The MacMedic

The first shift at any new job is enough to make you feel totally bewildered and bordering on incompetent. Last night was no exception. I got in about ten minutes before my shift was supposed to start and immediately needed to have help just to figure out how to punch in. The day shift paramedics we pleasant enough but I couldn’t help but have the feeling that I was not going to be accepted as a peer yet.

I met my preceptor who was younger than I am, probably by ten or twelve years, and we went right into the usual new employee routine of here’s where you can put your coat, here’s you mailbox, here’s the time clock, etc., etc., etc.. My packet of orientation materials and a pocket sized protocol guide were in my mailbox and we were off and running.

The ED was busy and I shadowed my preceptor as we went through triaging patients, ECG’s lab draws, IV starts, the paperwork, where everything was stored with little bits of how EMS works interjected in when time permitted. We stayed pretty busy until well after midnight and long after the other ambulance went off line. Most of what I saw and did was ED related stuff with only a little EMS stuff beyond the initial truck check when we came in.

The biggest problem I was having was that by 0300 I was starting to feel quite fatigued and by 0400 when we were finally able to go out and take a drive to look at the area I was downright drowsy. We were only gone 45 minutes but it felt like hours as I struggled to stay awake and remember the locations of main streets, landmarks, and other important things. I was quite spent by the time we got back and the only thing that made me feel a little better was that the other paramedic on the crew with us was also dragging as much as I was.

The two hours left seemed like they were never going to end. All in all I was less than happy with the night, I had done so little EMS related stuff and I was so tired that I really was wondering if this was the right job for me. I was never so relieved when the emergency phone rang and we were sent on a call. The 911 operator gave the call as difficulty breathing but the additional information made it seem like the problem was more related to nausea and vomiting.

The address was a mile from the hospital and it didn’t take us long to get there. We entered through the front door of a split level ranch and found the patient lying on her side on her kitchen floor. She was a fiftyish woman awake and alert but complaining of epigastric pain and nausea similar to what she had been seen in the ED earlier in the week and was clearly extremely anxious. It had been decided that the problem was not cardiac but a definitive diagnosis had not been found. Her vital sings were stable and her ECG looked good. We made one attempt to get her up to a sitting position which only made her nausea worse.

While the other paramedic went back to the ambulance to get the stretcher my preceptor started an IV while I drew up some Compazine and administered it. After a couple of minutes her nausea subsided “a little” but her anxiety was getting worse and didn’t start to decrease until after she got a milligram of Ativan in her IV as well as the Compazine.

It ended up being easier and faster to simply carry her bodily down the stairs and out to the ambulance and begin transport to the nearby hospital. She improved a little more with the fluid she received in the IV but as we backed into the ED complained of returning nausea. Just as we walked through the door she started to vomit again. Fortunately she missed the three of us on the crew and all of the ED staff but not the stretcher, wall, and floor.

We gave report to the nurse, wasted the remaining Ativan and got down to returning to service and writing the report. I am so slow when it comes to the electronic PCR partly because of my lack of familiarity with it and partly because of my obsession of having all the requested information in exactly the right place. I managed to finish it just in time to go home.

When I left I had said that I might be back tonight but now that I am home I can tell that that is just not going to happen. I didn’t have enough sleep and I don’t have the prospect of enough sleep today to give me the strength to go for another night.

Calls for the night: 1 ALS transport

A different day with a different preceptor but more of the same. The major difference today was the snow. We were being paid back for the relatively mild weather we had been having since I moved up here. Temperatures in the teens and heavy blowing snow were the order of the day. While I expected that this would have upped the call volume today was remarkably similar to yesterday with not much of anything outside the ED coming in except with services that had their own paramedic.

The ED was steady but not as busy as I expected it to be, the majority of the patients that came in were “treated and streeted” in a timely fashion.

Calls didn’t come in until late afternoon and resulted in three dispatches and a single transport. After the two cancellations we took a little while and drove the major routes close to the hospital as went went to fuel up. It was quite nice to get some familiarization in although with the weather being as bad as it was we didn’t go too far.

The only transport we did was a woman in her mid fifties with chest pain and difficulty breathing. Fairly straight-forward IV, oxygen, monitor (unremarkable), aspirin, and some nitro. The patient got some relief with the nitro but after the third one her chest pain changed in quality to where it was made better with deep breathing and palpation of her chest wall. As much as I didn’t think it was cardiac to begin with erring on the side of caution is definitely the better way to go. I’d rather overtreat than undertreat a potential serious problem.

By the end of the shift we had received a little more than a foot of snow. A volume that is much greater than I am used to getting. What was very weird was that where I used to live got significantly more snow even though they are three hours south of me now. Go figure.

My first day in the field here and it was….quite boring for most of it. The ED was busy when we got in but that quickly leveled off to a respectable and moderate rate of patients. Most of the day consisted of what I believe will be the usual, IV starts, lab draws, triage, ECGs and just general patient care stuff. The first calls didn’t come in until after 1700.

