Luck

Internship, day 5.

Early in the morning, while we posted, my preceptor and her partner ran me through some scenarios and we did equipment drills. I'm struggling as an intern. Not too badly, but I'm definitely not the best. I'm so nervous on scene and still not sure how to manage and delegate tasks out to everyone. My preceptor has faith in me, but she wants me to be strong. I describe her teaching method as a "Throw 'em in the water and don't jump in 'til they really start to drown" kind of idea.

We weren't far into going through a needle decompression scenario when our tones sounded over the radio.

"Medic 17, code 3 to an address for chest pain."

I sighed out of relief. Chest pain! This would be easy breezy. Go through OPQRST, SAMPLE, get a 12-lead, maybe some nitro, transport. Chest pain, I can do this!

We got into the neighborhood and ended up a little turned around. For lack of a better, more politically correct word, it was a trailer park, and one that wasn't numbered very well because we ran into the responding fire engine a few times around corners and turns before we both met at the right house. The firefighters got out, and we trailed along behind them, trying to find a good place to stick the gurney without it rolling away. Up some steep stairs and into the house, we found a 70-ish male sitting on his armchair.

At first glance, it appeared as though he was just casually lounging, waiting for us to come get him. But, even to the untrained eye, a second glance told you that something was not right. First off, it was around 10 am and still pretty foggy and cold outside, yet this gentleman was soaked with sweat and had undressed down to his boxers. Second, despite the lack of clothing and the profuse sweating, he was as white as a sheet. Third, the only part of his body that WASN'T white, was his chest... which was a deep purple and mottled.

The firefighters were good. They dropped their "let's haze the intern" act and got into serious mode, sticking an oxygen mask on the guy and sending others off to find his medications. A couple stuck around, quietly stood behind me, waiting for orders.

"Can I get a 12-lead please? What's his pressure?" I interjected between my questions to the patient.

"70 over 40.. Pulse is 120, you should look at the monitor while I hook up your 12-lead." My partner looked at me sideways and I knew something was up. I leaned around the chair to glance at the monitor that was sitting near the arm. My heart sunk. I could only see one 'view' of his heart but the rhythm was strange, unrecognizable and definitely not good. I needed a better picture and nodded at her to continue hooking up the 12-lead. I pushed my fear aside and continued my questions.

"Sir, when did this start?"

"Yesterday, I think.. I don't know really." He breathed back at me, eyes closed.

"And why did you call today, did it get worse in the last half hour or so?"

"Yes.. Yea, it started going down my arm. What's wrong, is my heart alright?"

"We aren't sure yet, we're trying to get a better picture, okay? What does it feel like, the pain?"

"I... I don't know...It hurts.."

My partner nudged me and whispered for me to give him some options as far as describing the pain. We're taught not to do that, ask leading questions, because patients will often say "Yes" to anything you describe. In this case, I took her advice because I needed some clearer answers.

"Sir, does it feel tight? Or like pressure? Like something heavy is on your chest?"

"I..I just.. I don't know it just hurts. What's wrong?"

"Okay, sir, don't worry. We'll take care of you."
My preceptor and partner ended up both searching for veins because I couldn't find one. I didn't mind not being able to get the IV because it wasn't important to me at this point. They ended up sinking a 20 into his hand.. Not great, but any access is good access.
"Okay, sir, I need you to hold really still for a few seconds while we take a look at your heart okay? Hang in there." My partner chirped from beside the chair. What seemed like hours was really only a few seconds of silence as the machine processed his rhythm and when it finally started to whir and print the EKG strip, my partner looked up at me.

"Looks like it's your lucky day, girl."

Wait.. What?!

Stunned, I stuttred back at her. "No.. You're joking, right?"

"Serious as a.. Well, you know."

"This can't be happening."

Oh God.. Here comes that spinning sensation again. She shoved the EKG strip into my hand and I saw it. Those big, looming tombstones marching out across the page. I knew what was going on, without looking at the huge print running across the top of the page that read:

***MEETS ST-ELEVATION MI CRITERIA***
Apparent septal infarct
Possible lateral infarct

He was having the big one. The most massive heart attack of heart attacks. Suddenly, everyone was rushing around, gathering up the firefighters, running outside to get the gurney, trying once again to find his medications. Bags of saline and bottles of aspirin were flying, tubes and wires and needles and alcohol swabs cluttered the carpet as we tried to zip up all of our bags and find a way to get the guy out of his house. At my preceptor's irritated demand, I grabbed the aspirin and gave the guy 2. Not that I hadn't thought of it, I had actually been looking for it when she asked me if I was going to 'give it to him or what,' but I stayed quiet and just did as I was told. My preceptor was on the phone immediately, making base contact.

