Final Exam

 You should never have been precepting. You did not have enough street experience, not to mention you were not even old enough to buy a drink when you started. But these days like too many of your peers, you go from EMT school to paramedic school without putting in the time on the road. Sure you worked for another service for awhile, but the volume was low and you mainly did transfers. Had I been in charge I would have insisted on your putting in a year in the city, banging out 911s, cleaning up the mess your paramedic partners would make in the back of the ambulance. But it was what it was. You showed up in your new yellow reflective coat and the freshly sew paramedic patch on your sleeve, and a copy of Tim Phalen's 12-Lead in Acute Coronary Syndromes under your arm, and they put us on the road together.

My first impression was you were you are nice young man, extremely polite, very nice to patients, respectful of other responders and health care professionals. Your work ethic was good. You were always there before me, always checking your gear out when you came in, even before you were permitted to punch in. After a call, you always listened to what I had to say, and thanked me, even if you made me feel like an old headmaster and not your partner, with yoru “thank you, sirs!” And when I didn’t have anything to say, you had your pencil out and were filling in all the answers to the questions Tim Phalen asks in his book.

Your IV skills were surprisingly good, which didn’t mean I didn’t have to step in a time or two, but that is what preceptors are for. I tried to teach you to be thorough, and met no resistance from you. It didn’t take you long for you to get into the routine. I would start to think you were doing okay, and then we would get a really sick patient, and you wouldn't perform as well as I wanted to see. You were slow to recognize, slow to react, and at the hospital, your reports were so jumbled, I often thought we had been on different calls.

That was were your lack of experience showed. It was hard for me to imagine you out on your own. You felt it too. You asked me twice if maybe we should end the experiment and have you put in your year of BLS in the city. I have never had a preceptee say that to me before. Normally, when they aren’t doing well, they are demanding to know how much longer until they are cut loose. They feel they paid their money for their course, they passed it, got their license and now they just want to know how much longer until their misery ends and they can start being their own bosses.

How many ALS calls have we done together these last three or four months? A lot. We bang out 9-10 transports a shift. Maybe from those we did two, three hundred ALS calls. We did three codes, you got two tubes, and on the one you couldn’t, you got a combitube in. While you weren’t as forceful as I would have liked to have seen, you weren’t completely lost. We got pulses back twice and kept them to the hospital (thanks epi and dopamine for contributing to yet more ICU deaths). We did a few STEMIs, some room one traumas, stroke alerts, used CPAP a few times, did a lot of 12-leads, and were exchanging controlled substance kits nearly every day.

I was still undecided about you. Every day I discovered something you didn’t know, but I suppose that also meant every day you learned something new. I tried to remember back when I was new, and how unprepared I had been, but that was a long time ago, and I am getting old and my memory is hazy.

Last week we got a call for a young adult with dyspnea. Young, early twenty something year old kid in the North End, complaining of difficulty breathing. They initially sent a BLS unit, but because we were floating, we said we’d take it on the theory the more calls we do the better. The kid was laying on the couch on the second floor, holding his chest and moaning. He said he had a history of asthma.

You set your gear down and knelt down in front of him and introduced yourself by name  like you always do, while I leaned against the wall, staying out of the way watching you. As you asked questions, you felt his forehead, which appeared dry, listened to his lungs, which were clear. You checked his vitals which were normal. His pulse SAT was 100% on room air. This was not asthma. Everything appeared normal in this otherwise fit young man who had this sudden onset of chest pain that he said felt like a squeezing in his chest.

You looked over at me then. I waited to see what you would say. “I guess I should do a 12-lead,” you said.

“Good,” I said. “Go ahead.”

You explained to the patient, you were going to put these stickers on his chest to check his heart. Then you entered his young age and pressed the button. You cautioned him to sit still. Finally, the 12-lead came out like so many we had done before. I watched as you tried to peel the 12-lead off the machine. All this time and you still have difficulty ripping it off smoothly. I saw you look at it. You seemed to stare at it. You kept staring and then saying nothing you walked over to me and held it up in front of me. You looked at me, then back at the 12-lead, as if to say. “Is this really what I think it is?”

