This post is my submission to The Grand Rounds blog carnival that’s being hosted by Medic999 over on his site. My regular readers are getting a sneak peak. Welcome Newcomers! Be sure to check out the normal day-to-day medic blogging at Http://proems.blogspot.com
The day started like any other nondescript day at the ambulance base did in those years of my career, racing to work like a madman through city traffic, swilling coffee, and cursing at the other drivers for being homicidal morons who drive like they’re either running with scissors or overdosed on benzodiazepines. I made it in time that day, like I honestly did most days. The unwritten rule was that we were supposed to arrive at least fifteen minutes early in order to take a late call for the off-going shift. It was a nice thing to do and still is these days. I wonder when the guys who relieve me will start doing it. Probably I shouldn’t hold my breath.
Life as an emergency paramedic is fun. I’ve always had what I describe as an abusive, co-dependent relationship with this profession that we call EMS. The Emergency Medical Services isn’t a job like most people have. It’s an addiction that pays poorly, works you long hours, and beats you severely. I still love it. Back then I was on a rotating 24 hour shift, with 24 hours on, and then 48 hours off. In those 48 hours I would do what every paramedic does, I’d work my 2nd job being a paramedic somewhere else. Of course, that was back some years ago in my career. I had two jobs then, a full-time one with a part-time job to make ends meet. Now, some years into my career progression things have drastically changed. I’ve got ten years on now and I work two full-time jobs and a part-time job. Oh yea, and I volunteer to do it in my off hours.
Once EMS gets under your skin, you can’t break away from it. If you like it, you love it and it’s always a part of you. It’s my job, my hobby, and aside from my wife and my son, it’s my passion. It has to be or I’d go nuts… or nuttier, as the case may be.
Why was the above necessary? Because as a paramedic who loves his profession as much as I truly do, I shudder when I think of what happens to it. I shudder when I look at it critically and see how disorganized it is, and how other healthcare professions must see us and do see us. I shudder to think of how the public perceives us. I am aware of why these things are and I’m not really planning on using this piece as a pulpit to explain why those perceptions are wrong, as most of them are. What I am going to write about is how I remember Earl.
The above nondescript day, where I made it to work on time, found me working with a part-timer who was covering my regular partner’s day off. Kevin, I’ll call him because that’s his name, was an EMT-Basic. For those of you who don’t know the difference, he had about two and a half years less education than I did. Comparable to a CNA and an RN. Our morning started uneventfully, with our daily truck checks to make sure that everything was in its place, in working order, clean, and well stocked. Check all of the equipment, check all of the medications, and do it all while swilling horrible station coffee. It had one good quality to it, it was free and available. Our station housed an Advanced Life Support (ALS) paramedic (EMT-P) ambulance and was a satellite station smack dab in the middle of the metro area, inside of the big city in the area where we weren’t responsible directly for 911 calls. There was plenty of things to do though, our company covered most all of the suburbs and the surrounding county area. We also covered darn near every bit of the next county over. We were a high performance ALS system covering 20,000 or so calls for service per year with 6 trucks. We were busy. Most of our day was spent running back and forth between the other stations to cover, handling their calls while they were out, covering our own little “pockets” of unincorporated area within the city, backing up the city for 911 calls, and of course, running transfers and answering private calls. Any given day would bring our little “Charlie Sixty-Four” as we were designated about 18 to 20 calls in our 24 hours on duty. That leaves barely enough time to eat, let alone get some quality nap time in there. Objective one for me, after truck checks of course, was: breakfast.
Take it from an experienced paramedic who has been there and done that. Every good ambulance shift starts with a hearty breakfast. This breakfast must be bad for you; It must be consumed at an out-of-the-way greasy spoon café; The waitress must know you well enough by now to pick on you; and always, have just enough coffee to get you going but not enough to start you on The Dreaded Diuretic Cycle… which when stuck on a busy ambulance responding to emergencies far, far away from a bathroom can ruin your day just as fast as it ruins your uniform.
But that didn’t happen on this day.
“Charlie Sixty-Four, six four” said the dispatcher on my hip. “Dooooo DOOOOOO” he continued. “Charlie Sixty Four, Code-3. Some commercial dialysis facility for a 68 year-old male patient with an abnormal pulse. Time out 7:46am. Private call”
“Crap”, said I as I set down my coffee, my dreams of breakfast shattering like the delicious two eggs I would unfortunately be missing. “It begins”.
Off we went to the dialysis facility, all twinkles and woo-woos. Normally anything we got from the dialysis facility was minor. It was in the city’s 911 territory and they only called us directly when they thought that the patient was minor. The city guys frowned on this, and passed them our business cards and marketing materials on a regular basis so that they’d call us instead of them for everything. I didn’t mind… except for when it interrupted breakfast. Today it did and that is always a bad omen.
I liked working for that company. As a high-performance ALS system, all of our trucks were at the paramedic level. We had good equipment and fair standing medical orders to use to treat patients. Paramedics, and all levels of EMTs have a big book of standing medical orders written by a physician medical director that we pick and choose from to use according to our field diagnosis of our patients. We have ACLS, PALS, and a bunch of other acronyms behind our licenses. On the ambulances I work on, we have about 45 different medications in our formulary, a cardiac monitor with all manner of ways to zap people, and a lot of room to improvise. I support all ALS systems, however there are a number of systems out there that prioritize calls and don’t send paramedic units to every call in order to “preserve ALS resources” or, translated to real life, to “save money” by staffing basic trucks with EMT-Bs. I have always worked for all ALS systems that ensure that there’s at least one paramedic attending every patient initially. That’s the way I likes it.
