The MacMedic

PALS is tomorrow so I requested to work for the next two nights at Medic 6 so that I could have a chance of getting some sleep. I’m getting too old to try to go to training on little or no sleep, I end up dozing through too much of it. At one point I thought about just not doing the refresher tomorrow but realized that I was already expired and if I went into any job hunt with such a glaring omission it would not be helpful.

I expect that I will spend most of the evening with my nose in the textbook and then try to get some sleep while I have the chance. It’s hard, I am just not used to sleeping while I am at work.

Nothing, not a damn thing all night long. By 0300 I was so bored that I ended up falling asleep for a while even though I slept for a good amount of the day. I did manage to get some studying done for PALS but not enough and I will need to spend some of my time over the next few days.

It was a strange feeling knowing that I am so close to the end of my time here. I said goodbye to the staff when I left this morning and got a quick hug from one of the nurses and a handshake from one of my former colleagues, now a nurse in the ED.

Only three shifts left now and I am beginning to think that I will be going out quietly. My next two shifts are Medic 6 and I will my last shift will be at Medic 2. Whatever comes will come.

I have been having soem trouble with tendonitis in my right elbow for the past several days and this morning when I got home I found it very painful to lift or move that arm. Motrin has been of little help and I have let it go too long. I dug around in some of the already packed boxes and found my splint and strapped that on with some relief. I shoudl have done this days ago but I kept thinking that it would get better with just the Motrin. With tonights shift being my last for a few days I am hoping that I can rest the elbow and only use it gently to see if it starts to recover. I could always make an appointment with my doctor and have it injected with steroids and lidocaine but with all of the work that needs to be done it is not likely that I will have the time to do that conveniently.

Clearly I was very tired when I got home, I fell asleep quickly and before I had a chance to set my Powerbook up to play my white noise track. My wife was going to be working in the attic most of the day packing the last remaining boxes and with that noise above my head I expected it to be disturbing. I was surprised when I awoke and found that not only had the noise not disturbed me I hadn’t even noticed it. The nice thing is that with all the work my wife was able to get done our attic should be empty within the next couple of days. Lots of stuff got packed, lots of stuff got thrown away, and only a few items remain, like the two Sun Sparcstations I have that have been sitting unused for the past couple of years.

Tonights shift is Medic 3 and I have mixed feelings about driving all the way out there. I don’t have a lot of choices as the only paramedic that would be able to swap locations with me is working Medic 6, somewhere I already have to go twice this week and don;t want to spend a lot of time at. Since we changed our cover assignment matrix Medic 3 is once again quite a slow station at night and I am guessing that I will have a lot of time to do things. Among the things that I will need to do is catch up on Emergiblogs memberships and start reviewing my Pediatric Advanced Life Support(PALS) for my refresher on Thursday. The refresher is the only reason I am not howling about the two nights in a row at Medic 6. With the refresher in between the chance for some rest before and after is actually a good thing.

All I have left in my career here are those two Medic 6 shifts and a single Medic 2 shift on my last night. It’s a weird feeling to know that I am so close to the end.

The night started out pretty busy although none of the dispatches ended up needing ALS and were downgraded to BLS or refused. Still it was fun and refreshing to be busy, I will miss that. The realization truly struck home when I realized that this will be my last Medic 1 shift for the rest of my career unless an unexpected location change comes up. I had hoped that I would go out with a bang but it seems that I am much closer to going out with a whimper. *sigh*

I am making every effort to stay positive about the changes that are coming and while it is very hard for me I think that I am doing better than I expected.

Total calls for the night: 7
4 BLS downgrades
2 Cancelled upon arrival
1 Refusal

Milage for the night: 87

Music for the night: “Audio” by Blue Man Group

Change is a difficult thing for me and I continue to struggle to accept all of the changes that are coming. Of all the changes, leaving my job will be one of the hardest. I am really feeling the anxiety that goes along with a change of this magnitude. I am not looking forward to my last night, fortunately tonight is not that night.