"This is Michelle with medic 17, we are on scene of a 70 year old male complaining of chest pain, coolpalediaphoretic," (It always comes out as one word.) "12 lead says 'Meets ST elevation MI criteria.' Yeah....Uh-huh.. Right, no it says it right here...No pressure is too low, we gave aspirin..Okay, see you soon."

The firefighters came up behind me kneeling in front of the patient and said they were going to stand him up and walk him over to the gurney. I looked up at them, with a look I'm sure resembled that of one you would give to someone who had just grown an extra head in front of your eyes. My partner stifled a smirk and quietly responded.
"I don't think that's a good idea, guys. Let's try to get the gurney up the stairs, okay?"

My brain screamed. Not a good idea?! That's the understatement of the century! Why don't we have him run wind sprints in the front yard for an hour for Christ's sake!
The firefighters shuffled uneasily but refused to budge.
"It would be easier to walk him though. Sir, do you think you could..."

My partner interrupted him and stood, facing them.
"He's not walking."

"Yeah, there's no way. Just not happening." I included, suddenly finding my voice.

"Get the gurney up here, someone needs to spike a bag in the rig for me. Thanks." My partner finished with a polite but urgent smile.

"Oh, we're gonna need one of you guys in the rig with us, just in case." My preceptor said. It was more of a statement than a question, but it brought the point across clearly enough.

Seconds later, the gurney was miraculously beside me and the firefighters lifted the patient onto it and headed out the door. Once inside the rig, equipment was flying again. The monitor beeped, crying for help. There may as well have been a giant sad face on the screen for all it had told me. The ride seemed to take days, which made it even more irritating that when we arrived at the hospital and walked in, I heard the intercom blaring loudly;

"CODE STEMI, ER, BED 4. CODE STEMI, ER, BED 4."

You're joking, right? We called 30 minutes ago, the STEMI team should have been ready! UGGGHHHHH!!!

The patient was moved onto a bed in the ER and we stood back and watched the action. Outside in the ambulance bay, I cleaned the gurney and monitor slowly, waiting for my preceptor and partner to come back out. Michelle was out first and handed me a printout of the 12-lead to keep.
"So, what went wrong?"

What went wrong..? Did I do poorly? Damnit, I'm sure I could have done better but come on!

"I was golden until I saw the 12-lead, and then I started spinning again."

She smiled and agreed, gave me a few pointers for next time and left me alone.



Wow. That wasn't so bad.

My partner walked back out and we finished cleaning up the rig. I stared down at the 12-lead in my hand and looked at her. She looked back at me and asked if I had any questions.

"Dude... That was so. Cool." I managed.

She grinned from ear to ear. "I KNOW! You're so lucky to have seen that on your internship. Not something that happens everyday."

When we came back by the hospital later that day, we were told that the guy had gone into cardiac arrest in the cath lab, but they had rushed him over to have bypass surgery right away. We still don't know if he made it, his chances were slim but there is a possibility he survived. Hopefully, luck was on his side. If not, meaningless as it may be, his heart attack contributed greatly to my education.



"Looks like it's your lucky day, girl."

Stumbling

I haven't posted for awhile. Partly due to laziness, partly due to the fact that for the past year my entire life has been consumed by a paramedic training program.
Yup, I took the plunge.
I'm out of didactic, done with my clinical hours at the ER and have now moved on to my field internship.

Field internship for a paramedic intern consists of anywhere between 480-720 hours over the course of 2-3 months on a real, living, breathing, functioning 9-1-1 transporting unit. Your work is overseen by a paramedic preceptor- a paramedic who has taken a specific course in working with new interns in the field and guiding them throughout to ensure that they are competent in their skills.

For me, my internship takes place about 75 miles north of the city I live in. It's a foreign country to me. It's a smaller area, much smaller population and the system is completely backwards from what I'm used to. So, basically, not only am I going into this as a new intern, I'm going into this as a new intern who is unfamiliar with the operations and area.

So let's get to it then.

