Tuesday, January 19, 2010
Why so serious?
Ask just about anyone who works in the fire service or EMS, and they will tell you one of our major coping mechanisms is humor. Not every emergency can be an emotional investment that leaves you feeling drained at the end. It would never work like that. It's no place to wear your heart on your sleeve.
As a result, lots of things become funny. Perhaps some things that normally wouldn't be funny. Now I'm not saying that we laugh in faces, usually at situations. And usually back at the firehouse. But sometimes...life is life.
The cops called us out the other day to assess an elderly man that they thought needed medical attention. He had originally called 911 stating that there was "someone in the house." There wasn't, and the more the officers talked to him, the more confused he appeared. That's when we stepped in.
His house was neat, and seemingly unchanged since the 60s--I could have been on the set of Madmen. A small and very Italian man sat in front of me. He was very upset that the neighborhood was out to get him, and that someone had been stealing his pills. I then asked him a serious of standard questions aimed at determining an individual's mental status: where are you, what date is it, who is the president, etc. Here's how our conversation went:
Patient: They're stealing my medications!
Me: I understand, that is concerning. Now, I have some silly questions for you. What month is it?
Patient: March!
Me: Are you sure?
Patient: Well, March comes after February, doesn't it?!
Me: Okaaay...well, who's the president:
Patient: You know who it is.
Me: I know. But could you tell me please?
Patient: Oh, its....Um. Well, it's Mr. Obbaajee Goobajee Schmoobly.
Me: Come again?
Patient: You know, Mr. Wheegee Agits Wharaa.
At this point, the man's clock behind me chimed the hour: "Cuckoo! Cuckoo! Cuckoo!"
Suddenly there was stifled laughter from around me, and in the next moment I was alone in the room as the rest of the crew was outside collecting themselves.
We never did find out if someone was stealing his medications. I think not. I would have gone for the clock first.
Wednesday, January 13, 2010
Leaving
Death in the field is a curious thing. I know it's something I've explored once before in my short list of posts. People die, obviously, everyday outside the hospital. Apart from a hospice situation, this usually means that we are called. We are called both to verify death and on the outside chance that perhaps this person can be resuscitated.
To be toned as a DOA, however, means the dispatcher has information that points to no resuscitation. Cold. Blue. Stiff.
Some situations are sad. The man alone in a cheap motel room, takeout dinner on the bed next to him, french fries his only company. The husband of fifty years whose wife "just hasn't been able to wake him." Anyone young. Others are merciful. Cancer patients come most often to mind, their bodies ravaged by pain and disease.
The thing of it is, it isn't the ones that have died that bother me. The situations can be painful, or awkward, or scary. But at the end of the day it isn't a load that I bear.
It's the ones that are dying that are imprinted on my mind. There is one in particular, the first of my career, that I think will always stick with me. Here is that memory.
************
It's a cool fall afternoon, and I was brand new on the ambulance. My uniform still had creases in it, and my boots were shiny and unscuffed. The call came in as a "core." In EMS-speak, this is someone who has gone into cardiac arrest. It can be a very dramatic call, but usually one with the same outcome. The national cardiac arrest "save" percentage (that is, the patient leaves the hospital breathing) is 2%. It is often an exercise in futility, a last ditch effort to safe a life.
I don't really remember the house coming into the call. I was a swirl of nerves, wanting to well both in front of my peers and for the patient. We find him upstairs in the bathtub. He looks young. Too young to have this happen. It appears he may have suffered a significant cardiac event and slipped under the water. A limp, wet body is not easy to heave out of the tub. Once out, we start a sort of odd dance. CPR is started, the cardiac monitor hooked up. A tube is pushed down his through to breathe for him, while an IV is started and drugs are pushed in the hopes of restarting his heart.
As the new guy, I was on CPR. It's harder than it appears in class. Instructors aren't kidding when they say you tire quickly doing compressions. I pressed hard and fast, feeling a stomach-turning crunch under my hands as I pumped. Sweat poured from my face as I looked at others working smoothly and seemingly without stress.
The lead paramedic makes the decision to transport. Still doing compressions, we load the patient on a backboard and begin to carry him out to the ambulance.
Leaving the house, my tunnel vision lifted. We walked out of a master bedroom, down a hallway. From a doorway, a girl of no more than six stands, phone held limply at her side. She must have called 911. We move as quickly as we can down the stairs. My lungs heave with the effort, and I notice the smell of fresh chocolate cookies permeating the house. Downstairs, we quick-step through the kitchen through which I can see the back door and the ambulance. Time stops as shadows darken the back door. Through it appear a teen boy and a woman who appears the same age as the patient. Their faces showed a raw human emotion I don't think I can put into words. His family.
