"[Hospital] Base, this is medic 23. We are enroute to your facility code 2 with an ETA of about 4 minutes. On board today we've got a 9 month old male who is alert in no distress. Mom found him in his crib this morning, ashen and unresponsive. Upon our arrival patient was awake but not acting appropriately for himself, patient is extremely lethargic and still slightly pale. We have an o2 sat of 95% on 6 liters blow-by, pulse of 122. This patient has a trach, and is often seen in your facility. Unless you have further instructions, we'll see you in about 3. Medic 23 out."
"[Hospital] base copies medic 23, nothing further, please take your patient to room one on arrival."
While my internship took a small break, I had signed up for several shifts with the ER in the area to gain some more experience. I listened intently to the radio reports of other medics, hoping that I could figure out how to sound as calm and collected as they did. Often, the nurse taking down the report would point out to me the good and bad and give me pointers for when I was in the field.
"I think I know this patient. He's here all the time for respiratory problems." Was all the nurse said to me as she turned away from the radio and walked towards room 1. I followed her in, and soon enough the familiar stomp of tactical boots was coming down the hallway. What we didn't hear was a baby crying, which concerned me.
When they rounded the corner into the room, I looked first upon the face of the silent child. He was an odd shade of gray, and absolutely still and quiet. Sitting propped up in his car seat, his huge head lolled around but his eyes never met anything, never focused or tracked movement. It was the thousand yard stare, which I never wanted to see from such a small person. I almost didn't notice the mask that covered his trach, it was precariously placed around his neck and looked odd on such a small child. I've seen tracheostomy patients, even kids, but never 9 month old babies. There were lumps on his abdomen under his onsie, he obviously had a feeding tube as well. This was a chronically ill little boy.
The usual joking banter of the medics was replaced by a quiet concern as they gave report again to the nurse and doctor in the room. Their brows furrowed and faces worried, they explained that his mother had found him in his crib after a nap, completely gray and not responsive, but awake. Despite his illness, he was a happy baby. He made facial expressions, cried, cooed like other babies. But not today. Parents said he had not been ill lately, they suctioned his trach religiously and he had no secretions that were indicative of an infection or problem in his lungs. As they carefully placed him onto the hospital bed, he still made no attempt to move, squirm or cry. He sat like a doll in an awkward position on the bed.
The nurses began throwing equipment on the bed. The pediatric crash cart was placed close by, and the doctor spoke his orders out loud before leaving the room. As they tied tourniquets around his arms and legs to search for IV sites, one of the nurses told me I was welcome to try for an IV, but only if I knew I would get it immediately. I shook my head and declined. I knew it would have been good practice, but there was no way I could have gotten it immediately. I wasn't even sure I could get one at all. They stuck him at least 10 times. Each time, I expected him to scream, to cry, to move away or pull the offending extremity out of reach from the nurses. Each time, he sat as still as he had been, silent as ever. He never even looked up. The doctor finally decided to do an IO [intra-osseous, an IV in your bone just below your knee.] As he manually drilled the needle into the baby's leg, the baby flinched slightly, but relaxed immediately. We all looked at each other, knowing that this was not a good sign.
After discovering he had a temperature of 103, and all the necessary chest X-rays and such were completed, he was transferred to another hospital with a pediatric and neonatal ICU. The doctor later told me that he suspected the child had a brain infection because of the size of his head when he came in.
"Babies have large heads, disproportionate to their bodies. We all know this, right? But his head was a monster, way to big for a boy his age. There's something going on in there I think. We see this baby all the time, he's in here a lot but this isn't normal for him. Something is definitely wrong." He said to me while looking over the boy's chart.
I watched as the CCT crew carefully gathered him up in his carseat on the gurney again. I gently brushed his hair off of his face and gave his arm a little squeeze before they left with him. His parents touched my shoulder and thanked me for helping him. I gave them a sympathetic smile as they walked out behind the gurney.
A couple of weeks later my mom, who works as a respiratory therapist at the hospital, called me.
"Hey, do you remember telling me about the little baby with the trach? What was his name?" She asked.
"Oh, uh... I can't remember. Why?" I said distractedly as my fiance and I drove to a party.
"Was it Marcus? Was that his name? 9 months old, trach patient. You said you saw him a couple times at your internship."
"Oh, yeah. Marcus, yeah I know him pretty well. Why? Was he a patient of yours?"
"Yeah, sweetie. He was. He died yesterday."
I stopped fiddling with my cigarette pack and lighter and looked at my phone.
"Hello? You still there?" She said.
"Yeah. I'm here. What happened?" I replied quietly. My fiance placed his hand on my knee and quickly looked at me, frowning.
"I guess his family was at the mall with him in his stroller and his mom noticed that he wasn't breathing. They called 9-1-1 and the medics came and they tried, but he was gone. They brought him into the ER and we worked him for a few minutes but his mom said to stop. She was pretty upset, she said he had already suffered enough in his life and it was a miracle he had even lived this long, so she asked us to stop and to let him go. It was just so sad."
"Yeah, that's just terrible. His family was so good with him too."
Later that evening, I looked in the paper. Under obituaries, there were 2 sentences about him.
'Marcus Soto, 9 months, resident of [city] passed away on Thursday. Funeral arrangements are under the direction of Smith Funeral Home.'
And that was it.
Monday, November 8, 2010
Tuesday, September 14, 2010
Stabbing
Internship, shift 13.
On this call, we heard police (APD) and fire (AFD) get dispatched to an "Unknown man down." My preceptor knew it would probably be ours, only because the engine we work with was sent, but for some reason a communication error occurred and an ambulance was never dispatched. We sat and waited for more information on the call, but it never came. Finally, my preceptor decided to just get in the rig and ask AFD for the address of the call because it still hadn't come through our end.
When AFD came back at us with the address, they also let us know that this wasn't just an "Unknown man down."
This was a stabbing.
My heart jumped a little bit. I tried to relax and tell myself, "Maybe it's just like a couple cuts and the dude is fine. Who knows?"
I knew that wasn't true. The firefighter on the radio did not sound like it was just a couple of cuts.
Remember in EMT school, when they tell you that your first priority is scene safety? You run through scenarios and mindlessly babble off,
"Is the scene safe?"
You always get a quick "Yes" and move on without even thinking about it. Today, I finally weighed that statement in my mind. As we pulled up, I saw yellow police tape criss-crossed across someone's front lawn and breathed a sigh of relief. The scene was safe, thank God.
"There he is!" Tracy yelled, as she pointed a finger out the window. I followed her gaze to a figure lying in the grass surrounded by firefighters. Next question on your scenarios from school?
"What's your general impression of the patient?"
My patient was not dead. That's good, right? No-one is doing CPR so he's alive. He has an oxygen mask on which means he's also breathing. Next step?
Always get your ABC's.
As we walked up to him, I looked at him closely.
Alert? Patient is alert and talking, tracks me as I approach him.
Airway? Airway is patent and patient is breathing.
Breathing? Breathing is slightly labored, but good chest rise.
Circulation? Screeching halt here. Everyone slipped and slid all over the grass because it was covered in blood. The firefighters had wrapped his right bicep in gauze, but it didn't seem to do much. Don looked up at me and pointed to the right arm.
"Entrance and exit wound here, entrance only on the left forearm with minimal bleeding. Over here, it's not controlled."
As he finished his sentence, the firefighter next to me on the patient's left side stood.
"Pressure is 70 palp and dropping."
I think back to class. Uncontrolled bleeding scenario:
Apply direct pressure.
Elevate the limb.
If the wound continues to bleed...
"Tourniquets!" Tracy said at the same time as I reached for them. She nodded and smiled at me. "Good, you've already got them." I threw 2 tourniquets to Sarah and Don while I started an IV on his left arm. Another medic stood behind me and spiked a bag. As I hooked it up, I heard Sarah mumbling to Don.
"Tighter, it's not stopping."