We switched off the lights and sirens a minute or two before arriving at the dialysis facility to avoid alarming any of the other patients. Its funny seeing the looks you get when you pull up to an otherwise quiet scene in an emergency vehicle with your lights going. While it’s appropriate to do this for accident scenes and big emergencies where people really want you there in a hurry, on scenes where people don’t know that there’s something going on and are going about their business as usual, they look at you funny. I don’t like scaring the straights when I don’t have to. We got out of the rig, threw the jump kit on the cot, and wheeled our way into the building. The staff were happy to see us, and lead us into the room where we met “Earl”.
“Earl” is not “Earl’s” name. I don’t remember the patient in this story’s real name, nor do I remember exactly how old he was. He was in his 60s I think, and his chief complaint to me when I walked in
an introduced myself was “Get this damn oxygen out of my nose” in reference to the nasal oxygen cannula that the dialysis techs had put on him. With all of this, I remember him as being “Earl” and therefore that’s what I’m calling him. The dialysis techs told me that he had experienced a syncopal episode (he fainted) during dialysis and that they’d felt an irregular pulse while he was out. They’d put him on oxygen at 1 liter per minute, called us, and were in the process of disconnecting him from the dialysis machine when we arrived.
“How are ya feelin, Sir?” I asked him while wearing my patented friendly paramedic smile.
“I’m fine. Get this damn oxygen out of my nose” he replied.
“The ladies here are awful excited about the fact that you had a faint here in the chair on them, and they’d like it if you’d come with me to the hospital if you don’t mind. Can I take a look at you?” I asked him.
“Whatever you want to do, chief” Earl said. Apparently he had little use for us young punks in the medical profession. I didn’t blame him. If I was a chronic renal failure patient in need of dialysis three days per week, I’d be pissed at medicine too. Heck, I’m not a dialysis patient and I get pissed at medicine myself. Can’t blame him I guess. He was amenable to being moved from the chair to the cot once the techs finished up closing his fistula, and we were on our way out to the sanctity of the truck to begin the secondary assessment and maybe even to do some treatment, although he certainly wasn’t in dire need of me poking much at him. We loaded him up, climbed in the back with him, and began to do our “medic stuff”.
Airway, breathing, circulation? Check. Chief complaint? “Damn oxygen in his nose”. Otherwise none. Vital Signs? BP 142/80, Pulse 86 and regular, Pulse ox 100% on the 3 liters we bumped him up to, Resps 18 and non-labored. Mostly clear and equal lung sounds, no chest pain, abdomen soft and non-tender, good distal pulse, motor, and sensation. Good hemispheric neuro check and negative stroke exam. Blood sugar was 118. He had no complaint other than the oxygen and let us know that he didn’t like it in his nose. Ok, Earl. I got that part. I decided that just to be sure I would put him on the EKG and was rewarded with normal sinus rhythm with the occasional PVC (premature ventricular complex) that was most likely quite normal for someone with his age and medical history. Also, to be thorough, and because it would save the hospital some time, I decided to poke in an IV. Better safe than sorry, right? Kevin got up and started driving, while Earl and I had ourselves a conversation. He was an old country boy like me now stuck in the city living with his kids. He didn’t like it, and didn’t like being sick. We talked about farming as Midwestern guys do, usually over breakfast in the greasy spoon café but the ambulance was serving this purpose just fine for the time being. After talking for a while, I got up and moved to the chair behind Earl to radio a report into the hospital and “Let them know we were coming in” as I tell my patients. It was a routine report about an uneventful call…
Until I got back into the other seat and took a look at Earl.
Earl, in the thirty or so seconds that I had taken to radio in the report, had decided to try and die on me. He was purple, frothing at the mouth, and was in a full-blown seizure. I looked quickly at the EKG screen and saw that he was in Ventricular Tachycardia, a real bad heart rhythm for those of you who don’t know. His heart had just gone all freaky on him and had decided that it wasn’t going to pump blood anymore. His brain, noticing that it wasn’t getting blood flow anymore, had decided that it was pissed off, and had started him seizing. For my part, I decided that I had to use some of them shiny paramedic skills that I’d been saving for just an occasion, and leaned over to my Lifepack 10, slid out the two paddles (Yep, paddles), Pushed the sync button, and charged up the capacitors to 100 joules.
“Hey Kevin! I’m Cardioverting!!” I yelled up to the front of the truck.
“Want me to get back there!?” He yelled back.
“No, just drive like a MoFo (yes, I used the real words) and get us to Tony’s (the hospital)” I yelled back.
Without further ado… “Zzzzzzzzzzzzap” went the Lifepack 10, with the two little wisps of smoke trailing up evidencing the fact that I forgot to lube up the paddles with defib gel. Time stood still and the “Butt Pucker Factor” was at a 10.7 when I looked over at the monitor to see normal sinus rhythm return. I checked Earl. He had a strong pulse.
“Get this damn oxygen out of my nose!” he said.
“Oh, I think we’ll be keeping that there in there Buddy!” I replied. “How are you feeling?!”
“Just get this out of my nose” He stated.
I gave him 100mg or so of lidocaine to calm down his ventricles after that, and arrived at the hospital shortly thereafter. They were surprised to see that he’d changed. So was I.
I never saw Earl again, nor heard of how he did after that. Really, I don’t get to see many people after I take care of them unless they become frequent fliers. Earl and his condition really aren’t the story here. Nor really is his condition. What this is about is that: Everything worked. Everything we had done to design our system, every dollar we spent on putting a paramedic on every truck, every hour we put into training, and every bit of the profession clicked for this guy and snatched him right out of the jaws of death right then and right there. It just fell into place for him. I think of him often when I am putting hours of effort into maintaining the EMS system that I work in now. Every ounce of preparedness saves an Earl sometime.
For the record, I did get breakfast that day. It was cold fast food, eaten at 10pm off of the hood of the ambulance. Good day.