Time started again, and we moved to the ambulance. I believe a police officer comforted the family. The rest of the call is again a blur--lights flashing and sirens blaring to the hospital, my compressions continuing the whole way. Our patient became one of the 98% that day.
It stays with me as motivation. It moves me to strive to find that 2% patient I can help. To do what I can so no family loses a loved one early. Because I still remember the smell of chocolate chip cookies.
To be toned as a DOA, however, means the dispatcher has information that points to no resuscitation. Cold. Blue. Stiff.
Some situations are sad. The man alone in a cheap motel room, takeout dinner on the bed next to him, french fries his only company. The husband of fifty years whose wife "just hasn't been able to wake him." Anyone young. Others are merciful. Cancer patients come most often to mind, their bodies ravaged by pain and disease.
The thing of it is, it isn't the ones that have died that bother me. The situations can be painful, or awkward, or scary. But at the end of the day it isn't a load that I bear.
It's the ones that are dying that are imprinted on my mind. There is one in particular, the first of my career, that I think will always stick with me. Here is that memory.
************
It's a cool fall afternoon, and I was brand new on the ambulance. My uniform still had creases in it, and my boots were shiny and unscuffed. The call came in as a "core." In EMS-speak, this is someone who has gone into cardiac arrest. It can be a very dramatic call, but usually one with the same outcome. The national cardiac arrest "save" percentage (that is, the patient leaves the hospital breathing) is 2%. It is often an exercise in futility, a last ditch effort to safe a life.
I don't really remember the house coming into the call. I was a swirl of nerves, wanting to well both in front of my peers and for the patient. We find him upstairs in the bathtub. He looks young. Too young to have this happen. It appears he may have suffered a significant cardiac event and slipped under the water. A limp, wet body is not easy to heave out of the tub. Once out, we start a sort of odd dance. CPR is started, the cardiac monitor hooked up. A tube is pushed down his through to breathe for him, while an IV is started and drugs are pushed in the hopes of restarting his heart.
As the new guy, I was on CPR. It's harder than it appears in class. Instructors aren't kidding when they say you tire quickly doing compressions. I pressed hard and fast, feeling a stomach-turning crunch under my hands as I pumped. Sweat poured from my face as I looked at others working smoothly and seemingly without stress.
The lead paramedic makes the decision to transport. Still doing compressions, we load the patient on a backboard and begin to carry him out to the ambulance.
Leaving the house, my tunnel vision lifted. We walked out of a master bedroom, down a hallway. From a doorway, a girl of no more than six stands, phone held limply at her side. She must have called 911. We move as quickly as we can down the stairs. My lungs heave with the effort, and I notice the smell of fresh chocolate cookies permeating the house. Downstairs, we quick-step through the kitchen through which I can see the back door and the ambulance. Time stops as shadows darken the back door. Through it appear a teen boy and a woman who appears the same age as the patient. Their faces showed a raw human emotion I don't think I can put into words. His family.
Time started again, and we moved to the ambulance. I believe a police officer comforted the family. The rest of the call is again a blur--lights flashing and sirens blaring to the hospital, my compressions continuing the whole way. Our patient became one of the 98% that day.
It stays with me as motivation. It moves me to strive to find that 2% patient I can help. To do what I can so no family loses a loved one early. Because I still remember the smell of chocolate chip cookies.
Friday, January 8, 2010
Close to Home
I think it's tough to write a post about what I do without sounding cliché. To me, that is. I read other paramedic blogs, or books, and see TV. So sometimes it's hard to write about a topic that has been elsewhere covered and not say what everyone has already said. BUT....I guess most everyone else doesn't know what is said, or what happens. And I remind myself I write this for me anyway. It's a way of processing.
So often in the field we deal with death. Yes, every once in a great while we deal with new life, but more often it is the end of life that we come in contact with. And, for the most part, I'm ok with it. It's not that it doesn't affect me, but I'm able to keep most of it at arms length. It's someone else's emergency. I don't think I'd be very good at what I do if I wasn't able to do this. EMS is not somewhere to wear one's heart on their shirtsleeve.
