I have a new preceptee again, and while we have been busy, most of our ALS calls – even our good ones -- have been routine – CVA/TIA, chest pain, asthma, dislocated shoulder, allergic reaction, pneumonia, nausea and vomiting. Lots of IV, 02, monitor with the basic drugs – NTG, Aspirin, albuterol, solumedrol, benadryl, zofran, morphine. I think the CVA that was really just a TIA was the only one we went lights and sirens to the hospital on. These calls are all good for getting into a routine, but as always, we need the knee buckling calls – the shooting to the head, the respiratory arrest, the tombstone ST MI.
Last week we get called for the patient not responding. Sounds like it has a possibility to be a code, but when we get the update – lethargic and low blood pressure, I think not. “Visiting nurse call,” I say. “Gotta be.” Whenever we go to a private home and the EMD update includes a blood pressure, it usually means there is a visiting nurse on scene, and if there is a visiting nurse, then it usually isn’t too bad of an emergency. After all the visiting nurse came by on a schedule. The patient or their family didn’t call.
The seventy eight year old woman is sitting up in bed. Her hands are cold and she says she doesn’t feel too well, and hasn’t been for a couple days. The visiting nurse asks my preceptee what he gets for a blood pressure. He says he can’t hear anything – that we will try again in the truck. The patient has thick edemadous arms, plus a left side mastectomy keeps us from using that arm.
We carry the patient out in the stair chair and then once out in the ambulance with the heat on, we try again for the blood pressure. Can’t hear anything. We go to the monitor’s automatic cuff and are pleased to see 90/60. At least that’s something. When my preceptee puts her on the monitor, the story starts to come clearer. Her heart rate is 34. The rhythm is a little funky – definitely not a third degree block, but not a sinus brady either. The ECG print out calls it a junctional rhythm. We put her on oxygen and start to the hospital. She denies any pain, just reiterates how weak she has been feeling. Neither of us can get an IV – I try twice and can’t even draw blood. Can’t see a vein, can’t feel one. Try by anatomy, but nothing. When I touch the jugular vein in her neck, she says, don’t put an IV in my neck. Just looking, I say.
Her heart rate is staying steady at 34. Her end tidal CO2 is also trending steady at 28/29. Not too bad considering. We aren’t even going lights and sirens. This is after all a visiting nurse call. The patient may have been in this rhythm for a couple days. Maybe it is an electrolyte imbalance. If we get an IV, we can try some atropine, but that may not work. We could also try dopamine or pacing(I'm not buying our monitor's BP). But we are after all only ten minutes from the hospital now. I touch the patient’s neck again, she again shakes her head. Don't even think about it.
We try another pressure. Can’t hear anything. The machine comes up 150/110. I don’t trust that. We check it again by electronic cuff 138/78. Don’t believe that either. Still, even though we can't hear or feel a pulse, the machine, for what it is worth, has read some kind of pressure three times. She’s stable enough, I tell my preceptee. Let the hospital put in a central line if they have to.
But even as I'm saying that, still I’m thinking here’s a chance for him to get an EJ or maybe even better, we just got the EZY-IO. I’ve never used it before. I might just pull rank and pull that baby out and drill her right in the leg. With IV access, we can really play.
But I say nothing. Her rate stays at 34. Her ETCO2 at 29. She’s 78 years old. No sense in getting her all riled up by jabbing her neck or pulling out the power drill.
We just take her on in with supportive care.
“She’s really sick,” the doctor says, looking at her. “You have access?" No, sorry. He tells the nurse to get the IV try. He sees me shaking my head, and then adds, "and bring a central line kit in here just in case."
They can’t get an IV line. They do get a pressure. 50 is all the nurse can hear, doing it manually. Their electronic cuff can’t get a reading. They hook her up to the standby pacer, and open up the central line kit. After two tries, they finally gain access. The atropine bumps her up to 40. The dopamine gets her pressure to 70. When we come back later we learn she is intubated and up in the ICU – likely dying of sepsis, multi-organ failure, including an infarct that started after she’d been in the ER awhile.