I looked over as they elevated his arm more and watched blood pour from the already-soaked gauze. I walked over to his right side, grabbed the second tourniquet and placed it just above the first, tightening it as much as it would go.
"There. It stopped. Sir, how are you feeling?"
The patient opened his eyes and winced. "This hurts, it's too tight. I feel dizzy."
"I know bud, but we need to keep it on because it's bleeding too much and this stops it, okay? We're gonna take care of you, don't worry."
He nodded in understanding and thankfully didn't argue any more.
"Are you hurt anywhere else? Did they stab you anywhere other than your arms that you can feel?"
He shook his head 'no' as I quickly ran my eyes and hands down the rest of his body, looking at his 'kill zones.' Chest was clear, abdomen was clear, neck and spine were clear. Good.
We slid him into the rig and Don jumped in next to me.
"You think I'm gonna let you have all the fun? No way! I'm stoked you got this call, kid. Hold still, you got some blood on your arm, I'm gonna get it with an alcohol prep"
I grinned ear-to-ear as I slid another IV in his arm. "Haha thanks. I know, right? Me too! What's his pressure now?"
"130 and holding. I'll keep his arm up for him cause he'll run out of gas." Don stepped over me and into the seat at the head of the patient. The patient winced again.
"It's really tight on my arm, it hurts."
"I know bud, I know. We have to keep it there for now, I'm sorry. You're bleeding too much from that arm okay? Can you feel me touching your hand? Wiggle your fingers for me."
He nodded his head and his fingers moved slowly in response. I grabbed the phone and went for my report.
"Base this is medic 12, we are coming to you code 3 with a 33 year old male who was involved in a stabbing, wound on the right bicep with suspected arterial bleed, entrance and exit on that side. Wound on the left forearm is entrance only with controlled minimal bleeding. Patient is awake alert oriented, on 15 liters o2 via non-rebreather. Initial pressure was 70 palp, we have 2 IVs established in the left arm, wide open, pressure has come up to 130, pulse remains 130 and tachy on the monitor, no other trauma noted, see you in 5."
"Medic 12, where are the stab wounds?"
"Base, wounds are on the right bicep, entrance and exit with suspected arterial bleed. Second wound on left forearm, entrance only, bleeding controlled."
"Medic 12, base copies. Trauma bay 4 please. Trauma bay 4, team will meet you upon arrival."
I sat back down on the bench seat, out of breath.
"Woah, kid relax. I've never seen someone talk so damn fast." Don said, smiling.
I laughed. "I know, it was like I couldn't get my mouth to move as fast as my brain was spitting out the info."
As we pulled the patient into the hospital and onto the bed, the ER doc came to the patient's right side.
"Tourniquets off, let's see what happens." He said, slowly releasing both tourniquets. Blood oozed quickly from the wound again as the doc inspected it.
"Yep, that's his brachial. Get a pressure cuff back on that arm, he'll need vascular surgery at the trauma center. Pressure is good though, he's probably stable enough to go now."
The team hustled around the bed as we walked out. Exhausted and blood covered, I stepped out into the ambulance bay and let the cool evening soak into my skin.
Smiling, I grabbed a towel and helped Sarah wipe the blood from every surface imaginable in the rig.
On this call, we heard police (APD) and fire (AFD) get dispatched to an "Unknown man down." My preceptor knew it would probably be ours, only because the engine we work with was sent, but for some reason a communication error occurred and an ambulance was never dispatched. We sat and waited for more information on the call, but it never came. Finally, my preceptor decided to just get in the rig and ask AFD for the address of the call because it still hadn't come through our end.
When AFD came back at us with the address, they also let us know that this wasn't just an "Unknown man down."
This was a stabbing.
My heart jumped a little bit. I tried to relax and tell myself, "Maybe it's just like a couple cuts and the dude is fine. Who knows?"
I knew that wasn't true. The firefighter on the radio did not sound like it was just a couple of cuts.
Remember in EMT school, when they tell you that your first priority is scene safety? You run through scenarios and mindlessly babble off,
"Is the scene safe?"
You always get a quick "Yes" and move on without even thinking about it. Today, I finally weighed that statement in my mind. As we pulled up, I saw yellow police tape criss-crossed across someone's front lawn and breathed a sigh of relief. The scene was safe, thank God.
"There he is!" Tracy yelled, as she pointed a finger out the window. I followed her gaze to a figure lying in the grass surrounded by firefighters. Next question on your scenarios from school?
"What's your general impression of the patient?"
My patient was not dead. That's good, right? No-one is doing CPR so he's alive. He has an oxygen mask on which means he's also breathing. Next step?
Always get your ABC's.
As we walked up to him, I looked at him closely.
Alert? Patient is alert and talking, tracks me as I approach him.
Airway? Airway is patent and patient is breathing.
Breathing? Breathing is slightly labored, but good chest rise.
Circulation? Screeching halt here. Everyone slipped and slid all over the grass because it was covered in blood. The firefighters had wrapped his right bicep in gauze, but it didn't seem to do much. Don looked up at me and pointed to the right arm.
"Entrance and exit wound here, entrance only on the left forearm with minimal bleeding. Over here, it's not controlled."
As he finished his sentence, the firefighter next to me on the patient's left side stood.
"Pressure is 70 palp and dropping."
I think back to class. Uncontrolled bleeding scenario:
Apply direct pressure.
Elevate the limb.
If the wound continues to bleed...
"Tourniquets!" Tracy said at the same time as I reached for them. She nodded and smiled at me. "Good, you've already got them." I threw 2 tourniquets to Sarah and Don while I started an IV on his left arm. Another medic stood behind me and spiked a bag. As I hooked it up, I heard Sarah mumbling to Don.
"Tighter, it's not stopping."
I looked over as they elevated his arm more and watched blood pour from the already-soaked gauze. I walked over to his right side, grabbed the second tourniquet and placed it just above the first, tightening it as much as it would go.
"There. It stopped. Sir, how are you feeling?"
The patient opened his eyes and winced. "This hurts, it's too tight. I feel dizzy."
"I know bud, but we need to keep it on because it's bleeding too much and this stops it, okay? We're gonna take care of you, don't worry."
He nodded in understanding and thankfully didn't argue any more.
"Are you hurt anywhere else? Did they stab you anywhere other than your arms that you can feel?"
He shook his head 'no' as I quickly ran my eyes and hands down the rest of his body, looking at his 'kill zones.' Chest was clear, abdomen was clear, neck and spine were clear. Good.
We slid him into the rig and Don jumped in next to me.
"You think I'm gonna let you have all the fun? No way! I'm stoked you got this call, kid. Hold still, you got some blood on your arm, I'm gonna get it with an alcohol prep"
I grinned ear-to-ear as I slid another IV in his arm. "Haha thanks. I know, right? Me too! What's his pressure now?"
"130 and holding. I'll keep his arm up for him cause he'll run out of gas." Don stepped over me and into the seat at the head of the patient. The patient winced again.
"It's really tight on my arm, it hurts."
"I know bud, I know. We have to keep it there for now, I'm sorry. You're bleeding too much from that arm okay? Can you feel me touching your hand? Wiggle your fingers for me."
He nodded his head and his fingers moved slowly in response. I grabbed the phone and went for my report.
"Base this is medic 12, we are coming to you code 3 with a 33 year old male who was involved in a stabbing, wound on the right bicep with suspected arterial bleed, entrance and exit on that side. Wound on the left forearm is entrance only with controlled minimal bleeding. Patient is awake alert oriented, on 15 liters o2 via non-rebreather. Initial pressure was 70 palp, we have 2 IVs established in the left arm, wide open, pressure has come up to 130, pulse remains 130 and tachy on the monitor, no other trauma noted, see you in 5."
"Medic 12, where are the stab wounds?"
"Base, wounds are on the right bicep, entrance and exit with suspected arterial bleed. Second wound on left forearm, entrance only, bleeding controlled."