Aside from being a chilly night it actually wasn’t too bad. Four dispatches resulting in two ALS transports. Oddly, neither of the transports ended up going to my base ED. It’s not often that that happens.

Neither of the calls were particularly challenging but both were nice, simple ALS calls that went smoothly from start to finish.

The first call was actually Medic 3’s. He had been sent to a theatre on the bank of the river that divides his territory from mine, probably a twenty to twenty-five minute response depending on the fog. As it happened I was clearing a call on my side of the river at an SNF and would be less than five minutes away. To me it made much more sense for me to do the call since I was so close and the call came in as an unresponsive person. Medic 3 agreed and four minutes later I was parked in front of a historic theatre and being guided to the patient by an usher.

The patient was a male in his early thirties who had experienced a sudden onset of diaphoresis and had a syncopal episode. He was assisted out of the theatre by a husband-wife team of nurses that are friends of both my wife and me and they gave me a quick run down on what they had found.

The patient himself looked pretty good except for being a bit pale. He denied any other complaints and only related some abdominal cramping just before his syncopal episode. His vital signs were stable and he felt fine otherwise but was quite agreeable to being transported to one of the satellite ED’s for evaluation. I decided to go along to monitor the patient, get some blood, and be there in case anything else happened.

The ride was uneventful and I put in an IV of saline and drew some blood. His glucose was 68, on the low side but not low enough to do something about considering he was mentating well. He did fine until we were backing up into the loading bay at the ED. All of the sudden he became extremely pale and diaphoretic and vomited a huge amount. “I feel a little better” he said. No doubt.

This brings up one of the trivial questions that have been going through my head for almost my entire career. Who thinks that those little kidney shaped basins are big enough for someone who is vomiting to both hold onto and manage to get the vomit into? As far as I can see these basins only manage to deflect the first couple hundred cc’s onto the surrounding area. Fortunately for all of us we grabbed a larger basin that was more appropriate.

The last call of the night came in just before 0600 and was initially dispatched for difficulty breathing. In reality it turned out to be a leukemia patient who had been unable to take any food or water by mouth for the past few days. She was in good humour and was joking with the fire department as they guided her to the stretcher. Her main complaint was just ongoing weakness. Her mouth was dry and when I pinched the skin on her forearm a bit the skin stayed tented. Clearly dehydrated and even though her blood pressure was normal her heart rate was over 120.

Essentially the treatment for this woman was almost identical to the last patient. IV of normal saline, blood sample, glucose check, and transport. She remained in good humour for the entire trip joking with me and the crew. By the time we arrived at the ED she had received about 300cc of saline which had no real effect on her vital signs. I suspect she will need much more fluid than that to rehydrate her. I’ll look up her chart when I get in tonight and see what the final disposition was.

Neither of the calls tonight were challenging but I felt good about them. I got to do my job and help some people feel a little better. It was made even nicer because both patients were so appreciative.

Total calls for the night: 4 
2 ALS transports 
1 BLS downgrade 
1 Cancelled upon arrival

Milage for the night: 74

Music for the night: “Blinded by light” by Weevil

I slept pretty well today considering that there were five kids in the house who played for most of the day in a room separated from me only by a bathroom. I finally was convinced to get out of bed pretty quickly by my oldest coming in and frantically shaking my shoulder and yelling something. All I could hear was “total” and 
“emergency” which was enough to get me up. It took 15 or 20 seconds to get the middle word out of her, that was “video”. She was having a “total video emergency” because she couldn’t get the video game to work with the television. Well, I was up and the emergency was a plug that wasn’t in all the way.

My sister-in-law will be going home with her two kids tonight and my mother and father-in-law tomorrow morning. With luck this will mean that the volume of the chaos around here will drop significantly. (Probably not, but I can always hope.)