It wasn’t like the pictures in your Tim Phalen book for pericarditis and it wasn’t like the ones for early repol. Twenty-two years old, be damned, it looked like the ones for an anteriorlateral STEMI with hyperacute T waves.

I nodded my assent.

A quick question about family history. Yes, with death at a young age. History, presentation, diagnostic 12-lead.

To our partner, get the stair chair, immediate STEMI alert from second floor, aspirin, down in the ambulance, transmit ECG, transport, strip patient, two big IVs, NTG, defib pads applied, …

100% occlusion in the cath lab.

I think of all the paramedics who might have blown that kid off. He’s only in his early twenties, his vitals are fine, he looks like he could outrun Wily E. Coyote. Walk him down the stairs, sit him on the bench seat, put him in the waiting room with all the other pleuritic chest pains.

So that patient was your final exam. I have made up my mind to pass you. That doesn’t mean you know everything there is to know. You are not close to that. But as I see it. You will never not medicate a hip fracture who is in pain. You will never not do a 12-lead on an elderly woman with weakness. You will never not treat a patient with respect. You may know less than other new paramedics, but at least you know that. And I would rather have you out there being cautious than someone who knows more, but thinks they know everything.

Your parents raised you well. And you will represent your profession and your service well. Sure there will be times, you will screw up. I have been doing this longer than you have been alive and I still screw up, but you will learn from your failures and your triumphs. And someday, you will sit in my seat and train a younger, less experienced paramedic. And when you do, remember what you went through.

You are not done with me yet.  I'm going to hold you for another week or two for final polishing, and then once you are on your own, I will still be around if you have questions or want to go over calls you did, and I will want to hear about them.  I will rejoice in your triumphs, and will talk your through the ones that don't go as well.

Now get out there, and do some good!

Wipe Out

 Darkness. Cold. Reflection of fire in the water. Hoses on the ground. Onlookers. The stretcher, pulled by my partner and a firefighter, races through the scene to the the unknown victim carried out of the building. Behind them my feet are up in the air. I am three feet above the ground, suspended parallel, my arms wide out. A snapshot in time. I land hard on the black ice. I lay there. I am fifty-five years old. I do a body assessment. Still have feeling in my hands and toes. No acute pain. I didn’t hear any cracks. I get to my feet and take a few tenuous steps, and then move quicker, Moments later I am at the patient’s side, giving commands, Still a working paramedic.

Status Quo

 We can all agree that these are goals of a perfect EMS system.

1. A paramedic on every priority one emergency call
2. A run form completed before leaving the hospital
3. A living wage for every paramedic

Ever since I have been in EMS -- 24 years now -- I have heard the discussions about ambulance availability, the need to leave a fully completed documented run form before leaving the hospital, and the need to improve paramedic pay.

I recently overheard an exchange between three people, one a paramedic, one a supervisor for an ambulance service and one a hospital administrator.

Here was the rub:

The hospital wanted the paramedic to not leave for the next call before they had finished writing the run form from the first call and they wanted the paramedic on the priority one emergency call.

The ambulance supervisor wanted the run form fully completed (for billing and data reporting) and the paramedic to clear the hospital quickly to do the priority one call.

The paramedic pointed out that is was often impossible to fully complete the run form, print it out and leave it for the hospital and get to the dispatched call in a meaningful time.

The paramedic said he skipped many of the boxes on the run form so he would get the form done quickly and be able to clear. He said he sometimes cleared to take the call without leaving the run form because the patient was alert and had no issue but a cut finger. The paramedic also said many times he did fully complete the run form, but the patient was still on his stretcher when the next call came in so even though his run form was done, he couldn’t clear to take the call.

The hospital administrator told the ambulance service to put more cars on the road so the paramedic could have the time to write the run form while the added paramedic did the call.

The ambulance supervisor wanted the hospital to hire more nurses so the triage lines weren’t so long and so that when the nurse heard the paramedic’s verbal report, they wouldn’t forget it immediately because they were taking care of so many patients. And he wanted the hospital to give his company more transfers so it could make enough money to put more cars on the road.