"Medic 12, base copies. Trauma bay 4 please. Trauma bay 4, team will meet you upon arrival."
I sat back down on the bench seat, out of breath.
"Woah, kid relax. I've never seen someone talk so damn fast." Don said, smiling.
I laughed. "I know, it was like I couldn't get my mouth to move as fast as my brain was spitting out the info."
As we pulled the patient into the hospital and onto the bed, the ER doc came to the patient's right side.
"Tourniquets off, let's see what happens." He said, slowly releasing both tourniquets. Blood oozed quickly from the wound again as the doc inspected it.
"Yep, that's his brachial. Get a pressure cuff back on that arm, he'll need vascular surgery at the trauma center. Pressure is good though, he's probably stable enough to go now."
The team hustled around the bed as we walked out. Exhausted and blood covered, I stepped out into the ambulance bay and let the cool evening soak into my skin.
Smiling, I grabbed a towel and helped Sarah wipe the blood from every surface imaginable in the rig.
Friday, September 10, 2010
Code Blue
Internship, shift 12.
"Medic 12, please respond code 3 to [hotel] for respiratory arrest."
It was 4 in the afternoon, so before the dispatcher could even finish her sentence, we were running out the door and into the rig.
"The patient is not breathing. The patient has foam coming from her mouth." Tracy read off of the dispatch page. "Yup, she's coded. Ready?" She said, looking back to me. I nodded and slipped my gloves on, then flipped my protocol book open to the cardiac arrest algorithm. As we pulled up, a slew of curse words erupted from Tracy as she saw one of our other crews running into the hotel.
"God DAMNIT! She KNOWS I have an intern WHY is she jumping this call?! OH HELL NO! Get in there, she shouldn't be here. Let's go!"
As we pulled out our equipment and trotted over to the appropriate room, a crowd of people stood hovering near the door. Police officers, firefighters, other guests of the hotel. I pushed my way past them and into the small hotel room to see a mess of more people. A young woman was draped across the floor, a firefighter was pumping at her chest furiously as we tried to step around and over them. I grabbed the intubation kit and tediously stepped over everyone to her head. Tracy settled in near the woman's right side with the IV kit.
"Just get your tube, okay? I'll run a line and drugs until you get an airway. Concentrate on your tube."
I nodded again as I pulled the laryngyscope out and snapped it open. As I assembled my supplies in a neat line next to me, a voice interrupted my thoughts.
"Hey kid. You ready for your tube?" The fire-medic who had been ventilating her looked up and grinned.
"Oh hey! It's you!" I said, recognizing Don. He had been on most of the shifts with us, and he was awesome. Always helpful, always with positive comments towards me. He had also been the one with us on the bad trauma call last week.
"Whenever you're ready, alright?" He said.
"I'm good here. Let's go. Hyperventilate her and pull the OPA [basic airway] out please."
He nodded, following the order and moving aside. I slipped the scope in and pulled up, leaning in to get a better view of her vocal chords.
"Nothing," I said to Don, "Suction please."
The suction tubing was in my hand immediately and as I snaked it into her mouth, vomit bubbled up. I leaned to the side to avoid being spewed on, but kept suctioning. When the vomit stopped, I leaned in again, pushing the scope deeper and pulling up harder. Nothing still.
"I can't see anything. Keep bagging her." I said, pulling the scope out and backing up slightly.
"I'll hyperventilate her again for a few, then come back in here and look again. I'll give you crich pressure if you need it." He replied. I nodded solemnly, and gazed at her face for a few seconds. This was not the face of a woman who would live. She was dead, she probably had been dead for quite some time. I don't think I would have even attempted to work her up if it had been me who was there first, but since everyone had already started before we got here, we didn't have a choice. Chaos was erupting all around me, but I hadn't noticed since I had been up at her head with Don. As he ventilated her for another few seconds, I looked up and saw the entire scene. Wrappers and packaging everywhere, tubing and wires snaked all across the floor. Blood leaking slowly from each arm as Tracy and the first arriving crew stuck her numerous times for IV access. It was a mess.
Don backed up again and motioned for me to try again. I guided the scope in and pulled up, leaning as far down as I could for a better view. I shook my head, I still couldn't see a damn thing. Don wrapped his hand around the scope's handle above mine and pulled up more.
"Here, I'll hold it. Look again, I think you'll see them."
I bent down, my chest and abdomen against the floor now, and looked. There they were, like a light at the end of the tunnel.
"Got it, I'm going in." I said, sliding the tube delicately down her throat. As soon as the tube passed her teeth, it blocked my view of her chords. I slid it in regardless, and hoped I had made it. As I removed the guide wire from the tube and hooked up the BVM, the firefighter doing chest compressions turned to me.
"I think it's in, I felt it slide down. I felt it go in, you're in."
As Don attempted to ventilate, vomit suddenly filled the tube and leaked from around the seal of the BVM.
"I'm not in, pull it."
Tracy looked up from her IV attempt. "What happened?"
"It's in her esophagus, I'm doing a King airway, I can't get the tube."
The medic that had gotten there first from the other crew stood and stepped over the woman's body.
"Let me look, okay? Get another tube ready."
I backed away and assembled another tube. She grabbed the scope from my hands and looked again.
"Screw it, hand me a King." She withdrew the scope and jammed the King airway in. Immediately vomit filled the tube again, but this time it shot out of the BVM like a volcano, covering her and Don with brown liquid.
"Just try to BVM her, maybe we're still in."
Don squeezed the bag, but it only made the vomit spew more.
"Damnit, okay. I'm gonna have to try for a tube."
Again, she slid the scope in and immediately reached her hand back to me.
"I see it, tube, NOW!" She yelled. I shoved the tube into her hand and she passed it through the chords.
"Okay, it's in. Ventilate."
Don squeezed the bag again and the woman's chest rose slowly. With that problem solved, I finally looked up and let the chaos sink in.
"We can't get an IV, get me the IO.."
"Still asystolic, why aren't the compressions showing on the monitor?"
"IO is in, no infiltration. I think it's running."
"Epi and Atropine, please!"
"Keep checking the pads. When we touch the wires it shows on the monitor, but the compressions just aren't registering."
"Epi and Atropine in, record it!"
"Are you getting good compliance with the bag?"
"She's vomiting again, suction!"
The more everyone talked, the more I sunk into my corner of the room. PD hovered anxiously outside the door, further back I could see curious bystanders struggling to get a look inside the room. I looked at the woman's face again and shook my head.
There's no way. She's been dead for hours.
As everyone shuffled around, I took the BVM from Don and ventilated so he could stand for a few seconds. I listened intently to the metronome.
"Click, click, click, click, click, click, click, click, VENTILATE! VENTILATE!" The robotic voice demanded.
Tracy stood from her spot near the door and walked outside, phone pressed to her ear. I heard a few seconds of her report before she walked beyond earshot. She returned a few seconds later and stood in the doorway.
"Okay everyone, stop. We're calling it. Time of death, 1535. Let's clean up."
Everyone stopped, sat back on their heels, and began breaking everything down. I yanked at the BVM but couldn't detach it from the tube. I struggled, grunting and straining, before Don's hand reached down and held the tube while I yanked one final time, breaking it free. I looked up and smiled tiredly, he grinned back at me and grabbed the airway kit.
Sarah grabbed a blanket and draped it carefully over the woman. She looked up at me and pointed outside.
"There's kids running around outside. I just... It's not something I would want my kids to see."
I nodded and pointed at the woman. "Leave everything on her, right?"
"Yup, just like it is. Everything stays with her."
"Okay."
We quietly tip-toed around each other as we gathered all of our supplies and trash. I glanced one final time down at the outline of the woman, now just a lump under a thin blanket, and turned and walked out.
Back at the station, I sat down next to Tracy as she filled out the paperwork on the laptop.