I am starting to really feel the end coming. Only five shifts remain after tonight before my career here is over. In a way I am looking forward to the new challenges that a new job in a new area will bring but mostly I am feeling anxious about the enormity of the change in my professional life. I can’t help but wonder if being a paramedic there will satisfy and challenge me the way it does now. I know it won’t be the same but just how different will it be?

You would think that a holiday would be a busy night but that was not the case for the majority of the night. I had two ALS calls early in the shift and then nothing until the shift was almost over.

Both of the ALS calls we interesting in a “things that make you go hmmmm” type of way.

The first call was for an 80 year old female complaining of epigastric pressure radiating to both flanks and up into the center of her chest. It came on pretty soon after eating dinner and did not seem to be making her uncomfortable at all. Looking at her rhythm strip showed her to be in a sinus tach at about 130 with no ectopy or other abnormalities. Because of the clothes she was wearing it was going to be a significant effort to get to her chest to do a 12 lead and she didn’t want us to try. No amount of convincing was going to change her mind.

The ALS ambulance loaded her onto the stretcher and headed for the ambulance as I went to set up. I suppose I could have turfed the call to the ALS ambulance and made myself available but we were within five minutes of the hospital and I really wanted to do calls not cancellations.

In the ambulance we put a line in and just as I was about to get the nitro out of my pack her rhythm spontaneously changed from the sinus tach at 130 to a normal sinus rhythm at 80 and her discomfort was totally gone. We delivered her to the ED discomfort free a minute or two later and I made sure to leave a copy of my strips with the doctor just so he could se what was going on before she converted.

I hadn’t even gotten the patient off the stretcher before they were requesting me on the air for another chest pain call, this time in my home town. It took me a couple of minutes to make the handoff to the ED staff and I was on the way.

When I arrived the patient was in the back of the BLS ambulance and the report I was getting from one of the first responders was disjointed and mostly unhelpful. No matter I was getting in the ambulance anyway to do my own assessment.

The patient was a sixty year old man complaining of pain “all over”. He wouldn’t localize the pain, qualify or quantify it, just complain. Other questions were ignored or answered with nonresponsive answers. He was clearly agitated and also clearly intoxicated. All we could get out of him for history was a “liver problem” and hypertension. Without much more to go on I was left pretty close to square one and decided that whatever was going on he was so clearly not a candidate for BLS downgrade that I would be going along.

We started the trip to the ED, about seven minutes away, and I popped an IV in and drew blood. While I was drawing the blood I happened to glance over at the monitor and saw something that made me lurch towards the monitor and hit the record button. The strip that got printed was this (click for the complete image):

With the line now secured down I could take a few seconds and take another, better, look at this strip. I was 90% sure that it was just some artifact but the ambulance had been stationary waiting for some traffic to clear the intersection before we proceeded. The patient was not moving and none of the leads were lose. It was just suspicious enough that when we arrived at the ED a few minutes later I disagreed with the triage nurse and requested a bed “up front” where the patient could be more closely monitored.

I could tell that the doc was not impressed with the strip and that he was pretty skeptical. I admit that I was a little skeptical myself but had just enough suspicion to make me belief that it could be exactly what I thought it could be.

The patient would eventually be admitted for rule out MI and possible episode of V-Tach. Over the next few hours I showed the strip to a number of people and most of them had the same reaction. “It looks like atrifact but…..” which made me feel a little better about my own doubts. I wish I had been able to grab a twelve lead during the episode and wish even more that the patient had been a little more cooperative and able to give us some more detailed information to help me make a differential diagnosis.

My last call came at about 0630 and I was cancelled along with the engine company as we rode up to the ninth floor of an elderly housing complex. The ambulance had been there ahead of us and decided we woudl not be needed. Fine by me, I had seen my relief driving down the street as I was responding and knew I could be going home soon.

With six shifts left now I was really hoping for a busy night rather than what I had but I can’t change it and I have to accept what comes.

Total calls for the night: 4
2 ALS transports
1 Cancelled upon arrival
1 Cover assignment

Milage for the night: 67

Music for the night: “Mirrorball” by Sarah McLachlan