The paramedic said while you are spending more money on hiring more nurses and putting more ambulances on the road, how about kicking a few extra dollars my way because I’m not keeping up with the cost of living despite working 60 hours a week.

The bartender interrupted the conversation then, by asking if they would all like another round, which they did. On the TV over the bar there were news stories about crumbling schools, jobs moving out of state, and other bad news.

Here’s what happened. The paramedic did the best he could to leave the run forms and get to the calls so the patients didn't suffer. Sometimes he completed the run forms, sometimes he didn’t. No nurses were hired. No cars were added. The triage lines stayed long. Calls were still dispatched before the crews had the patient off their stretcher. The paramedic did not get his raise. The three continued to drink beer together.

The Nether Zone

On TV, the paramedics are met at the ambulance bay by at least two doctors who ride the rails as the medic gives the story. The patient is moved over to the hospital bed where a team of ED staffers are ready to go to town in a seamless continuum of care.

Sometimes this mirrors real life. Except for the two doctors running alongside the stretcher.

Too often, however, I find there is a significant interruption in the care continuum. There is a nether zone where the patient who has been getting fully attended care is no longer being seamlessly cared for.

While some of this is hospital dependent, I don’t believe any hospital is immune to it.

Here are some examples.

The triage line: While you wait to be triaged, the patient’s breathing treatment runs out, their pain medicine starts to wear off, they are due for their next nitro, or perhaps they start seizing. Unless you bring your gear into the hospital, there is a gap in care.

The hallway: Your patient is left in the hallway or placed in a room, and they throw up or they need to be suctioned. If you are in a room, at least you can use the in-room suction. If you are in the hallway, and can’t shout for someone to bring you an emesis basin, you need to think fast and grab a towel or something else to try to contain the splatter, and hold them on their side to protect their airway.

The code room: The staff is there, but monitors need to be switched, tubes reconfirmed. The dopamine gets shut off and not restarted. The pacer is disconnected. The doctor is still trying to figure out what is going on. The patient maybe has gone back into arrest. An IV line is pulled out by overanxious ED staffers. No one is doing CPR or maybe the ED staffer doing it has not had the latest ACLS push hard, fast and deep lecture.

Many people believe that once you enter the hospital doors, you are no longer in charge of your patient. The problem with that thinking is who is in charge of the patient? They are in the nether zone where they may be under the care of the hospital, but have not yet been placed in the care of a medical professional with the available equipment to properly treat them.

We don’t turn off the 02 when we enter the hospital’s doors. We don’t shut off our running IV lines. We don’t turn off our heart monitor. We don’t stop doing CPR as we roll down the hallway. I argue that we should continue to care for the patient, including bringing our equipment into the ED until the ED is ready to assume complete control and care for the patient.

If we are in the triage line and our patient with CHF needs their next SL NTG, we should give it to them. If their pain scale rises back up because the fentanyl is wearing off, we should redose them (I usually redose in the ED parking lot to avoid this). If they start seizing again, we should be ready to hit them with our Versed. If our patient is post cardiac arrest, we should keep them on our monitors, and our drips running until we are sure that the receiving MD is fully aware of the care we are providing and is ready to assume seamless care. If we are doing CPR, we should insist that proper CPR and rhythm checks and defibrillations are done until we are satisfied proper transition has occurred. If it is time for the next epi, we should give it until the ED is in position to have their drug cart open and drug in hand be able to give it. We are responsible for our patient’s care and for an orderly transition to the hospital’s care. If we do not feel the transition offered is acceptable, we need to advocate for our patient. If we think our patient is too unstable to be left alone in a back hallway we need to make that clear. If a nurse is too busy to take our report, and we feel the report needs to be given, then we have to either find a doctor to give the report to or insist to the nurse that the report be given. Our patients rely on us to do the right thing by them.

Back when we first started using CPAP, I had a situation at the hospital where a nurse told me to take the patient off CPAP because her ED required an order for it to be given and she did not want to lose her license but having the patient on it without the order. I refused to discontinue the CPAP and refuse to let her discontinue it until a physician came into the room and issued the order to continue it.