"I'd just rather have you watch me do this one, it's a lot of information to try to do yourself and I want you to see it done before you have to do it next time." I nodded quietly and folded my hands in my lap.
"How do you think that went?" She asked.
"I mean.. She was a difficult airway. I really just... Couldn't see anything. But I really was trying."
I looked up at her and she stared blankly at the computer screen.
"As a code though, it went horribly." I finished.
"Yeah. There was just too many people trying to do too much." She said quietly, before resuming her typing.
That night, I had a dream about the code. I was at her head, scope in hand, and leaned in closely to look at the chords again. As I leaned in to get a better view, the woman's eyes shot open.
I sat straight up into bed, gasping. Tracy poked her head through the door.
"We have a call."
"Ok, I'm right behind you."
"Medic 12, please respond code 3 to [hotel] for respiratory arrest."
It was 4 in the afternoon, so before the dispatcher could even finish her sentence, we were running out the door and into the rig.
"The patient is not breathing. The patient has foam coming from her mouth." Tracy read off of the dispatch page. "Yup, she's coded. Ready?" She said, looking back to me. I nodded and slipped my gloves on, then flipped my protocol book open to the cardiac arrest algorithm. As we pulled up, a slew of curse words erupted from Tracy as she saw one of our other crews running into the hotel.
"God DAMNIT! She KNOWS I have an intern WHY is she jumping this call?! OH HELL NO! Get in there, she shouldn't be here. Let's go!"
As we pulled out our equipment and trotted over to the appropriate room, a crowd of people stood hovering near the door. Police officers, firefighters, other guests of the hotel. I pushed my way past them and into the small hotel room to see a mess of more people. A young woman was draped across the floor, a firefighter was pumping at her chest furiously as we tried to step around and over them. I grabbed the intubation kit and tediously stepped over everyone to her head. Tracy settled in near the woman's right side with the IV kit.
"Just get your tube, okay? I'll run a line and drugs until you get an airway. Concentrate on your tube."
I nodded again as I pulled the laryngyscope out and snapped it open. As I assembled my supplies in a neat line next to me, a voice interrupted my thoughts.
"Hey kid. You ready for your tube?" The fire-medic who had been ventilating her looked up and grinned.
"Oh hey! It's you!" I said, recognizing Don. He had been on most of the shifts with us, and he was awesome. Always helpful, always with positive comments towards me. He had also been the one with us on the bad trauma call last week.
"Whenever you're ready, alright?" He said.
"I'm good here. Let's go. Hyperventilate her and pull the OPA [basic airway] out please."
He nodded, following the order and moving aside. I slipped the scope in and pulled up, leaning in to get a better view of her vocal chords.
"Nothing," I said to Don, "Suction please."
The suction tubing was in my hand immediately and as I snaked it into her mouth, vomit bubbled up. I leaned to the side to avoid being spewed on, but kept suctioning. When the vomit stopped, I leaned in again, pushing the scope deeper and pulling up harder. Nothing still.
"I can't see anything. Keep bagging her." I said, pulling the scope out and backing up slightly.
"I'll hyperventilate her again for a few, then come back in here and look again. I'll give you crich pressure if you need it." He replied. I nodded solemnly, and gazed at her face for a few seconds. This was not the face of a woman who would live. She was dead, she probably had been dead for quite some time. I don't think I would have even attempted to work her up if it had been me who was there first, but since everyone had already started before we got here, we didn't have a choice. Chaos was erupting all around me, but I hadn't noticed since I had been up at her head with Don. As he ventilated her for another few seconds, I looked up and saw the entire scene. Wrappers and packaging everywhere, tubing and wires snaked all across the floor. Blood leaking slowly from each arm as Tracy and the first arriving crew stuck her numerous times for IV access. It was a mess.
Don backed up again and motioned for me to try again. I guided the scope in and pulled up, leaning as far down as I could for a better view. I shook my head, I still couldn't see a damn thing. Don wrapped his hand around the scope's handle above mine and pulled up more.
"Here, I'll hold it. Look again, I think you'll see them."
I bent down, my chest and abdomen against the floor now, and looked. There they were, like a light at the end of the tunnel.
"Got it, I'm going in." I said, sliding the tube delicately down her throat. As soon as the tube passed her teeth, it blocked my view of her chords. I slid it in regardless, and hoped I had made it. As I removed the guide wire from the tube and hooked up the BVM, the firefighter doing chest compressions turned to me.
"I think it's in, I felt it slide down. I felt it go in, you're in."
As Don attempted to ventilate, vomit suddenly filled the tube and leaked from around the seal of the BVM.
"I'm not in, pull it."
Tracy looked up from her IV attempt. "What happened?"
"It's in her esophagus, I'm doing a King airway, I can't get the tube."
The medic that had gotten there first from the other crew stood and stepped over the woman's body.
"Let me look, okay? Get another tube ready."
I backed away and assembled another tube. She grabbed the scope from my hands and looked again.
"Screw it, hand me a King." She withdrew the scope and jammed the King airway in. Immediately vomit filled the tube again, but this time it shot out of the BVM like a volcano, covering her and Don with brown liquid.
"Just try to BVM her, maybe we're still in."
Don squeezed the bag, but it only made the vomit spew more.
"Damnit, okay. I'm gonna have to try for a tube."
Again, she slid the scope in and immediately reached her hand back to me.
"I see it, tube, NOW!" She yelled. I shoved the tube into her hand and she passed it through the chords.
"Okay, it's in. Ventilate."
Don squeezed the bag again and the woman's chest rose slowly. With that problem solved, I finally looked up and let the chaos sink in.
"We can't get an IV, get me the IO.."
"Still asystolic, why aren't the compressions showing on the monitor?"
"IO is in, no infiltration. I think it's running."
"Epi and Atropine, please!"
"Keep checking the pads. When we touch the wires it shows on the monitor, but the compressions just aren't registering."
"Epi and Atropine in, record it!"
"Are you getting good compliance with the bag?"
"She's vomiting again, suction!"
The more everyone talked, the more I sunk into my corner of the room. PD hovered anxiously outside the door, further back I could see curious bystanders struggling to get a look inside the room. I looked at the woman's face again and shook my head.
There's no way. She's been dead for hours.
As everyone shuffled around, I took the BVM from Don and ventilated so he could stand for a few seconds. I listened intently to the metronome.
"Click, click, click, click, click, click, click, click, VENTILATE! VENTILATE!" The robotic voice demanded.
Tracy stood from her spot near the door and walked outside, phone pressed to her ear. I heard a few seconds of her report before she walked beyond earshot. She returned a few seconds later and stood in the doorway.
"Okay everyone, stop. We're calling it. Time of death, 1535. Let's clean up."
Everyone stopped, sat back on their heels, and began breaking everything down. I yanked at the BVM but couldn't detach it from the tube. I struggled, grunting and straining, before Don's hand reached down and held the tube while I yanked one final time, breaking it free. I looked up and smiled tiredly, he grinned back at me and grabbed the airway kit.
Sarah grabbed a blanket and draped it carefully over the woman. She looked up at me and pointed outside.
"There's kids running around outside. I just... It's not something I would want my kids to see."
I nodded and pointed at the woman. "Leave everything on her, right?"
"Yup, just like it is. Everything stays with her."
"Okay."
We quietly tip-toed around each other as we gathered all of our supplies and trash. I glanced one final time down at the outline of the woman, now just a lump under a thin blanket, and turned and walked out.
Back at the station, I sat down next to Tracy as she filled out the paperwork on the laptop.
"I'd just rather have you watch me do this one, it's a lot of information to try to do yourself and I want you to see it done before you have to do it next time." I nodded quietly and folded my hands in my lap.
"How do you think that went?" She asked.
"I mean.. She was a difficult airway. I really just... Couldn't see anything. But I really was trying."
I looked up at her and she stared blankly at the computer screen.
"As a code though, it went horribly." I finished.
"Yeah. There was just too many people trying to do too much." She said quietly, before resuming her typing.