I’ve written about this before in Practice. When you have a preceptee you always weigh the educational experience for him. You get him an EJ or an IO, and you push atropine and dopamine, it makes for a good story, something for him to boast about to the other preceptees – all hoping for the bad one.
I feel a little bit of a failure – I certainly could have justified the aggressive treatment. But on the other hand. We didn’t overly traumatize her, we kept her calm, got her to the hospital – a higher level of care. Some days, you lean one way, some days you lean another.
I'm hoping that the lesson, if there is one, is you do what you can with what you have to work with on each particular call according to the texture of the call. I don't mean to teach him that on this particular call less is better than more or that more is better than less -- just that, on each call, you need to have that debate within yourself.
Either way, she’s probably going to die.
Friday, December 28, 2007
Tuesday, December 18, 2007
Your Choice
He was on his way out to the car when he slipped on the ice. We find him on his knees, leaning into the open front seat of his car. He says he isn’t hurt, but he needs help getting up. He is a big man. I’m guessing three hundred pounds of dead weight. It takes three of us to get him up and even then, we just barely do it. He is unsteady on his feet and we lead him carefully back into the house. In the doorway, his knees buckle and we have to slowly lower him to the ground, unable to support his weight. We finally manage to get him up into a chair. I’ve got him in a bear hung from behind, but can barely straighten my legs up from a squat during the lift. My partners are on each leg.
We let him sit a bit to catch his breath. He tells us he has congestive heart failure and it has been a struggle of late. He can barely walk a block on his own. All this weight, the water pills can only do so much, he says. I try to talk him into going to the hospital, but he wants no part of it.
Well, if you are not going, we need at least to see you stand up.
“I understand,” he says. “Just give me a minute, just give me a minute to get my strength.”
The house is cluttered with newspapers and old books. The light shade is heavy with dust and dead insects.
“My mind still thinks I’m young,” he says, “my body is a different story. It doesn't want to work anymore. Just give me a minute here. Just let me rest.”
***
We see him standing by the side of the road, a strong lean man with a long white beard, wearing a baseball cap. He is there most days; hands in his sweatshirt pockets, watching traffic go by. Every once in awhile he gets an inkling to go for a walk, striding mightily along the avenue. Sometimes we hear about it on the radio. Elderly man doesn’t know where he is, talking gibberish. They call us to check him out. His eyes are bright and engaging, his arms muscled and veined. “Pork chops sunny running through only one ninety nine, how about that, Ford Fairlane!” he exclaims, but doesn’t wait for an answer. "Titille lovely yesterday, huh? Googen corn whoosh, Hmm, hmm.”
We take him home.
***
Your mind or your body? What kind of choice is that.
We let him sit a bit to catch his breath. He tells us he has congestive heart failure and it has been a struggle of late. He can barely walk a block on his own. All this weight, the water pills can only do so much, he says. I try to talk him into going to the hospital, but he wants no part of it.
Well, if you are not going, we need at least to see you stand up.
“I understand,” he says. “Just give me a minute, just give me a minute to get my strength.”
The house is cluttered with newspapers and old books. The light shade is heavy with dust and dead insects.
“My mind still thinks I’m young,” he says, “my body is a different story. It doesn't want to work anymore. Just give me a minute here. Just let me rest.”
***
We see him standing by the side of the road, a strong lean man with a long white beard, wearing a baseball cap. He is there most days; hands in his sweatshirt pockets, watching traffic go by. Every once in awhile he gets an inkling to go for a walk, striding mightily along the avenue. Sometimes we hear about it on the radio. Elderly man doesn’t know where he is, talking gibberish. They call us to check him out. His eyes are bright and engaging, his arms muscled and veined. “Pork chops sunny running through only one ninety nine, how about that, Ford Fairlane!” he exclaims, but doesn’t wait for an answer. "Titille lovely yesterday, huh? Googen corn whoosh, Hmm, hmm.”
We take him home.
***
Your mind or your body? What kind of choice is that.