Day 1:
I made sure to get to station 45 minutes before my shift, just so I had some time to look around and meet people. My preceptor Michelle arrived about 10 minutes before our shift started and basically threw the keys to the rig at me and told me to check it out.
In the back of the rig, I was lost. There's SO MUCH MORE equipment than what I'm used to working with as an EMT, and although I recognized a lot of it from class, some of it looked slightly to severely different than what we used in school.
I had already started to panic, pulling stuff out and trying to put it together, trying to figure out that if I have a 1cc vial with 5 mg of medication and the orders are to give 2 mg and I can't find a 1cc syringe and what are the contraindications to this medication and is this a base hospital order or a standing protocol and....
WAIT. Okay. Breathe. Relax.
I put the vial down, took a deep breath and continued to look around and determine where everything is. My preceptor and her partner got in the rig and we left the station. She didn't really talk to me much, at one point she yelled from the front to the back, where I was sitting, and asked if I had any questions.
Do I have any questions? Hmm.. Yeah. When would be an appropriate time to cry, Michelle? No, nevermind. I don't have any questions.
We posted at a nearby park for awhile, and when we started driving again, I didn't think much of it. I had assumed we were switching posts or maybe going to get food. I didn't become alarmed until I heard the driver chirp the siren, just for a moment, because it was at that point that I realized we were probably running to a call, and I had had no idea because no one had said a word to me.
I looked down at my hands. Shaking. Crap. Jesus, why was it so loud in there? Oh, wait.. It was just the sound of my heart beating in my ears. Okay, you can do this. Chill.
We pulled up in front of an urgent care and Michelle opened the back. She looked at me and told me, in a bored voice, that we had a call. Our eyes locked for a second and she smiled. Not a calm, reassuring smile. An amused smile. She could smell my fear. The smile was gone so quickly that I questioned whether or not it was even there in the first place.
She knows I'm an intern right? She doesn't expect me to run this call.. It's my first day, am I supposed to run this call? Oh God.
Relax. It's okay.
I trailed behind her and her partner like a puppy with it's tail between it's legs. We entered and were greeted by a mass of people. Firefighters, nurses, people in lab coats.. All rushing around, trying to be helpful and direct us into the right room. From down the hall I could hear a heart monitor beeping loudly. An alarm that can only be described as the most terrifying sound to any intern.
Something was wrong.
Michelle pushed me into the room of people and stood back, arms crossed. The firefighters looked at her, confused, until she explained that I was the intern, and that I'd be handling the call. They didn't seem phased, and suddenly the mass of people descended on me.
"He came in today because he felt his heart beating rapidly and...."
"...220 on the monitor, pressure's fine..."
"....doctor in the ER wants to cardiovert him so it's just a transfer but..."
"...drinks occassionally, no medical history and..."

Wait, did these people honestly think I knew what I was doing? Why were they telling me all this stuff? I'm not a doctor.. Why is this firefighter talking to me? Wait, what did he say? Shit. Shut up, shut up SHUT UP brain! He's trying to tell you something..

"So, yeah. That's all I've got so far."

"Umm. I'm sorry. Umm...." I looked over my shoulder at Michelle for encouragement. Nothing. Just a blank stare. I looked back at the firefighter and he cocked his head to the side, looking concerned. Everyone was silent, except for the loud, obnoxious beeping of the heart monitor. To me it sounded something like, "IDIOT! IDIOT! IDIOT!" I looked at Michelle again, and this time she uncrossed her arms, rolled her eyes and came into the room. Not a word was spoken to me, she took over the call and ran it smoothly. I was in absolute awe of how calm she seemed, even though I had surely thought the patient was dying.
Wait, what was even wrong with this guy?
"Came in to the clinic today because he was having palpitations. When they hooked him up, he was in a rapid a-fib at a rate of 220." Michelle's report to the nurse at the ER interrupted my thoughts.
Jesus, we were already at the hospital? Had I been blacking out or something?!

She finished her report and pushed the gurney at me. "Outside. Now," she demanded in a stern voice.
Uh-oh.
Standing in the ambulance bay, she calmly leaned up against the gurney and crossed her arms again.
"So.. What the hell was that?"

"I'm sorry. I got scared. I don't know what I'm doing and I just... I'm sorry. I blanked."

"Yeah, I see that. It's unacceptable. I'm here to make sure you can do this, not to hold your hand. You need to be strong and confident in your skills. You need to take charge. You know, at the end of this, I'm not gonna be over your shoulder to pick you up when you start stumbling. Completely unacceptable. If you had questions, you should have asked. You said you didn't, so I assumed you knew what you were doing."

"I.. I'm sorry. I'm so nervous. I'm just... I'm sorry."

She eyed me up and down, uncrossed her arms and sauntered back to the ambulance. I quietly got in the back, sat down and took my school books out. I could feel my face getting hot, I could feel that lump forming in my throat.
Please, not now.
Tears started to stream down my face, and I eventually gave in and silently sobbed for a few minutes, letting them hit my book and distractedly trying to wipe them away.

What have I gotten myself into?