That night, I had a dream about the code. I was at her head, scope in hand, and leaned in closely to look at the chords again. As I leaned in to get a better view, the woman's eyes shot open.
I sat straight up into bed, gasping. Tracy poked her head through the door.
"We have a call."
"Ok, I'm right behind you."
Thursday, September 9, 2010
Trauma
Internship day 10
Medic 12, please respond code 3 to (freeway exit) near the entrance of (campground) and (lake) for an MVA.
It was 3 am, so I groggily dragged myself from my bed on the couch as soon as I heard my preceptor's tones go off in the next room. I quickly wiped the sleep from my eyes, buttoned my shirt and ran out to the rig. I grabbed gloves and slipped them on, checked my pockets for a pen and sat in the jump seat. My preceptor and her partner climbed in shortly after and we were off.
"Where is it? I can't see it on the map. Oh, there it is. Shit, it's on the pass." My preceptor was talking to her partner while looking on the computer for directions. I tensed as I heard this, the pass was a difficult road to navigate and accidents up there were usually not minor.
"Oh, dispatch is updating the info..Let's see here... Male driver is not conscious, unknown if he is breathing... There is serious blood loss.. Shit." This time, she was speaking to no one in particular, but after saying this, turned to me and spoke again.
"This is going to be bad, and I'm not saying that to scare you, okay? I just want you to know it's going to be bad. Be ready for the worst."
I sat back in my seat, buckled my seat belt and closed my eyes. Taking deep breaths, I tried to calm myself. Opening my eyes again, I saw flashing lights in the distance behind us.
I turned back towards the front of the rig.
"Tracy.. Fire is behind us. Like, wayyy behind us."
"What?! Oh, crap. We're gonna get there first."
What seemed like an eternity passed before my partner, Sarah, slowed to a stop.
"PD is here. Where is the-... Shit, there it is. This is bad."
Because I had been in the back, I had not yet seen what Sarah and Tracy saw. She pulled up further, in front of the wreck, and flashing lights illuminated a truck behind us. From the rig I could see that the truck was unrecognizable as having once been a vehicle. It looked like a ball of twisted metal, and as the lights flashed over it, I caught quick glimpses of an arm dangling from what used to be the driver's side. I jumped out, throwing my reflective vest on, and ran to the truck. A man in plain clothes approached me quickly, flashlight in hand, and started talking to me.
"We were just camping down by the lake. We heard him hit the side of the mountain and came up to make sure everyone was okay. I don't think he's breathing. We've been looking for other people but we don't see anyone, just car parts strewn everywhere."
I nodded quickly and ran past him to the arm hanging from the wreck. I grabbed it, and held his wrist for a few seconds before yelling out to Tracy, "Strong radial pulse. Snoring respirations. We wont be able to get him out though."
She came up behind me and also grabbed the arm. From where we stood, what used to be the driver's door was now a tiny opening from which we could see his head, facing the passenger side, and his arm. Nothing else was in view. The engine was in his lap, the steering wheel over his right shoulder. The truck was angled up, and access through the passenger side was out of the question. The smell of alcohol was drifing from the car, and it was strong. He was drunk.
The fire department arrived and we stood back, waiting for them to extricate him. Cables were running everywhere, loud generators drowned out any noise as they fired up the Jaws of Life. One of the firefighters, also a medic, turned to me.
"If you grab me your IV bag, I'll get a line for you on this arm. Just don't get too close, okay kid? The truck isn't stable, I don't want you getting hurt."
I nodded and ran back to the rig for my IV bag. Once there, Tracy stopped me and quickly said, "Everything out, get everything ready. Your airway bag, the gurney with a backboard. Everything." I nodded again and pawed at my trauma bag, ripping out everything, opening it and throwing it on the bench seat.
Airway kit, check.
Gurney with backboard, check.
Line spiked... Sarah is working on it, check.
IV bag..
I grabbed it and dashed back to the firefighter. He quickly established a 16 guage IV and ran it wide open, throwing the bag towards me.
"Hold this, and squeeze. It's gonna be awhile before we can get him out."
I stood back, IV bag tightly in my hands as I weaved in and out of the firefighters with the IV line, trying to untangle them all as they rushed around the truck. Tracy stood beside me, yelling things back to Sarah who was preparing the rig.
"Get the fast patches out and hooked up. Oh, and another line spiked please. Is the gurney ready to go?"
Tracy turned back to me and spoke quietly.
"How are you doing?"
"I'm okay. I'm scared for this guy. What if they take the dashboard off of him and he codes? What if he's not even in once piece under all of that shit?"
"I know. He's gonna be bad. Just be ready for him to code. We're all scared for him."
"It's been almost 20 minutes." I said quietly, dropping my gaze to the ground.
The fire-medic turned towards us. "He's almost ready, get the gurney over here."
Tracy took the IV bag and nodded for me to go help Sarah. We grabbed the gurney and backboard, wheeling it around all the cables and glass, and up to the driver's side. Suddenly, the man was plopped onto the backboard and we were all feverishly strapping him in, securing his neck with a collar while lifting the gurney and running back to the rig. "We need a rider, who wants to come?" Tracy yelled back to the firefighters. One of the younger guys, another medic, came running up and jumped in. "I'll go," he said, smiling at me, while he sat down on the bench and began cutting the man's clothes off.
"Okay. We're taking him straight to the trauma center, bypassing the local ER. Probably gonna be a 45 minute plus transport. Let's do as much as we can."
The back doors slammed shut and the chaos began. Supplies were flying, all of us yelling out findings over each other.
"Airway is patent, but he's snoring. Jaw clenched, get a non-rebreather on him."
"Pupils unequal. Left is blown and unreactive, right is reactive."
"Pulse still strong at the radial at 140, pressure is 110, lets drop another line."
"Left leg is broken, compound fractures at the tib/fib. I'm leaving the pant leg on because it's controlling the bleeding."
"Pelvis is stable, abdomen is clear so far."
"I've got another line, right bicep, running wide open." I said, with a sigh of relief. The firefighter grinned at me again and slapped my back.
"Good stick, kid." He said. I smiled meekly back at him.
Grabbing my stethescope, I attempted to listen to his lungs over all of the noise. His chest expansion looked odd, but I couldn't quite put a finger on why.
Right lung... Concentrate, listen, drown out all of the other noise and listen..
Grunting, but he was moving air.
Left lung.. Listen, concentrate.
Nothing.
I pulled the bell of the stethescope back up and tapped it to ensure it was working. I heard the "thump thump" of my finger clearly in my ears. I put the bell back down on his left side.
Nothing.
"Right is clear, just grunting. Left is absent." I said, pulling the stethescope off my ears and looking at Tracy. She stopped midway through cutting the collar of his shirt off and looked at me.
"You're sure it's absent? Maybe it's just diminished."
"I'll check again." I said.
I listened again over his left side, tapping his chest wall with my fingers. It felt full, not hollow. There was blood in his chest cavity.
"Absent. His oxygen sat is holding at 98, but there's nothing there."
She nodded again and said "Okay, since his sat is holding we'll leave it. If he starts to drop you'll have to dart him."
I nodded and gulped. A chest decompression? That's such a rare skill to utilize in a paramedic's career, let alone as an intern. I shook my fear and continued re-assessing him. The fire-medic gave a radio report, which I was thankful for because I don't think I would have been able to get the words out as fast as my brain thought them to let the hospital know we were coming. I listened intently as I tried to control bleeding and check the man's pupils again.
"Trauma base, this is Paramedic Gavin on medic 12 enroute to your facility code 3 with a 15 minute ETA. On board we have a 40 year old male involved in a single vehicle accident, truck versus side of a mountain, off the pass. Extensive cab intrusion, patient is unconscious with snoring resps. We have unequal pupils, no obvious head trauma, absent lung sounds on the left with a sat of 98 on 15 liters. Compound tib/fib fractures on the left, no other significant findings. Pressure is holding at 120, we have 2 large bore IVs established. Pulse is 140 and sinus tach on the monitor, he is positive for ETOH, unless you have anything further for us we'll see you on the other side."
