I was talking with a hospital management person the other day about how much I love being a street paramedic, and how I didn’t think I could do my new job – a part-time position as a clinical coordinator at the hospital if I wasn’t still working in the street. The manager’s response was I could do more good in my new position and that the manager never understood all the big deal about putting on a collar. Anyone could put on a cervical collar.
I’ve been thinking about the comment, and while the manager did have a point – good management people can affect a far greater array of patients than a single clinical practitioner – being an EMS responder is of course, about much more than putting on a collar, about much more than simple do again and again skills.
I had a call the other day that helped bring the question into focus. We were called to a local restaurant for a woman passed out in the bathroom. Not an unfamiliar call. Usually, a person with a bad case of diarrhea or vomiting. Sometimes a young woman having her period, who hasn’t been eating or drinking enough.
Then we were updated that it might be a cardiac arrest, and then another update – a likely diabetic.
So I go in, for better or worse, in diabetic mode. I have all my equipment (house bag, monitor, 02, stretcher), but I am thinking, check the sugar, it’ll be low, pop in an IV, push an amp of D50, try to persuade the patient to go to the hospital, but likely end up with a refusal. We’d watch the patient now alert, eat some food and then leave under the care of a friend. Done variations of it 100 times.
A morbidly obese woman is lying on her back in the middle of the bathroom – not in a stall. For all intents and purposes she is out cold. Her skin is warm and dry and her breathing has just a hint of the dreaded “guppy breathing.” I try to ignore that ominous sign. Already I am thinking this is probably not a diabetic, but maybe she is breathing this way because she is so fat and laying on her back is not helping her breathe any. I slap the nasal end-tidal on her and am relieved to see a reading of 30. While a partner tries to get a blood pressure -- I can't feel a pulse, but her wrists are fat -- my plan is do a quick sugar check. If it reads low, then we are all set, if it is normal or high, it’s on the stretcher and out to the ambulance lickety -split. 220. Let's get her out of here, I tell my crew. I'm now thinking maybe CVA. We roll her on board, lift her quickly and are on our way, ambu-bag in hand to assist ventilations if necessary and I am thinking it may soon be necessary.
In the ambulance, I intubate her quickly. No gag at all. Good tube. I can't make out the chords, but can see the epiglottis and lift it as high as I can. I have preattached my capnography filter and am confident I can slide the tube in. I pass it carefully. My fingertips feel a little resistance. I think I am at the chords and I push through. On the monitor, I see the beautiful ETCO2 wave form. I check lung sounds. Pefect. I secure the tube and then look back at the monitor - the ECG leads now attached. She is bradycardic in the 40’s and looks almost like she has a funky block. Is it from hypoxia or is this a cardiac event. I don’t see a hint of a vein, so without investigating further I get out the EZ-IO and drill, baby, drill. The only problem is her leg is so fat, I am already up to the hub of the catheter and it is spinning around and around in the gelatin of her skin, finding no purchase in bone. I take the needle out, find a new spot and bear down hard. This time I make it though to the bone, solid. I secure the IO, attach a bag of fluid, wrap a pressure dressing around it, and then push in a milligram of atropine. No change. A couple minutes later, I push a second milligram, and this time it does the trick. Her rate comes up to the 80’s. With a hundred ccs of fluid in and her heart cranking to boot, we finally get a blood pressure -- 100/60. Her end tidal is a perfect 40.
As we approach the hospital, I am feeling pretty good about my care, and I’ve got that old medic stud rush going on, but then when we get to the ED, the doctor asks for the story, and it occurs to me then I never really got a story beyond the dispatch. I was so caught up in the moment, I never did find out what happened. I knew nothing about the patient other than the fact she was a diabetic. I had no witnesses, no one who could tell me anything about her or what had happened, before, during and after. While I immobilized her on a spine-board, that was more to be able to lift her and manage her in the event she arrested than to protect her spine. I never considered the fact she might have been a trauma. As I sit to write my run form, and come to the boxes about pupils, I slap my forehead. Pupils? Do’oh. I never looked. Suddenly I wonder if maybe she was a heroin OD and could have been woken up with a touch of narcan before dismissing the idea as sudden paranoid fantasy. When I go to put down my drug doses, I realize I lapsed back to the old dosing scheme for atropine, not the latest ACLS guidelines, which call for a half milligram instead of the whole. My bad.
Later, after the family comes to the hospital, we get more of the story. The woman had started acting confused, and then went to the bathroom with an awkward gait, and then synocopized entering a stall, was helped to the ground, and then dragged out of the stall by her ankles. I’ve followed up a couple times, and she remains in the ICU. Her labs weren’t significantly off. Her CAT scan clean. They don’t seem to know what happened. A mystery.
But anyway, the point of this story is that what I like about EMS is the challenge – the array of skills you need to bring to a call -- assessment, scene management, intubation, pharmacology, and that no call, no matter how well you may think you are performing goes flawlessly. I did great in some areas and was weak in others. But it just goes to show how much is involved in a call. It is not just about putting a collar on. In this case particularly because I never got around to putting one on(if i could have found one to go around her ox-like neck), which certainly would have been indicated if I thought she was a trauma or merely indicated because it is good practice because I don't know it is not a trauma.
I no longer expect to be perfect. But I still relish the challenge. A situation is thrown at you and you have to perform. Sometimes you do great, sometimes you stumble, most of the time, you are somewhere in between. It is exciting. I am much better at it than when I first began, but always have room for improvement. You learn from each call, and although you never get the same call twice -- there are no direct do-overs -- you always get a chance to redeem and hopefully, shine. I took pride in my tube, but next time I will work to improve my history taking skills or delegation. I should have just said to one of my partners. Find out what happened for me. Be quick about it and report back. I love delegation. I need to use it more.
So anyway, after several days working the new desk job, I’m back on the street. Instead of reading other medics run forms and living vicariously through their exploits, I’m out there doing it, touching patients and writing my own run forms again. And it’s been busy today, only the calls are not really what I had been hoping for. No big tests yet.
Old lady with a heart history in a neck high bathrobe stone cold deaf having chest tightness with a congested cough. I like to get my patients in a Johnny, but disrobing her was just going to be too hard, plus it was pouring rain outside and we needed to stair chair her out and I didn't want her to freeze. In the ambulance, trying to do a 12 lead, and explain to a deaf lady why I needed to reach down her robe was challenging. Not as challenging as the lady in the restaurant, but a challenge nonetheless. Then it was two nursing home calls one for a woman with dementia and paranoia with a fever and coughing up green phlegm which she had all over her fingers, the other for a man with MRSA affected weeping wounds. That patient refused to get on our stretcher until he had put his good clothes on and gone to the bathroom. He was also close to four hundred pounds. And it was still pouring rain. The challenge on those calls was how many times and with what variety of soaps, sanitizers and disinfectants could I wash my hands.
The potential paramedic skill set is limitless.