Saturday, December 08, 2007
5 Hour Gap
The call is for a hypoglycemic in the lobby of the nursing home. The nurse tells us the woman sleeping in the chair is an admission from a hospital post cardiac care . They were expecting her five hours earlier, but she has just now showed up in the last ten minutes, apparently by private vehicle (not an ambulance) with her suitcase and altered mental status, but no admission papers. Without the admission papers, they can’t admit her. Since she has a bracelet identifying her as a diabetic, they checked her sugar. It was 38. They have given her some oral glucose, but since she is not admitted, they cannot give her any glucagon. They want us to take her back to the hospital.
I look at the woman. “Gena!” I say.
The woman looks up at me with glazed eyes and smiles, pleased to be recognized, and then she drops back off.
Gena is an old frequent customer. I can’t call her a frequent flyer because we rarely ever transported her – hers was always a treat with dextrose and they she’d refuse transport. I have not seen her for years. She used to work in a local convenience store. A customer would come in and find her unresponsive behind the cash register. How many customers would come in and help themselves to chips and soda before one would call 911, I don’t know. We’d strap a tourniquet around her arm, put in an IV, check her sugar, find it always in the 20-40 range, and give her an amp of D50. She’d wake up, give us a big smile, say, “Hey how’ya doing, what’s going on?” and then refuse to go to the hospital. Sometimes we’d get called to her house in town. Her brother would check on her and find her unresponsive sprawled on the couch in front of the TV. Same deal. Amp of D50. Refusal. Then one day while working in the city, I found her unresponsive in a car in the city’s north end – not a place you’d expect to find a fifty-five year old white woman. I checked her sugar – it was 140. She was still unawake and breathing a little irregularly. I looked at her pupils. Pinpoint. 1.2 mg of narcan. She woke right up with the same old smile. “Hey, how’ya doing. What’s going on?” We took her to the hospital. The next day we were sent lights and sirens to a familar address for the lawnmower crash into a tree, patient unresponsive. We arrived to find a riding lawnmower halfway up a tree and rolled on its side with the driver still in the seat. Gilda, snoring. Blood sugar 35. We disentangled her from the lawn mower. Gave her some D50, but despite her brother’s pleadings, she refused to go to the hospital. “She had a blood sugar problem yesterday, too,” the brother said. “Maybe she should go in and get checked.” “Is that what you told him,” I said to Gilda. She looked at me sheepishly and said nothing.
“I know Gena,” I say to the nurse. “We’ll fix her up.”
“I want her taken back to the hospital. No papers, no admission.”
“Well, let’s just wake her up and find out what’s going on. Maybe she can tell us where the papers are.”
“We already looked in her suitcase.”
The IV line goes in and then the amp of D50, and Gena is much more awake now and giving us that big smile. “Hey how’ya doing? What’s going on?” she says.
“What’s going on with you? How’d you get here? Where are your papers?”
“Papers?” she says, as she looks around trying to figure out just where she is. Then she nods off.
She still seems a little out of it. I recheck her sugar. 215. I look at her closer. Asleep with her mouth open. I open an eyelid. Pinpoint.
I gesture to my partner to get her up on the stretcher. The nurse seems pleased now that we are transporting and there will be no battle over trying to make them take the patient.
“Back to the hospital,” I announce.
In our region we are only allowed to give narcan to a patient if their respirations are less than 8 or they show signs of hypoventilation. Gena is easily stimulated, but she then falls back to sleep midsentence. I put a capnography cannula on her and then dim the lights. Ever the scientist, I am curious what the capnography will reveal. Her initial reading is 50 – a bit on the high side, but her respiratory rate is actually 30, although her respirations are erratic and many of them are shallow interrupted by an occasional larger breath. I nudge her; she opens her eyes and then falls back to sleep. I watch the capnography. While her respiratory rate stays high, her ETCO2 starts to rise. Very steadily – the staircase effect. 52, 54, 55, 56, 57, 58, 59. That qualifies as hypoventilation. I get out the narcan and draw up a small dose. .4mg, which I push slowly into the IV, and then wait. A minute passes. No change. Her ETCO2 is now 60. Her pulse SAT has also dropped to 89. I draw up another .4mg. Just as I am ready to push it, she suddenly opens her eyes, sees the syringe and say, “Hey. What’s going on? What are you injecting me with?”