"Trauma base copies medic 12, nothing further for you. Trauma team will see you in trauma bay 1 upon arrival."
"Medic 12 copies."
The remaining 15 minutes in the rig passed quickly as we continued to assess and stabilize him. When we suddenly came to a stop and I saw the lights from the trauma center gleaming into the back of the rig, I was surprised we had gotten there so quickly. We pulled him out, trailing blood and guaze and wires behind us, and into the trauma bay. The staff descended on him, and I quickly gave the doc a run down of what we found while he did his assessment, shouting out findings between my report.
"Head is normal, no obvious trauma. Pupils unequal, can we get respiratory in here to RSI him? No JVD, trachea midline. Where's that o2 mask? Lungs absent on the left, I think it's a hemo[thorax]. Abdomen is clean, pelvis stable. Compound tib/fib on the left with major bleeding, we'll need lab up here with a type and cross. Prep an OR, let's get him in."
We left the ER as the sun was coming up. The fire-medic jumped in the back and joked with all 3 of us while we drove him back to his station. I smiled and let out a few chuckles, but I was exhausted and my head was spinning. When we got back to station, Tracy handed me my paperwork for the day and I left for my 2 hour drive home.
On the way home, I pulled off the road and stopped in an empty parking lot. I slowly pulled my shaking hands from the steering wheel and into my lap as I leaned my head down onto the dash. Tears streamed down my face and I wiped them away quickly. I don't know who I was trying to hide it from, no-one was around, but I was still embarrassed that the call had bothered me so much.
I was angry that the guy was drunk. He could have easily killed someone, and he may have killed himself. I was upset with myself for not taking better control of the call, but I knew it was just a bad call and I couldn't let it get to me.
We still wonder if the guy made it. We never found out what happened to him.
I still wonder if I wish he had made it.
Medic 12, please respond code 3 to (freeway exit) near the entrance of (campground) and (lake) for an MVA.
It was 3 am, so I groggily dragged myself from my bed on the couch as soon as I heard my preceptor's tones go off in the next room. I quickly wiped the sleep from my eyes, buttoned my shirt and ran out to the rig. I grabbed gloves and slipped them on, checked my pockets for a pen and sat in the jump seat. My preceptor and her partner climbed in shortly after and we were off.
"Where is it? I can't see it on the map. Oh, there it is. Shit, it's on the pass." My preceptor was talking to her partner while looking on the computer for directions. I tensed as I heard this, the pass was a difficult road to navigate and accidents up there were usually not minor.
"Oh, dispatch is updating the info..Let's see here... Male driver is not conscious, unknown if he is breathing... There is serious blood loss.. Shit." This time, she was speaking to no one in particular, but after saying this, turned to me and spoke again.
"This is going to be bad, and I'm not saying that to scare you, okay? I just want you to know it's going to be bad. Be ready for the worst."
I sat back in my seat, buckled my seat belt and closed my eyes. Taking deep breaths, I tried to calm myself. Opening my eyes again, I saw flashing lights in the distance behind us.
I turned back towards the front of the rig.
"Tracy.. Fire is behind us. Like, wayyy behind us."
"What?! Oh, crap. We're gonna get there first."
What seemed like an eternity passed before my partner, Sarah, slowed to a stop.
"PD is here. Where is the-... Shit, there it is. This is bad."
Because I had been in the back, I had not yet seen what Sarah and Tracy saw. She pulled up further, in front of the wreck, and flashing lights illuminated a truck behind us. From the rig I could see that the truck was unrecognizable as having once been a vehicle. It looked like a ball of twisted metal, and as the lights flashed over it, I caught quick glimpses of an arm dangling from what used to be the driver's side. I jumped out, throwing my reflective vest on, and ran to the truck. A man in plain clothes approached me quickly, flashlight in hand, and started talking to me.
"We were just camping down by the lake. We heard him hit the side of the mountain and came up to make sure everyone was okay. I don't think he's breathing. We've been looking for other people but we don't see anyone, just car parts strewn everywhere."
I nodded quickly and ran past him to the arm hanging from the wreck. I grabbed it, and held his wrist for a few seconds before yelling out to Tracy, "Strong radial pulse. Snoring respirations. We wont be able to get him out though."
She came up behind me and also grabbed the arm. From where we stood, what used to be the driver's door was now a tiny opening from which we could see his head, facing the passenger side, and his arm. Nothing else was in view. The engine was in his lap, the steering wheel over his right shoulder. The truck was angled up, and access through the passenger side was out of the question. The smell of alcohol was drifing from the car, and it was strong. He was drunk.
The fire department arrived and we stood back, waiting for them to extricate him. Cables were running everywhere, loud generators drowned out any noise as they fired up the Jaws of Life. One of the firefighters, also a medic, turned to me.
"If you grab me your IV bag, I'll get a line for you on this arm. Just don't get too close, okay kid? The truck isn't stable, I don't want you getting hurt."
I nodded and ran back to the rig for my IV bag. Once there, Tracy stopped me and quickly said, "Everything out, get everything ready. Your airway bag, the gurney with a backboard. Everything." I nodded again and pawed at my trauma bag, ripping out everything, opening it and throwing it on the bench seat.
Airway kit, check.
Gurney with backboard, check.
Line spiked... Sarah is working on it, check.
IV bag..
I grabbed it and dashed back to the firefighter. He quickly established a 16 guage IV and ran it wide open, throwing the bag towards me.
"Hold this, and squeeze. It's gonna be awhile before we can get him out."
I stood back, IV bag tightly in my hands as I weaved in and out of the firefighters with the IV line, trying to untangle them all as they rushed around the truck. Tracy stood beside me, yelling things back to Sarah who was preparing the rig.
"Get the fast patches out and hooked up. Oh, and another line spiked please. Is the gurney ready to go?"
Tracy turned back to me and spoke quietly.
"How are you doing?"
"I'm okay. I'm scared for this guy. What if they take the dashboard off of him and he codes? What if he's not even in once piece under all of that shit?"
"I know. He's gonna be bad. Just be ready for him to code. We're all scared for him."
"It's been almost 20 minutes." I said quietly, dropping my gaze to the ground.
The fire-medic turned towards us. "He's almost ready, get the gurney over here."
Tracy took the IV bag and nodded for me to go help Sarah. We grabbed the gurney and backboard, wheeling it around all the cables and glass, and up to the driver's side. Suddenly, the man was plopped onto the backboard and we were all feverishly strapping him in, securing his neck with a collar while lifting the gurney and running back to the rig. "We need a rider, who wants to come?" Tracy yelled back to the firefighters. One of the younger guys, another medic, came running up and jumped in. "I'll go," he said, smiling at me, while he sat down on the bench and began cutting the man's clothes off.
"Okay. We're taking him straight to the trauma center, bypassing the local ER. Probably gonna be a 45 minute plus transport. Let's do as much as we can."
The back doors slammed shut and the chaos began. Supplies were flying, all of us yelling out findings over each other.
"Airway is patent, but he's snoring. Jaw clenched, get a non-rebreather on him."
"Pupils unequal. Left is blown and unreactive, right is reactive."
"Pulse still strong at the radial at 140, pressure is 110, lets drop another line."
"Left leg is broken, compound fractures at the tib/fib. I'm leaving the pant leg on because it's controlling the bleeding."
"Pelvis is stable, abdomen is clear so far."
"I've got another line, right bicep, running wide open." I said, with a sigh of relief. The firefighter grinned at me again and slapped my back.
"Good stick, kid." He said. I smiled meekly back at him.
Grabbing my stethescope, I attempted to listen to his lungs over all of the noise. His chest expansion looked odd, but I couldn't quite put a finger on why.