The first call was for a pediatric with difficulty breathing which we were cancelled on shortly after we went enroute, BLS only. Immediately after we shut down we got the next call for altered mental status in another town only to be cancelled within five minutes when the ambulance signed on with a paramedic.

It wasn’t until about 1840 when we finally got a call that we actually made it to and transported. An elderly male with a fever and altered mental status, a known urinary tract infection, and a diabetic history. When we arrived on scene he was in care of the intermediate ambulance and while a little disoriented was quite stable with a normal blood sugar level.

Had it not been my first opportunity to do ALS in the field at this job I probably would have allowed the intermediate ambulance to take it in since there was very little paramedic level care that was required. I had the intermediate start the IV and we took a very comfortable transport back to the ED where the patient would eventually be discharged on a different antibiotic for his UTI and sent back home.

A couple of things that I will need to get used to that are going to effect the way I practice here. First is that a service can be a paramedic service for some calls and not others not depending on the nature of the call but rather on the availability of paramedic personnel. Add the fact that you don’t know what level the ambulance will be responding at until they sign on and it becomes such a foreign concept to me coming from a state that required 24×7 paramedic coverage in order to be authorized as a paramedic service.

The other adjustment is going to be working somewhere where EMT-Intermediates actually have a scope of practice that allows them to function and be useful. Limited medications, simple single lead monitoring and the like make the Intermediate capable of handling some of the most simple ALS calls without paramedic assistance. For my entire career, until I moved to this state, Intermediates were a dying breed, their scope of practice had been such as they were not very useful and their guidelines made it such that actually having them perform ALS was much too time consuming with online medical direction that many services just no longer bothered to maintain the level of service, preferring to stay at the BLS level and getting their ALS from other services who could provide paramedic coverage full time.

I will adjust, it will just take time. My biggest worry right now is that I will not be able to adjust to the lower call volumes and will either start to rust or just plain go crazy.

A satisfying day, it feels really good to have been back to work and now to be finished. When I got in the ED was on diversion, just like they had been for the past 14 hours, and boarding enough patients that they had almost no room for incoming emergencies. My preceptor was already there and showed me the basics right away, where to put my bag, where the time clock was, where to hang my coat, and the like. We hit it off very well, we were about the same age and while I had considerably more experience in the field than he did we had similar outlooks on things. Looking back that may be part of why I am here since he was on the panel that interviewed me.

The day shift for the intercept unit arrived a little later. They do shift change at another location on the hospital campus and do their daily equipment check before they come to theED. I had only met one of the paramedics before, during my interview, and after being introduced promptly forgot their names just like I had forgotten the names of most of the EDstaff as well. That will come with time.

The system here runs differently from what I have done in the past. Here one paramedic is dedicated to the ED at all times working a twelve hour shift. The intercept unit is staffed with two paramedics working a twenty-four hour shift. They’ll take assignments in the ED when they are not out on a call or doing other chores.

I’ll figure out more about how the intercept assignments work when I work my first shift later in the week.

The morning was pretty busy trying to take care of the admitted patients as well as the emergency patients that were coming in as well. My rusty phlebotomy skills got a workout and I was able to finish my required competencies in that skill early on in the day. IV starts were next and I managed to get a few of those in as well.

After a few hours things started to loosen up and we were able to transport some of the patients to beds on the floors. My preceptor and I transported the monitored patients while the PCT’s transported the unmonitored one’s. As much as I would like to have been doing something more clinically challenging none of the transports took very long or were very difficult and they gave me a chance to get out of the ED and see some of the other units of the hospital. I have to admit, in my last job I saw very little of the inpatient units and kind of nice to see them here.

A little after noon the ED was finally in shape to come off diversion. The ambulances started coming in shortly thereafter. Not too many, but a steady trickle. None of the patients were particularly critical but they did allow me to finish up my IV competencies with the IV starts that came from them.

I will admit that one of the ambulances did hit one of my “hot buttons”. Paramedic staffed ambulance transports a middle aged, overweight man with chest pain to the ED. He gets an IV and aspirin but they elect to not give nitroglycerin because “they were only a few minutes away”. How much time does it take to drop a tablet or spray some nitro under the patients tongue? Come on, even if the patient gets the med while the ambulance is backing into the ambulance bay it’s better than not getting it at all. I really despise lazy patient care.

Other than that it was a good day, and a good way to work myself into the system. I’ll be back on Saturday to work part of an intercept shift. Days only until I am finished with my orientation and ready to be cut loose on my own.

I’m tired but it feels really good.

My first day at work, I’m up early and ready to go well before I have to leave so I have a few minutes. I’m excited to start even though I know that my first shift with my preceptor will be an ED only shift. The only way I will get out of the ED today is if we need to do a Critical Care Transport and the only available ambulance is not at the paramedic level. Not likely.

Even though I will not have any field time today I am still excited to get back to work. New job, new challenges, and a big role reversal for me. The “master” is now the student. Where I was I had been there long enough that I had pretty much mastered the job. Now I am starting at the bottom again and will be working with my own preceptor who will have to show this dinosaur where everything is kept, make sure that I can start IVs, draw blood, do paperwork and the like. I honestly think his job will be harder than mine.