But death close to home. That's something else. Something I don't do well with. Something I compartmentalize and shut away, to deal with another day. There have been passings in the family recently. People my parents were closer to than I. But that made me take stock of my reality more than I care to. A friend's mother is passing. This too, hits close to home and makes me think of my parents. It's draining, these emotions. I'm not sure what to do or where to put them. I suppose that will come with time. The silver lining? At a memorial service reading recently, a few lines of prose were read that gave meaning to what I do, what I want to do. It's incorrectly attributed to Emerson--it's author is unknown, perhaps Betty Stanley. The part that meant something to me was this:
"To know that even one life has breathed easier because you have lived
This is to have succeeded."
So often in the field we deal with death. Yes, every once in a great while we deal with new life, but more often it is the end of life that we come in contact with. And, for the most part, I'm ok with it. It's not that it doesn't affect me, but I'm able to keep most of it at arms length. It's someone else's emergency. I don't think I'd be very good at what I do if I wasn't able to do this. EMS is not somewhere to wear one's heart on their shirtsleeve.
But death close to home. That's something else. Something I don't do well with. Something I compartmentalize and shut away, to deal with another day. There have been passings in the family recently. People my parents were closer to than I. But that made me take stock of my reality more than I care to. A friend's mother is passing. This too, hits close to home and makes me think of my parents. It's draining, these emotions. I'm not sure what to do or where to put them. I suppose that will come with time. The silver lining? At a memorial service reading recently, a few lines of prose were read that gave meaning to what I do, what I want to do. It's incorrectly attributed to Emerson--it's author is unknown, perhaps Betty Stanley. The part that meant something to me was this:
"To know that even one life has breathed easier because you have lived
This is to have succeeded."
Drowning
The ambulance's siren wails ahead of us as my partner navigates through suburban traffic. I adjust the elastic strap that holds my safety glasses tight against my head. I only use the strap when I think I'll really need to keep them on. An "unconscious party" is one of those times. I'm prepared for the absolute worst--a "core," or someone in cardiac arrest. The thought is, if you're prepared to pull out the big guns for the worst case scenario, then there is less of a chance of being surprised on scene. In my mind, I run through drug dosages and ACLS algorithms.
I grab the airway bag, leaving the rest of the gear for my crew to grab as I navigate through the ranch home that stinks of cigarettes.
I can hear my patient before I can see her. It's the oddest sound. Her breathing--it sounds like someone blowing bubbles underwater. An obese, elderly woman lies semi-upright against a mountain of pillows in a dirty bed. She makes no acknowledgement of my presence, her entire existence focused on her next breath. An oxygen cannula hangs crookedly from her nose, her son awkwardly fiddling with it as he explains no one knows how long she has been like this. The family, as is often the unfortunate case, is of little help. Either from an ignorance of her condition or the stress of the situation, they offer little in the way of a medical history, and barely a name. I take a quick listen to her lungs, redundant in retrospect as it merely confirms the gurgling that I can hear across the room.
For all purposes, she is unconscious. On demand, she opens her eyes to me. But there is no fear, or panic. Just defeat. Her congestive heart failure has filled her lungs with fluid, and she is drowning.
This is a patient to move quickly with. My crewmates struggle and place the patient in a chair they've found in the next room--more expedient than returning outside to grab the ambulance's specialized chair. A circus of oxygen tubing, bags and people, we make our way down the hallway to the stretcher. An oxygen mask is placed on the patient and as the stretcher makes its way to the ambulance I formulate my plan of care.
Through my direction, a bag of saline is spiked for an IV, the patient is loaded, a second paramedic is assigned to the back with me for the ride in and vitals are taken. But not taken. My FI reminds me we can do this on the way to the hospital, and in the interest of time I belay the last. No matter though, as a minute ticks by as my lieutenant shows up with the proverbial wrench in the monkey works: the patient is in hospice care with a DNR. This means that the patient is in end of life care, and in the event of cardiac arrest does not wish to be resuscitated. This, for the moment, does not change my care. The patient still deserves and wishes care and comfort for her condition. But it puts in a brief question in mind of how to proceed: is this a priority patient to rush to the hospital? Though there was some debate, the answer in my mind was clear: yes. This patient deserved to be made as comfortable as quickly as possible, and if nothing else this young paramedic did not want her dying in the back of HIS ambulance.
The doors slam shut and our new guy takes off lights and sirens to drive us to the hospital. As is always the admonishment, we caution him to take it "nice and easy" and to "mind the bumps." Either way, an emergent return to the hospital is usually like trying to do patient care inside a paint mixer.