Right lung... Concentrate, listen, drown out all of the other noise and listen..
Grunting, but he was moving air.
Left lung.. Listen, concentrate.
Nothing.
I pulled the bell of the stethescope back up and tapped it to ensure it was working. I heard the "thump thump" of my finger clearly in my ears. I put the bell back down on his left side.
Nothing.
"Right is clear, just grunting. Left is absent." I said, pulling the stethescope off my ears and looking at Tracy. She stopped midway through cutting the collar of his shirt off and looked at me.
"You're sure it's absent? Maybe it's just diminished."
"I'll check again." I said.
I listened again over his left side, tapping his chest wall with my fingers. It felt full, not hollow. There was blood in his chest cavity.
"Absent. His oxygen sat is holding at 98, but there's nothing there."
She nodded again and said "Okay, since his sat is holding we'll leave it. If he starts to drop you'll have to dart him."
I nodded and gulped. A chest decompression? That's such a rare skill to utilize in a paramedic's career, let alone as an intern. I shook my fear and continued re-assessing him. The fire-medic gave a radio report, which I was thankful for because I don't think I would have been able to get the words out as fast as my brain thought them to let the hospital know we were coming. I listened intently as I tried to control bleeding and check the man's pupils again.
"Trauma base, this is Paramedic Gavin on medic 12 enroute to your facility code 3 with a 15 minute ETA. On board we have a 40 year old male involved in a single vehicle accident, truck versus side of a mountain, off the pass. Extensive cab intrusion, patient is unconscious with snoring resps. We have unequal pupils, no obvious head trauma, absent lung sounds on the left with a sat of 98 on 15 liters. Compound tib/fib fractures on the left, no other significant findings. Pressure is holding at 120, we have 2 large bore IVs established. Pulse is 140 and sinus tach on the monitor, he is positive for ETOH, unless you have anything further for us we'll see you on the other side."
"Trauma base copies medic 12, nothing further for you. Trauma team will see you in trauma bay 1 upon arrival."
"Medic 12 copies."
The remaining 15 minutes in the rig passed quickly as we continued to assess and stabilize him. When we suddenly came to a stop and I saw the lights from the trauma center gleaming into the back of the rig, I was surprised we had gotten there so quickly. We pulled him out, trailing blood and guaze and wires behind us, and into the trauma bay. The staff descended on him, and I quickly gave the doc a run down of what we found while he did his assessment, shouting out findings between my report.
"Head is normal, no obvious trauma. Pupils unequal, can we get respiratory in here to RSI him? No JVD, trachea midline. Where's that o2 mask? Lungs absent on the left, I think it's a hemo[thorax]. Abdomen is clean, pelvis stable. Compound tib/fib on the left with major bleeding, we'll need lab up here with a type and cross. Prep an OR, let's get him in."
We left the ER as the sun was coming up. The fire-medic jumped in the back and joked with all 3 of us while we drove him back to his station. I smiled and let out a few chuckles, but I was exhausted and my head was spinning. When we got back to station, Tracy handed me my paperwork for the day and I left for my 2 hour drive home.
On the way home, I pulled off the road and stopped in an empty parking lot. I slowly pulled my shaking hands from the steering wheel and into my lap as I leaned my head down onto the dash. Tears streamed down my face and I wiped them away quickly. I don't know who I was trying to hide it from, no-one was around, but I was still embarrassed that the call had bothered me so much.
I was angry that the guy was drunk. He could have easily killed someone, and he may have killed himself. I was upset with myself for not taking better control of the call, but I knew it was just a bad call and I couldn't let it get to me.
We still wonder if the guy made it. We never found out what happened to him.
I still wonder if I wish he had made it.
Saturday, July 10, 2010
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."
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."
Sunday, July 4, 2010
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?
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?
Thursday, November 12, 2009
Is it working for your patient?
3 weeks away from passing my paramedic class, I was on shift at work. My partner and I got a call for one of our regular dialysis patients. . .
"You wanna just head in?" Kyle asked me.
"Sure. Pick up is in 10 minutes but she's probably ready."
We're lead into the house by the home caretaker through the garage. As I approached our patient Mary, I heard her whimpering softly. She was lying in her bed which is set up in the middle of her large, ranch-style home. Her husband turned away from the TV only to greet us with a nod.
"Hi Mary. How ya feeling today?" I asked.
"Ooooh.. Ohhh owww.. My legs hurt... And my arms...Owwww ooohhh..." she moaned. I looked up at my partner and cocked my head to the side, giving him the 'this-don't-look-right' expression. We've been partners for awhile, so he understood immediately and held out his hand for the BP cuff and stethescope. I tried talking to her caretaker quickly to see if there was something else going on.
"No blood presha. Hard to get on her." she said in a thick accent.
"No blood pressure? Since when?"
"Tursday. Been seeek. No good."
"Ok. When was she dialyzed last?"
"MMmm... Friday. No, Saturday..ya."
"Hmm.. Ok so that's 2 days."
My partner looked up at me with obvious concern in his face. "Nothing. Can't hear a thing."
"Really? Let me see."
He handed the cuff and stethescope over and I wrapped the cuff around her arm and pumped it up to 180. I released the knob to allow the air to flow out, listening desperately for a heartbeat under her bicep. The needle jumped faintly around 60 but continued to fall rapidly. I heard nothing. I tried again, but this time the needle fell without a single twitch. I took the scope off and tried to palpate a pulse. No radial, no brachial, no carotid.
"Mary? Sweetie, you with me?"
"Ya honey. I'm ok. Just hurtin'. Owwww."
I looked over again at Kyle and shrugged. "She's alert and oriented. She probably just needs dialysis. Maybe she's just got too much fluid, causing the edema so it hurts and makes it hard to hear a pulse." I said.
He nodded again. "Should we go to the ER?"
I looked down at Mary. Since she's a regular patient, I know her well. She looked a little pale, but not bad. No trouble breathing, lungs sounded clear, but she definitely seemed ill.
"Her dialysis center is just next to the hospital. Let's head over and see how she does. If anything we can bring her into the ER if she gets worse."
He nodded again and we loaded her onto the gurney. As we walked out, I repeat to him what my paramedic instructor has drilled into my head; 'is it working for your patient?' Normally, a patient with no blood pressure and no pulse would be, well, very bad. In this case, my patient had what we call co-morbidity; a laundry list of medical problems that might contribute to her symptoms. She was awake and oriented, but in pain. There was obviously something wrong, but not necessarily life threatening. So, is it working for my patient? She was alive, and seemed basically okay.
We loaded her into the rig and I sat down beside her on the bench to do paperwork. I looked at her closely after a couple of minutes had passed. She looked strange, different than just a few minutes before.
"Mary? Mary, how are you doing?"
"Aw hun. Can you let the kitty in? She's crying. Oooohowww ohhh.."
"Mary, sweetie, do you know where you are?"
"Yea but my kitty is cryin'."
I frantically searched her again for a pulse, looking for anything that may have caused her sudden drop in mentation. I gingerly placed a finger on her neck and drowned out the diesel. I felt it. Very faint, and very fast, but it was there and it didn't feel too good. I poked my head through to the cab.
"Hey, divert to the ER. I'll call and update dispatch and have them notify. She's not okay. Don't turn on the siren just yet." I said softly. He nodded again in understanding and turned his worried face from the rearview back towards the road, focused on getting us there. When I sat back down and looked at her again, I realized what was making her look so strange. Her color had gone from slightly pale to downright gray. Almost jaundiced looking, her skin now held a yellow-green-gray color and her eyes looked sunken in and clouded. I kept talking to her, but she still wasn't making any sense, even though she had been just a few minutes prior. I called my dispatcher to update them on the situation, letting them know we would be taking her to the ER across the parking lot from the dialysis center. One of our newer dispatchers answered the phone.
"Sure. Pick up is in 10 minutes but she's probably ready."