“Nothing,” I say. “I was just flushing the line so it doesn’t clog. Now that you’re awake, tell me how you got to the nursing home and what happened to your paperwork?”
“I need to go to the nursing home. They’re expecting me.”
The monitor shows her ETCO2 is down to 42. Her SAT up to 98%. Impressive.
“We just came from the nursing home,” I say. “That’s where we picked you up.”
She looks confused.
“Let’s try to start from the beginning,” I say. “You got discharged from the hospital. Who picked you up?”
“Two of my roommates,” she says.
“Where did they take you?”
“We went to my apartment to get my stuff.”
“And then what happened?
“The car wouldn’t start so I got a cab.”
“To the nursing home?”
“Yeah, where’s my suitcase and boxes?”
“Your suitcase is right here. We don’t have any boxes.”
She looks around in a panic.
“I brought them with me.”
“Well, they are either there or they’re in the cab of your friends’ car or at your place. Tell me a little more about what you did at your place.”
“What I did?”
“Yeah, like heroin.”
“I did not.”
“Gena, come one, you can tell me.”
She starts to deny it again, but then she breaks into a smile as she shrugs. “Hey, they offered,” she says, “Who am I to say no?”
“And do you know where the paperwork is?”
“I had it with me. Where are my boxes?”
I tell the story at the hospital. Discharged from the cardiac unit. Shows up at the nursing home five hours later by cab. No papers. Hypoglycemic and with heroin on board. The triage nurse just shakes her head and tells me, “Put her in the hall outside 21.”
I look at the woman. “Gena!” I say.
The woman looks up at me with glazed eyes and smiles, pleased to be recognized, and then she drops back off.
Gena is an old frequent customer. I can’t call her a frequent flyer because we rarely ever transported her – hers was always a treat with dextrose and they she’d refuse transport. I have not seen her for years. She used to work in a local convenience store. A customer would come in and find her unresponsive behind the cash register. How many customers would come in and help themselves to chips and soda before one would call 911, I don’t know. We’d strap a tourniquet around her arm, put in an IV, check her sugar, find it always in the 20-40 range, and give her an amp of D50. She’d wake up, give us a big smile, say, “Hey how’ya doing, what’s going on?” and then refuse to go to the hospital. Sometimes we’d get called to her house in town. Her brother would check on her and find her unresponsive sprawled on the couch in front of the TV. Same deal. Amp of D50. Refusal. Then one day while working in the city, I found her unresponsive in a car in the city’s north end – not a place you’d expect to find a fifty-five year old white woman. I checked her sugar – it was 140. She was still unawake and breathing a little irregularly. I looked at her pupils. Pinpoint. 1.2 mg of narcan. She woke right up with the same old smile. “Hey, how’ya doing. What’s going on?” We took her to the hospital. The next day we were sent lights and sirens to a familar address for the lawnmower crash into a tree, patient unresponsive. We arrived to find a riding lawnmower halfway up a tree and rolled on its side with the driver still in the seat. Gilda, snoring. Blood sugar 35. We disentangled her from the lawn mower. Gave her some D50, but despite her brother’s pleadings, she refused to go to the hospital. “She had a blood sugar problem yesterday, too,” the brother said. “Maybe she should go in and get checked.” “Is that what you told him,” I said to Gilda. She looked at me sheepishly and said nothing.
“I know Gena,” I say to the nurse. “We’ll fix her up.”
“I want her taken back to the hospital. No papers, no admission.”
“Well, let’s just wake her up and find out what’s going on. Maybe she can tell us where the papers are.”
“We already looked in her suitcase.”
The IV line goes in and then the amp of D50, and Gena is much more awake now and giving us that big smile. “Hey how’ya doing? What’s going on?” she says.
