as I've heard thus far- neither do the doctors. It is a little frustrating to not know, to remain in the dark after such a fervent effort.
I did my best though, and I stand by my decisions. In work where often nothing is certain, and choices must be made quickly and accurately based on experience and talent: I think that counts for something.
Sunday, July 1, 2007
Planet Paramedic
I feel like a different person. I am acutely aware of the new patch on my shoulder, yes, but there is more than that. I have done a lot of this before. Routine clinical practice in school, calls on my ride-time internship, more calls while precepting. All of them, experiences designed to bolster my confidence and add wisdom to my choices, but still: sitting in the front of the ambulance - the paramedic with an EMT at my side - I feel like I am in a new and strange place.
The feeling strikes me as contrast to those Peter Canning expressed in his most recent blog entry. He writes how things havnt seemed to "stand out" lately, that he could write about some of the things he has seen, but he has been there before- written about it and now considers it old news. He's met a lot of amusing patients, seen the good medicals, and was there for the big traumas. ...And yet the experiences no longer seem to stimulate as much as they once did. Peter is experienced. Stable.
I sure as hell cant say that for myself. I've seen a total of 4 patients so far in my career as a cut-loose paramedic, and each one has seemed so important, so groundbreaking, that I really had a hard time choosing what I wanted to write about.
It isnt as if I have had all great calls, either. A seizing, ex IV drug abusing hypoglycemic who woke up after 3 tough IV attempts and an amp of D50, a deformed ankle, female weakness x 6 days, and a drunk. I went through my routines with each patient, assessed, treated, and even downgraded one of them-- but the experiences were so fresh and new. I was shocked to watch a first responding firefighter glance at our patches and then come to me to give his report. It was such an odd experience to act as the final word on scene. We're going to stay here and take a look. We're going to get going as soon as we can. The words came out of my mouth, not for the first time but with newfound impact. I was in charge of the scene, and people listened. Maybe they have no idea how new I am, that this is my first day and that behind my sunglasses, my eyes probably betray this overwhelming uncertainty.
I hung tough though. Played it cool and, I think, made the right choices for these first four patients. Even the routine feels new these days though, and I worry how I will fare when something really tough, some zebra comes along and forces me to make a decision. I hope I make the right choices and, even more, I hope I dont have to make those until I can get a little more experience under my belt. This job seems to favor trial by fire, though, so I doubt it.
Things sure are different here on planet paramedic.
***
I left my last entry with the news that my first shift would be with a friend, standing-by at a boxing event. So it was, although we didnt get any patients. We did, however, get awesome seats to a pretty good show:
Cant complain about that!
The feeling strikes me as contrast to those Peter Canning expressed in his most recent blog entry. He writes how things havnt seemed to "stand out" lately, that he could write about some of the things he has seen, but he has been there before- written about it and now considers it old news. He's met a lot of amusing patients, seen the good medicals, and was there for the big traumas. ...And yet the experiences no longer seem to stimulate as much as they once did. Peter is experienced. Stable.
I sure as hell cant say that for myself. I've seen a total of 4 patients so far in my career as a cut-loose paramedic, and each one has seemed so important, so groundbreaking, that I really had a hard time choosing what I wanted to write about.
It isnt as if I have had all great calls, either. A seizing, ex IV drug abusing hypoglycemic who woke up after 3 tough IV attempts and an amp of D50, a deformed ankle, female weakness x 6 days, and a drunk. I went through my routines with each patient, assessed, treated, and even downgraded one of them-- but the experiences were so fresh and new. I was shocked to watch a first responding firefighter glance at our patches and then come to me to give his report. It was such an odd experience to act as the final word on scene. We're going to stay here and take a look. We're going to get going as soon as we can. The words came out of my mouth, not for the first time but with newfound impact. I was in charge of the scene, and people listened. Maybe they have no idea how new I am, that this is my first day and that behind my sunglasses, my eyes probably betray this overwhelming uncertainty.
I hung tough though. Played it cool and, I think, made the right choices for these first four patients. Even the routine feels new these days though, and I worry how I will fare when something really tough, some zebra comes along and forces me to make a decision. I hope I make the right choices and, even more, I hope I dont have to make those until I can get a little more experience under my belt. This job seems to favor trial by fire, though, so I doubt it.
Things sure are different here on planet paramedic.
***
I left my last entry with the news that my first shift would be with a friend, standing-by at a boxing event. So it was, although we didnt get any patients. We did, however, get awesome seats to a pretty good show:
Cant complain about that!
Friday, June 29, 2007
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?
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?
Tuesday, June 26, 2007
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.
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.
Monday, June 25, 2007
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.
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.
Monday, June 18, 2007
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.
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.
Wednesday, June 13, 2007
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!
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!
Thursday, June 7, 2007
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.
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.
Wednesday, June 6, 2007
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.
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.
Wednesday, May 30, 2007
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.
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.
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.
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