While my partner obtains vital signs and looks for an IV, my first order of business is her airway. I pull out CPAP, a positive pressure airway mask. It is a slightly medieval looking device that straps to a patient's head, but the oxygen forced into their lungs can push enough fluid out of the way to drastically improve breathing. My patient submits to the mask easily, and the audible sound of gurgling goes away.
Cardiac monitor on. Vitals taken. IV attempted, unsuccessful. Again, this time successful. Nitro given, lasix pushed, all to try and relieve some of the fluid on her lungs. All the while, I look from the patient to the airway kit I have laid out beside me. Mentally, I figure that I'll try a 7.5 tube to intubate the patient if she becomes unconscious.
Through this the ambulance siren wails, cars whiz by, and every bump is amplified.
After what seems like an eternity, we arrive at the hospital. In we go, a tangle of wires and tubes. A quick report to the ED doc and my job is done. It is, technically, a success for us: our patient was still breathing on her own when we arrived.
While we clean up and I write my report, my self-critique of the call begins. We could have moved faster. Got her on CPAP faster. I think that I probably should have tried to nasally intubate this patient. I think she was borderline in our protocols for CPAP. But intubation wouldn't have pushed that fluid out of the way. Perhaps CPAP was the right choice. My FI says I did fine. But I still question. As I write my report I calm down. My FI joins me in the EMS break room and says he saw our patient go into V-fib in the room, briefly. What? I'm nervous again, thinking that I somehow missed the patient doing that on our monitor. A careful review of the strips, and my worries are assuaged. Report done, pram clean. Our unit clears, ready for the next call, but my mind lingers on the what if.
I grab the airway bag, leaving the rest of the gear for my crew to grab as I navigate through the ranch home that stinks of cigarettes.
I can hear my patient before I can see her. It's the oddest sound. Her breathing--it sounds like someone blowing bubbles underwater. An obese, elderly woman lies semi-upright against a mountain of pillows in a dirty bed. She makes no acknowledgement of my presence, her entire existence focused on her next breath. An oxygen cannula hangs crookedly from her nose, her son awkwardly fiddling with it as he explains no one knows how long she has been like this. The family, as is often the unfortunate case, is of little help. Either from an ignorance of her condition or the stress of the situation, they offer little in the way of a medical history, and barely a name. I take a quick listen to her lungs, redundant in retrospect as it merely confirms the gurgling that I can hear across the room.
For all purposes, she is unconscious. On demand, she opens her eyes to me. But there is no fear, or panic. Just defeat. Her congestive heart failure has filled her lungs with fluid, and she is drowning.
This is a patient to move quickly with. My crewmates struggle and place the patient in a chair they've found in the next room--more expedient than returning outside to grab the ambulance's specialized chair. A circus of oxygen tubing, bags and people, we make our way down the hallway to the stretcher. An oxygen mask is placed on the patient and as the stretcher makes its way to the ambulance I formulate my plan of care.
Through my direction, a bag of saline is spiked for an IV, the patient is loaded, a second paramedic is assigned to the back with me for the ride in and vitals are taken. But not taken. My FI reminds me we can do this on the way to the hospital, and in the interest of time I belay the last. No matter though, as a minute ticks by as my lieutenant shows up with the proverbial wrench in the monkey works: the patient is in hospice care with a DNR. This means that the patient is in end of life care, and in the event of cardiac arrest does not wish to be resuscitated. This, for the moment, does not change my care. The patient still deserves and wishes care and comfort for her condition. But it puts in a brief question in mind of how to proceed: is this a priority patient to rush to the hospital? Though there was some debate, the answer in my mind was clear: yes. This patient deserved to be made as comfortable as quickly as possible, and if nothing else this young paramedic did not want her dying in the back of HIS ambulance.
The doors slam shut and our new guy takes off lights and sirens to drive us to the hospital. As is always the admonishment, we caution him to take it "nice and easy" and to "mind the bumps." Either way, an emergent return to the hospital is usually like trying to do patient care inside a paint mixer.
While my partner obtains vital signs and looks for an IV, my first order of business is her airway. I pull out CPAP, a positive pressure airway mask. It is a slightly medieval looking device that straps to a patient's head, but the oxygen forced into their lungs can push enough fluid out of the way to drastically improve breathing. My patient submits to the mask easily, and the audible sound of gurgling goes away.
Cardiac monitor on. Vitals taken. IV attempted, unsuccessful. Again, this time successful. Nitro given, lasix pushed, all to try and relieve some of the fluid on her lungs. All the while, I look from the patient to the airway kit I have laid out beside me. Mentally, I figure that I'll try a 7.5 tube to intubate the patient if she becomes unconscious.