“What’s going on with you? How’d you get here? Where are your papers?”
“Papers?” she says, as she looks around trying to figure out just where she is. Then she nods off.
She still seems a little out of it. I recheck her sugar. 215. I look at her closer. Asleep with her mouth open. I open an eyelid. Pinpoint.
I gesture to my partner to get her up on the stretcher. The nurse seems pleased now that we are transporting and there will be no battle over trying to make them take the patient.
“Back to the hospital,” I announce.
In our region we are only allowed to give narcan to a patient if their respirations are less than 8 or they show signs of hypoventilation. Gena is easily stimulated, but she then falls back to sleep midsentence. I put a capnography cannula on her and then dim the lights. Ever the scientist, I am curious what the capnography will reveal. Her initial reading is 50 – a bit on the high side, but her respiratory rate is actually 30, although her respirations are erratic and many of them are shallow interrupted by an occasional larger breath. I nudge her; she opens her eyes and then falls back to sleep. I watch the capnography. While her respiratory rate stays high, her ETCO2 starts to rise. Very steadily – the staircase effect. 52, 54, 55, 56, 57, 58, 59. That qualifies as hypoventilation. I get out the narcan and draw up a small dose. .4mg, which I push slowly into the IV, and then wait. A minute passes. No change. Her ETCO2 is now 60. Her pulse SAT has also dropped to 89. I draw up another .4mg. Just as I am ready to push it, she suddenly opens her eyes, sees the syringe and say, “Hey. What’s going on? What are you injecting me with?”
“Nothing,” I say. “I was just flushing the line so it doesn’t clog. Now that you’re awake, tell me how you got to the nursing home and what happened to your paperwork?”
“I need to go to the nursing home. They’re expecting me.”
The monitor shows her ETCO2 is down to 42. Her SAT up to 98%. Impressive.
“We just came from the nursing home,” I say. “That’s where we picked you up.”
She looks confused.
“Let’s try to start from the beginning,” I say. “You got discharged from the hospital. Who picked you up?”
“Two of my roommates,” she says.
“Where did they take you?”
“We went to my apartment to get my stuff.”
“And then what happened?
“The car wouldn’t start so I got a cab.”
“To the nursing home?”
“Yeah, where’s my suitcase and boxes?”
“Your suitcase is right here. We don’t have any boxes.”
She looks around in a panic.
“I brought them with me.”
“Well, they are either there or they’re in the cab of your friends’ car or at your place. Tell me a little more about what you did at your place.”
“What I did?”
“Yeah, like heroin.”
“I did not.”
“Gena, come one, you can tell me.”
She starts to deny it again, but then she breaks into a smile as she shrugs. “Hey, they offered,” she says, “Who am I to say no?”
“And do you know where the paperwork is?”
“I had it with me. Where are my boxes?”
I tell the story at the hospital. Discharged from the cardiac unit. Shows up at the nursing home five hours later by cab. No papers. Hypoglycemic and with heroin on board. The triage nurse just shakes her head and tells me, “Put her in the hall outside 21.”
Tuesday, December 04, 2007
The Motions
I haven’t been writing much lately. I’ve been working a lot, doing lots of calls, but nothing I haven’t done before. I’ve been trying to follow my renewed anti-whine, anti-complaint, try to be an easy going nice guy policy. I’ve had a fair amount of success. It is much less tiring going with the flow than constantly complaining. Want to go to the farthest hospital? Fine. Don’t want to give me your social security number, no problem. Complaining about being cold even though you are already bundled up, here’s another blanket. Not comfortable, let me get you more comfortable? You want me to do transfers all day while you send basics on codes? Fine, as long as my pay check is good at the bank. You want me to go on a priority for a psych because we have a long response because we were three towns away when you gave us the call, fine, I’m just not turning my lights on. Sorry about that one. You called an ambulance for a runny nose, okay, what hospital do you want to go to?
I come to work on time, I check my gear, and I do my job. ABCs, head to toe, vitals, IV, 02, monitor. Write up my report. Sign here. Good luck. Hope you are feeling better. You are very welcome. It’s not bad work.