We're lead into the house by the home caretaker through the garage. As I approached our patient Mary, I heard her whimpering softly. She was lying in her bed which is set up in the middle of her large, ranch-style home. Her husband turned away from the TV only to greet us with a nod.
"Hi Mary. How ya feeling today?" I asked.
"Ooooh.. Ohhh owww.. My legs hurt... And my arms...Owwww ooohhh..." she moaned. I looked up at my partner and cocked my head to the side, giving him the 'this-don't-look-right' expression. We've been partners for awhile, so he understood immediately and held out his hand for the BP cuff and stethescope. I tried talking to her caretaker quickly to see if there was something else going on.
"No blood presha. Hard to get on her." she said in a thick accent.
"No blood pressure? Since when?"
"Tursday. Been seeek. No good."
"Ok. When was she dialyzed last?"
"MMmm... Friday. No, Saturday..ya."
"Hmm.. Ok so that's 2 days."
My partner looked up at me with obvious concern in his face. "Nothing. Can't hear a thing."
"Really? Let me see."
He handed the cuff and stethescope over and I wrapped the cuff around her arm and pumped it up to 180. I released the knob to allow the air to flow out, listening desperately for a heartbeat under her bicep. The needle jumped faintly around 60 but continued to fall rapidly. I heard nothing. I tried again, but this time the needle fell without a single twitch. I took the scope off and tried to palpate a pulse. No radial, no brachial, no carotid.
"Mary? Sweetie, you with me?"
"Ya honey. I'm ok. Just hurtin'. Owwww."
I looked over again at Kyle and shrugged. "She's alert and oriented. She probably just needs dialysis. Maybe she's just got too much fluid, causing the edema so it hurts and makes it hard to hear a pulse." I said.
He nodded again. "Should we go to the ER?"
I looked down at Mary. Since she's a regular patient, I know her well. She looked a little pale, but not bad. No trouble breathing, lungs sounded clear, but she definitely seemed ill.
"Her dialysis center is just next to the hospital. Let's head over and see how she does. If anything we can bring her into the ER if she gets worse."
He nodded again and we loaded her onto the gurney. As we walked out, I repeat to him what my paramedic instructor has drilled into my head; 'is it working for your patient?' Normally, a patient with no blood pressure and no pulse would be, well, very bad. In this case, my patient had what we call co-morbidity; a laundry list of medical problems that might contribute to her symptoms. She was awake and oriented, but in pain. There was obviously something wrong, but not necessarily life threatening. So, is it working for my patient? She was alive, and seemed basically okay.
We loaded her into the rig and I sat down beside her on the bench to do paperwork. I looked at her closely after a couple of minutes had passed. She looked strange, different than just a few minutes before.
"Mary? Mary, how are you doing?"
"Aw hun. Can you let the kitty in? She's crying. Oooohowww ohhh.."
"Mary, sweetie, do you know where you are?"
"Yea but my kitty is cryin'."
I frantically searched her again for a pulse, looking for anything that may have caused her sudden drop in mentation. I gingerly placed a finger on her neck and drowned out the diesel. I felt it. Very faint, and very fast, but it was there and it didn't feel too good. I poked my head through to the cab.
"Hey, divert to the ER. I'll call and update dispatch and have them notify. She's not okay. Don't turn on the siren just yet." I said softly. He nodded again in understanding and turned his worried face from the rearview back towards the road, focused on getting us there. When I sat back down and looked at her again, I realized what was making her look so strange. Her color had gone from slightly pale to downright gray. Almost jaundiced looking, her skin now held a yellow-green-gray color and her eyes looked sunken in and clouded. I kept talking to her, but she still wasn't making any sense, even though she had been just a few minutes prior. I called my dispatcher to update them on the situation, letting them know we would be taking her to the ER across the parking lot from the dialysis center. One of our newer dispatchers answered the phone.
"Hey Mark. We're diverting to the ER, she's not looking good." I said quickly, almost whispering.
"Okay. Give me some vitals so I can let them know."
"Uh, that's the problem. I can't get any BP or pulse on her really. I can feel a weak, rapid carotid but nothing else. Sorry. Respirations are 24, unlabored and slightly shallow on 6 liters of oxygen, but her mentation just dropped and her color is all wrong."
"Uh, that's the problem. I can't get any BP or pulse on her really. I can feel a weak, rapid carotid but nothing else. Sorry. Respirations are 24, unlabored and slightly shallow on 6 liters of oxygen, but her mentation just dropped and her color is all wrong."
"Ok, so she's alive, you just can't feel a pulse or BP?"
"Yea. Just let them know we're coming in."
"Alright, thanks, I'll call right now."
We pulled into the ambulance bay and brought her in. Usually, BLS crews stand around waiting for upwards of 30 minutes for a bed in the ER, regardless of the patient'scondition. Today was different.
"Is this Mary?" a nurse asked me.
"Yea. Can't palpate or auscultate any BP or pulse. Caught a weak rapid carotid but lost it pretty quick. She's awake and talking but not making much sense and she's really ashen."
"Ok, bed 5. Hook her up to the monitor, let's try to get some vitals. Why didn't you call for paramedics on scene?"
"I, uh... I don't know. She looked okay, she just started... doing this... enroute. We thought she was okay." I replied, wheeling her into a room. A nurse came in and scowled at us, irritated with our lack of a full medical history and medications. I explained that her caretaker would be here any minute with all of that information, but she waved me away.
"Sixty over thirty, pulse 140. She's compensating, get the doctor in here." she yelled out the door suddenly. I spun around and stared at the monitor, disbelieving the numbers that had popped up.
"She was okay.... I don't understand... When we got there.... She was okay I thought.." I heard my voice trail off towards the end. I turned to walk out of the room and talk to our nurse when a doctor ran into me in the hall.
"Why didn't you ALS this?! This is NOT a BLS call!"
"Her mentation dropped enroute, and her color changed. She was alert and oriented on scene, even though we couldn't get a pulse, she didn't LOOK seriously ill."
He, like the nurse, waved me off and went into the room.
My partner and I left the ER like 2 puppies with our tails between our legs. We pulled out of the bay and parked down a nearby street so I could finish writing my report. I re-wrote the PCR at least 4 times, trying to detail everything so that I could unravel it all in my own head. Everything sounded right; at her house, she seemed to be doing alright. In the rig, she changed. I diverted to the ER like I was supposed to. So why did I feel like I had done something wrong? Kyle admitted his own guilt, saying he felt that he, too had done something wrong. When we got back into station we went over the call again with our supervisor.
"We just wanted to know what you would have done if you had been on the call."
He sighed and rested his head on his fist. "The same thing. I mean, it sounds like you guys did what you were supposed to. You're not going to get into trouble, you know. Screw the doctor, what were you supposed to do? You got her to the ER. You noticed the changes and you took her to the right place. It's not your fault, really."
"I know," I said, "and I'm not worried about getting into trouble. I'm worried that I did her wrong. That I didn't do all that I could have because I waved off the lack of pulses to her medical history. I feel like I should have caught it."
"You couldn't have possibly known. You did everything right." He replied.
I walked outside for a smoke and Kyle joined me.
"I feel a little better." He said suddenly, after a minute or two had passed in silence. I nodded in agreement. I felt a little better too, but still somewhat guilty. I brushed it off and got through the rest of my shift forcing myself not to think about it too much more.
Kyle called me the next morning while I was on my way to school.
"Mary died. At the hospital yesterday I think. I'm not really sure how, dispatch just told me. They called her house to see if we would be taking her to dialysis tomorrow and her husband said she passed away. I just thought you would want to know."
"Oh.. Yea. Um.. Thanks man." I said, slowly.
"Yea, no problem." he replied quietly.
He was silent for a second before speaking again. "I still feel bad."
"Yea, me too."
'Sixty over thirty, pulse 140. She's compensating.'
'Is it working for your patient?'
No. I thought it was, but I suppose I thought wrong.
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