Through this the ambulance siren wails, cars whiz by, and every bump is amplified.
After what seems like an eternity, we arrive at the hospital. In we go, a tangle of wires and tubes. A quick report to the ED doc and my job is done. It is, technically, a success for us: our patient was still breathing on her own when we arrived.
While we clean up and I write my report, my self-critique of the call begins. We could have moved faster. Got her on CPAP faster. I think that I probably should have tried to nasally intubate this patient. I think she was borderline in our protocols for CPAP. But intubation wouldn't have pushed that fluid out of the way. Perhaps CPAP was the right choice. My FI says I did fine. But I still question. As I write my report I calm down. My FI joins me in the EMS break room and says he saw our patient go into V-fib in the room, briefly. What? I'm nervous again, thinking that I somehow missed the patient doing that on our monitor. A careful review of the strips, and my worries are assuaged. Report done, pram clean. Our unit clears, ready for the next call, but my mind lingers on the what if.
First Overdose
We are called to a small, one level apartment complex. A low rent, 10 unit place, with a blandness that blends it into the surroundings were you not looking for it. As we pull up, two men peer out from under an old gold Cadillac up on blocks while two children look up curiously from where they were playing in the broken asphalt of the parking lot. Our customer lives in the corner unit. His daughters, who can't be more than 16 and 12, found him. Tears paint the younger girls face, while the older girl, still on the phone with our dispatchers, points us to the bathroom with an exasperated expression. He took a bunch of these pills, she says, thrusting empty bottles of Oxycodone at me.
I walk in to find a middle-aged man slumped in the bathtub, legs hanging over and head on his chest, barely breathing. A syringe and burnt spoon stick out of his pocket. The syringe has been recapped, and I appreciate his thoughtfulness. He doesn't respond to me, nor the sharp sternal rub. The engine medic and I pull him out of the tub and into the hallway, onto the scoop board there. Our customer is covered in sweat, and slides too easily as we adjust him on the board and his head runs into the top with a dull thud. I decide it's the least of my worries. I'm wrapped up in what I need to do for this man, to bring him back from what he's done to himself. My crew knows what to do, but waits patiently for me to delegate tasks. They want to be sure I know what to do. Almost before I ask for it, the engine medic packages the patient onto the stretcher, while I insert an airway and begin to breath for our customer, while another crew member pushes Narcan into his nose. Narcan reverses the effects of narcotics, such as Oxycodone and heroin.
Still squeezing the BVM to force air into his lungs, we move the customer to our ambulance. My FI asks me what I'd like to do. I decide that we will get a full set of vitals in the ambulance, start an IV and obtain a sugar reading, to make sure our customer isn't diabetic as well. If the Narcan hasn't woken him up by then, I plan to place an advanced airway in his throat, to protect him from getting emesis into his lungs if he vomits.
In the ambulance, the man still doesn't move, even as crew carries out my tasks. I ready the airway kit, and am excited. I've never had a "field tube" before. But just as I am ready to go, my FI rubs the mans chest sharply again, and this time he groans and opens his eyes. Damn. Good for him, bad for me. No field tube this time. I put my equipment away, and announce that we're ready to go to the hospital. As we bump down the road, the customer slowly regains consciousness. We remove the nasal airway and he is able to talk with us.
What did you take? Heroin. It was my first time. What about these pills? Oh yeah, those too. Any alcohol? A pint. Were you trying to kill yourself? Nah, nah. I'm ok.
These are the questions I ask, but the unasked ones float in my head. Why are you lying? This isn't your first time. What kind of role model are you to your daughters? But we aren't there to fix his social problems. Just keep him alive till his next fix.
New Beginnings
I first got involved in EMS when I was in high school, on the grounds that it "looked cool." Having been bit by the bug, I went on to volunteer for a fire department and work for a couple of different private ambulance services throughout college. Although I have a collegiate business background, I was compelled to pursue this new passion of emergency services after college. I now work as a paramedic/firefighter for a busy urban/suburban fire department.
At one point, I believed that the fire service held all things present and future for my life. After experiencing a drop of medicine in paramedic school, however, I find myself longing for more involvement in medicine. As a result, I am perhaps working my way towards a career as a physician associate.
These posts are a result of my time on the street. They are a chronicle of real calls and the reflections stemming from them. I will attempt, at first, to backtrack a bit. I want to start from the end of paramedic school--with my first days as a medic on the street.
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