Baby Medic has a new post. Sailing Rough Waters After six months of being a medic, he is starting to get in a routine and is worried because he is no longer on edge about each call, he is losing his edge. By no longer looking for zebras in the low priority routine call, he is worried he might miss something important. I enjoy reading his posts because it reminds me of my own past and often causes me to question my present.
The ebbs and flows of a medic’s excitement toward the job always fascinate me. What causes burnout? What motivates excitement? I often feel that lately I have just been going through the motions. But I really think now that there is nothing wrong with that. When I started it was very important that I get everything right – that I not miss anything. And while I still don’t want to miss anything and kick myself when I do, I am less concerned about getting the diagnosis right. It is less important that I know exactly what is going on, than that I treat the patient appropriately or appropriately don’t treat. I know now that in many cases it is mostly beyond us to know what is wrong. That’s what they do at the hospital. They have lab tests, X-rays, MRIs and a host of other technological tests and medical experts that help them pinpoint what is really going on. And even then, they might not be able to figure it out. This is particularly true with many of the patients I have who are old and sick. An EMT asked me what I thought was wrong with one elderly patient, and my answer was just that, “She’s old and sick.” I find no shame in telling the nurse, “I don’t know what’s going on. It might be CHF, it might be COPD. It could be pneumonia or a combination of the 3.” Better that than to insist it is CHF and give them lasix and have it turn out to be pneumonia. Do no harm.
I heard a funny joke recently: An internist, a surgeon and an ED doctor are out duck hunting. Five birds fly by. The internist raises his rifle, follows the flock, but doesn’t shoot. Why didn’t he pull the trigger? He is asked. “I’m not certain if any of them were ducks,” he responds. “I need to do more tests.” Then another flock flies past. The surgeon raises his rifle and takes one shot, knocking a single bird from the sky. “How do you know that was duck? The internist asks. “Never question me,” the surgeon says. “It was a duck.” Then another flock flies past. The ED doctor raises a shot gun and shoots from the hip. All five birds drop from the sky. The internist and surgeon look at the ED doctor and say, “What are you doing?” “I don’t know about all of them,” the ED doctor says, “But one of them was definitely a duck.”
The idea being that in emergency medicine you sometimes have to fire everything you have to get the job done, to kill the duck.
That may be true when the patient is circling the drain, but for most of our patients as paramedics, it is not important that we cure them, that we kill the duck.
I view my calls now in different categories. There are calls where I have to do something (meaning provide a treatment) and calls where I don’t. There are obviously some calls where you need to act aggressively to save the patient’s life, when you have to kill the duck. You have to not only think critically, you have to be fast and successful in your skills. These include cardiogenic shock, acute respiratory failure, any unstable airway call, and sudden anaphylaxis. Then there are the routine critical calls – asystolic cardiac arrest, ST elevation MI with stable or stroke with patent airway and stable vitals -- where you need to know what you are doing, but you are basically following an established algorithm.
In the non-critical category, there are as well those you treat to stabilize (hypoglycemia, asthma, etc) and those you merely assess and transport (weakness, for example). And there are those you merely provide comfort (morphine for the woman with the broken hip, Zofran for the man with nausea/vomiting).
I think as important a skill for a paramedic as figuring out what is going on with a patient is the ability to see that the patient gets the proper attention at the hospital. This is probably only true for large hospitals, but a paramedic can make a huge difference in whether or not that patient with the hidden MI masking as weakness gets put in a medical alert room or a hallway, that a trauma patient without a mark on him (but a lacerated liver)gets the full work up in the trauma room or again the hallway. It is more important for a medic to be able to say “I don’t know what is going on with this patient, but they need to be seen right away,” than to be able to definitively say what the diagnosis is.
Going through the motions as a medic is okay -- as long as going through the motions means doing your assessments, taking your histories, doing your routine ALS. You do that; your patient will be in good hands.
