Precepting

I'm assigned a paramedic student. And while I love students, I’m not too happy to be precepting this one. She is as close to clueless as you can get and still be allowed to ride.

I precepted her a couple weeks ago. She talked a good game so I figured it would be an easy day. We did a call for a violent psych. We get there and find four mental health workers holding down a screaming fifteen year old, one adult on each junior, though muscled limb. I call and get orders for ativan and benadryl. I draw up the ativan and hand it to her, then turn my back to draw up the benadryl. When I turn back, there is blood all over the place. I look at the patient’s AC, and see that is where the blood is coming from. She gave her an IM shot in the AC. The other medic, who was at the call, watching, says he was going to say something, but thought maybe they were teaching a new technique in school these days.

Today she blows an IV on a chest pain, blows it bad enough that I switch places and do the IV myself instead of giving her a second shot. I run off the 12-lead and ask her what she thinks. She looks at me for an answer. I show her the inverted T's in the anteroseptal leads.

"Reciprocal changes," she says.

I shake my head and show her there are no elevations in the any of the other leads.

"Should we do a right-sided ECG?" she asks.

I shake my head again.

At triage she tells the nurse there are reciprocal changes.

We go over it after the call. She looks at me, almost coldly like she is pissed that I am semi-scolding her. I’m not scolding. I am just telling her some of the basics of cardiology.

Her assessments are poor, her IV skills are terrible. We do a shooting, 18 year old shot in both arms in a drive by. Right elbow, left proximal humerous. He's alert, warm and dry. Good pulse. We get him in back. I tell my partner to drive. The student is already trying for an IV.

"How about a blood pressure?" I ask.

After she gets that, she goes right back to the IV. She uses a 16, and gouges a hole in the kid's AC, and grinds it so hard, the kid who's right elbow is completely shattered, shouts at her to stop.

I switch places again and pop an IV in.

In the trauma room, I am showing the trauma doctor, the bullet holes. Right elbow, left proximal humerous.

"What about there?" the doctor says pointing to the left AC. "There's a third."

"No, no, no," I say. "That's an IV attempt."I

t’s almost time to head in for the day. The student reluctantly hands me her evaluation papers, then we get a call for an unknown, not far from the hospital.

We show up and see the telltale relatives standing outside, urging us frantically to hurry. The fire department has arrived just before us.

"Step it up," a fire fighter says.

We charge in through the old house. I can hear people yelling and crying. When I get in the room, I see a man doing mouth to mouth on a woman who looks to be in her thirties. She has a dialysis port coming out of her naked chest. The fire guys are putting the defibrillator on. Shock advised. Shock.

I hand the rider our monitor and tell her to attach it. I tell the fire guys to start CPR, as we ease the family member out of the way, and I get out an ambu bag.The woman is in V-fib.

"Go ahead and shock," I tell the student.

I get out the intubation kit, lay the laryngoscope to the side of the woman's head, then stick a stylet in a tube and attach a syringe, as the student shocks again.

"Ready to tube," I ask her.

She looks surprised like she didn’t think after how the day had gone I was going to let her tube."

Go for it," I say.

She scoots to the head, and sticks the blade in her mouth. She seems to struggle with it.

"You've got it?" I ask. I'm not giving her a second change if she can't pass it.

"Yeah, yeah, I do."

And I see her pass the tube. I hand her the ambu-bag and it looks good. Check the lung sounds and they are present and equal.

“Good job,” I say.

We work the lady hard. She's got no IV access, and its dark in the room, so we move her out to the ambulance, where I put in an EJ, and we slam some IV drugs. She's still in and out of v-fib, and then settles into ventricular asystole. They work her for a little while at the hospital.

The student is ecstatic. She is wired, running around the ER like she just scored the winning basket in the NCAA championships, telling everyone about it in detail.

I see the family coming down the hall. They look distraught. I ease the student outside where she can do her funky chicken dance out of the family’s sight.

The truth is I am happy for her. She had a shitty day, then she got her code, got her first field tube. I remember when I got mine. I was just as excited.

I've been doing this for twelve years. The truth is I was clueless once too.

In the Dark

We're called for a stabbing.

Its dark and when we pull up on scene, we can see officers with guns drawn. We stage and wait the word to go in.

It's hard to tell what's going on, then another cop comes running out into the street right for us. We step out. "You're going to need your stretcher," he shouts, "and, and disinfectant, lots of it. Give me the strongest stuff you got. I got blood on me. He got HIV and he bleeding all over the place." The officer is hopping up and down and moving his hands like he's got posion ivy, but can't itch himself.

I grab a couple trauma dresssings and a box of vionex, which I hand to the officer.

We go down the hill behind the house and find six cops standing in the dark. They attack the box of vionex, shining their flashlights on each other as they scrub their hands.

I look around and see a body lying face down on the ground, handcuffed. "Can I get a light over here?" I ask. "Is this guy alive?"

"He's fine," an officer says. They are scrubbing each other like surgeons.

I shine my tiny pen light on the man. His eyes are closed, but I can see a little chest movement. He's got some lacerations about his head. His hair is matted with blood. Smells like etoh. He's got a nice steady pulse in his neck. Rate of 80. "You okay, buddy?" I ask.

He opens one eye, looks at me like he's bored, then closes it.

I look back at the officers. "You missed a spot," one says, shining his big mag light on the other's hands. "Right there."

Behind Every Door

I'm standing in triage with my patient when I find myself looking at a man standing unsteadily by the entrance to the ER. A security guard has his hand on the man's upper arm, both holding him up and keeping him from walking away. The guard tells the nurse. "I found him outside. What room does he belong in?"

"I put him in the East Wing about an hour ago," the nurse says.

I am staring at the man wondering where I know him from. I can't place him, but I know I know him.

By the computer there is a list of the demographics of recently placed patients. I see a name I recognize and it comes to me. My God. Its Dave Thomas. I grew up with him. He lived just down the street. I played little League baseball with him. Neighborhood basketball. I ran his campaign for student council president.

I watch as the guard leads him back to his room.

I ask the nurse who is taking care of him, what's his story.

"Him -- He's in here all the time." She makes a motion of a man downing a bottle.

Every now in this job there is a reality check, and this is one of them. Dave Thomas -- what happened? All that promise? What tragedy caused his life to unravel? Or was it preprogrammed in his genes?

You deal with drunks all the time. Each one of them was someone's child friend, someone who was looked up to, someone with promise.

You just don't think about that.

***

I get a letter from my college girlfriend and we take up a correspondence. I learn that her husband died of brain cancer five years before. She tells me about the hospital trips, the feeding tubes, and cleaning. It is hard to imagine something like that happening to her, of her having to go through with all the pain and hardship.

I wheel my stretcher down the hall of a hospital floor. In each open door, I see a family member watching a sick relative, a room of balloons and flowers and heartache.

Now she is behind every door.