And then there is the questions of what do you do when you are standing in line with your patient and there is a BLS crew in line with their patient, and their patient is having a severe asthma attack? Using every accessory muscle, diaphoretic, frightened, with declining SATs and no audible air movement. Do you run out to your ambulance and come back in with your equipment and intercept with them right there in the triage line? I will leave that discussion for another day. (But if I had to answer, I would say, you need to bring that patient to the attention of the triage nurse and be fairly insistent). 

Sickle Cell

 Sickle cell anemia is a horrible, painful disease. Over the years I have gone from viewing sickle cell anemia patients as drug-seekers (here I blame the EMS culture at the time) who I did nothing more than put on the stretcher and take to the hospital to human beings suffering from a painful disease who I aggressively treat with narcotic analgesics and fluid.

Still, I find some of these patients problematic.

Case in point. Patient calls 911. Meets us at corner and requests transport to hospital 30 minutes away. There are at least 5 hospitals closer, including one only two miles away. When asked why she did not get someone to drive her, she says she has no ride. When asked why she doesn’t want to go to the closest hospital, she has no answer. She just doesn’t want to go there. We tell her that we will medicate her, but we really would prefer not to have to take her 30 minutes, and likely more away during rush hour. She relents and agrees to go to the hospital four miles away. She says she has very poor IV access. She says they usually put an EJ in her neck to give her her pain meds. We try a 24 in her wrist with no success. We offer Fentanyl intranasally. 100 mcgs does not touch her pain, she says. We offer 100 more. She declines. It just stuffs up my nose, she says. Your choice, we say. In the hospital, we wait in triage for 20 minutes, and then then put her in the waiting room.

So, let’s analyze this. Her pain is so bad she needs an ambulance, but is willing to travel 30 miles to go to the ED. Why is that? Maybe because she knows she will not get the pain meds she wants at the closer hospital? Maybe her pain is so bad, she is willing to wait that extra length of time to reach the distant hospital for the promise of more lasting treatment. She refuses more Fentanyl IN because it stuffs up her nose. Maybe she knows the Fentanyl won’t work for her? Maybe her pain is so great that she cannot take the added discomfort of a stuffed up nose with little relief in pain?

She never appears to be in pain at any time, but I know that sickle cell patients are so used to pain that they rarely show it.

She is just in her twenties, but she does not look healthy for what should be her prime.

Some will call her a drug seeker. If I call her that I will have to qualify it that she is seeking drugs because she is in pain.

This call causes me to review my stance on sickle cell patient, but not change it. I only wish that we could have gotten an IV in her. As far as doing an EJ or an IO, our guidelines call for their use only in extremis. Is pain extremis? I wasn’t willing to go that far, but will discuss it with some ED doctors I trust for their take.

Next day, we get a man in sickle cell crisis. He is from out of state and calls from the side of the road. He looks like a homeless man. Like the young girl the day before, his arms are pocked with scars. Like the girl, his pain is also a ten and when asked where is the best place to get an IV, he points to his neck. Fortunately, we get an IV this time in his hand and give the pain meds IV along with fluid.

If I were the younger medic of years ago, I might question the older me. What are you doing giving these pain meds to these people?

And now today, as the older medic, I say to my younger self, “It is not your place to judge. If they are in pain, and you have no persuasive reason to doubt their word, you take them at their word.”

But then my stubborn and possibly lazy younger self responds. “Okay, but even if they are not a drug seeker, why medicate them because they have such a high tolerance, all the drugs we carry are unlikley to touch them.”

My older self replies, “Well, fortunately today we carry twice as much as we used to. 20 of morphine and 400 mcg of Fentanyl. And even if that is not enough to take away someone’s pain, as our ED doctors have told us, get them started on the road to being pain-free, you will make it easier for the ED to complete the job.”

“But...”

“No, buts.”

***

We pick up another sickle cell patient, requesting to go to the cross town hospital. No amount of convincing works. The patient had just been discharged from the ED two blocks from the gas station where he is calling from. He says he is still in pain. We just monitor the patient and report the story to the nurse. The patient is put in the waiting room. I don't know how they end up treating him.

Sometimes I don't know what to think. I'm glad I don't have the disease.