I come to work on time, I check my gear, and I do my job. ABCs, head to toe, vitals, IV, 02, monitor. Write up my report. Sign here. Good luck. Hope you are feeling better. You are very welcome. It’s not bad work.
Baby Medic has a new post. Sailing Rough Waters After six months of being a medic, he is starting to get in a routine and is worried because he is no longer on edge about each call, he is losing his edge. By no longer looking for zebras in the low priority routine call, he is worried he might miss something important. I enjoy reading his posts because it reminds me of my own past and often causes me to question my present.
The ebbs and flows of a medic’s excitement toward the job always fascinate me. What causes burnout? What motivates excitement? I often feel that lately I have just been going through the motions. But I really think now that there is nothing wrong with that. When I started it was very important that I get everything right – that I not miss anything. And while I still don’t want to miss anything and kick myself when I do, I am less concerned about getting the diagnosis right. It is less important that I know exactly what is going on, than that I treat the patient appropriately or appropriately don’t treat. I know now that in many cases it is mostly beyond us to know what is wrong. That’s what they do at the hospital. They have lab tests, X-rays, MRIs and a host of other technological tests and medical experts that help them pinpoint what is really going on. And even then, they might not be able to figure it out. This is particularly true with many of the patients I have who are old and sick. An EMT asked me what I thought was wrong with one elderly patient, and my answer was just that, “She’s old and sick.” I find no shame in telling the nurse, “I don’t know what’s going on. It might be CHF, it might be COPD. It could be pneumonia or a combination of the 3.” Better that than to insist it is CHF and give them lasix and have it turn out to be pneumonia. Do no harm.
I heard a funny joke recently: An internist, a surgeon and an ED doctor are out duck hunting. Five birds fly by. The internist raises his rifle, follows the flock, but doesn’t shoot. Why didn’t he pull the trigger? He is asked. “I’m not certain if any of them were ducks,” he responds. “I need to do more tests.” Then another flock flies past. The surgeon raises his rifle and takes one shot, knocking a single bird from the sky. “How do you know that was duck? The internist asks. “Never question me,” the surgeon says. “It was a duck.” Then another flock flies past. The ED doctor raises a shot gun and shoots from the hip. All five birds drop from the sky. The internist and surgeon look at the ED doctor and say, “What are you doing?” “I don’t know about all of them,” the ED doctor says, “But one of them was definitely a duck.”
The idea being that in emergency medicine you sometimes have to fire everything you have to get the job done, to kill the duck.
That may be true when the patient is circling the drain, but for most of our patients as paramedics, it is not important that we cure them, that we kill the duck.
I view my calls now in different categories. There are calls where I have to do something (meaning provide a treatment) and calls where I don’t. There are obviously some calls where you need to act aggressively to save the patient’s life, when you have to kill the duck. You have to not only think critically, you have to be fast and successful in your skills. These include cardiogenic shock, acute respiratory failure, any unstable airway call, and sudden anaphylaxis. Then there are the routine critical calls – asystolic cardiac arrest, ST elevation MI with stable or stroke with patent airway and stable vitals -- where you need to know what you are doing, but you are basically following an established algorithm.
In the non-critical category, there are as well those you treat to stabilize (hypoglycemia, asthma, etc) and those you merely assess and transport (weakness, for example). And there are those you merely provide comfort (morphine for the woman with the broken hip, Zofran for the man with nausea/vomiting).
I think as important a skill for a paramedic as figuring out what is going on with a patient is the ability to see that the patient gets the proper attention at the hospital. This is probably only true for large hospitals, but a paramedic can make a huge difference in whether or not that patient with the hidden MI masking as weakness gets put in a medical alert room or a hallway, that a trauma patient without a mark on him (but a lacerated liver)gets the full work up in the trauma room or again the hallway. It is more important for a medic to be able to say “I don’t know what is going on with this patient, but they need to be seen right away,” than to be able to definitively say what the diagnosis is.
Going through the motions as a medic is okay -- as long as going through the motions means doing your assessments, taking your histories, doing your routine ALS. You do that; your patient will be in good hands.
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