The MacMedic

I don’t know what triggered my headache before my last shift but even when I got up to go to work I was not back to normal. Just a little foggy and a little run down. It was probably a good thing that the ED was not exceptionally busy and it seemed like the bulk of my duties last night were IV starts, lab draws, and the like. I’m looking forward to getting some more sleep to see if I can clear my head and feel more rested.

Tonight was supposed to be another shift at “the other hospital” and hopefully more of my orientation packet signed off. I didn’t feel well as I drove in, just a little sour stomach that felt better with some antacid and a full feeling in my head.

The shift started out OK with a short conversation with one of the other paramedics who works for both hospitals and the same volunteer service I do. I talked about how I was frustrated by the low call volumes and how much I really wanted to be busy. He also worked per diem in a neighbouring state for a nontransport paramedic service in an fairly urban area which averaged 10-12 calls on a 12 hour shift. He had been there full time until recently but the 80 minute commute was killing him and he had to find something closer for his full time position.

I would be lying to say that I am not tempted by the prospect of being very busy even if it is just a few days a month. I should say busy in the field, I can be busy in the ED at either of the hospitals that I work for now but being in the ED is drastically different from being in the field. I am very tempted.

I did my beginning of shift vehicle and equipment check and was ready to go. After doing some work around the ED our first call came in for a fall victim at a nearby SNF. We arrived on scene in less than three minutes and were guided into the room where a 90 year old woman had fallen out of her wheelchair and landed face first on the floor. She was still prone on the floor complaining of pain in her forehead. Fortunately I had had the forethought to bring a longboard in with us and we were able to log roll her right onto the long board and secure her down.

She had a 2cm laceration to her right eyebrow. Staff who witnessed the fall denied any loss of consciousness and she was acting as she normally would. A quick set of vital signs, dressing and bandage and we were off to the ED. Total time for the call, 18 minutes.

With the patient turned over I sat down at the computer terminal to write the report and realized that I was extremely diaphoretic, my sour stomach had turned into roiling nausea, and the full feeling in my head had gravitated to my left side right behind my eye and was turning into a pounding migraine headache.

My preceptor took one look at me as I came around the corner with a “convenience bag” in my hand and asked “are you going to barf?”. I honestly didn’t know and it didn’t take much convincing on his part for me to clock out and go home.

If there is one thing I can count on it is that I will feel good doing my volunteer shift. Last night was no exception. I had a good crew that I knew I could count on and who were interested in learning and all of the calls we did went well.

Three responses and three ALS transports for the night. I am quite happy with it even if most of the calls were no more than routine ALS and I didn’t even get to perform the skills. Since I had two EMT-Intermediates on the crew with me I let them do the IV starts and, for the most part, run the call. The experience is good for them and it gave me a good chance to sit back and see how well they could do. I was very pleased that both did well even though two of the patients were difficulty due to dementia and hearing loss.

I’m going to try to pick up some additional calls during the week just to fill out my monthly call requirements and to give me a little bit of enjoyment.

This has been the end of my first 24 hour shift a probably 15 years. I was really unsure how I was going to feel at the end of it or even if I was going to make it through. As it turns out I did pretty well. That being said my partner made it clear to me that not every shift is like this one.

At 0700 yesterday we took over for the previous crew and did the usual truck and equipment checks. It’s only supposed to take us half an hour to check two full sets of gear and the truck itself. Since I am new and still adjusting to the layout of the gear it always takes me longer and this was no exception so it wasn’t until almost 0745 that we were finally able to report to the ED and pitch in there. As usual for a Sunday the ED was slow for a couple hours and then all hell broke loose with the wait time to be seen by the doctor continually getting longer and longer until it was finally five hours before some of the patients were finally getting seen.

In the middle of all this chaos my partner and I responded to three calls. Responded to three calls, transported two, and I actually got to work up one of them. Even the call I got to transport with was soft. A dehydrated patient that the EMT-Intermediate couldn’t get an IV on after three attempts. I started the line and sate on the bench seat for the rest of the transport trying to look like I was being useful. The only “real” call we had during the day was the one that my partner transported with, a woman in her fifties with chest pain who ended up going to the cath lab and getting admitted to the CCU. We were cancelled on the last call when the ambulance signed on at the paramedic level making us redundant.

The chaos continued in the ED for most of the day and it wasn’t until around 1800 that the waiting room had been cleared out and we once again had beds in the ED. At 1900 we were cleared to head to our night quarters. Actually we were going to get some dinner first but we were released from ED duty anyway.

I let my partner choose the restaurant and was pretty surprised when he chose a “sit-down” place instead of the usual fast-food or diner type place. On our way we got sent to two more calls, both cancellations, and I thought that we were really tempting fate trying a sit down meal but that was what he wanted.

Maybe I am just not used to being such a big risk taker but I was quite surprised when we sat through the entire meal without so much as a burst of static from the radio. I can’t recall ever having a job where I would even consider a “sit-down” meal yet here we were.

We were in quarters by 2100 and in our bunks by 2130. I never sleep all that well at work and this was no exception. I kept waiting for a call to come in. I woke up every hour or so, checked to make sure that the radio was turned on and then uneasily drifted back to sleep. I kept checking the radio and checking it and, nothing happened. 0630 and the alarm clock on my cell phone went off waking me up and hammering home that I just spent the night worrying about the call that never came. My partner came out of his room looking quite refreshed after getting almost eight hours of sleep. He warned me that not every night was like this, usually they get woken up once or twice.

I looked in the mirror and I looked like hell warmed over. I was not rested. I did not feel great and even though I had just been paid to sleep I would have preferred to have been busy. Five responses with just the one transport was just enough to frustrate me. I really am wondering if I shouldn’t be looking for a position somewhere busier even if it is just once in a while.

Third night in a row and last night I was at the other hospital based service. It’s a little more urban setting and I could only hope that that would translate into more calls. That’s the plus side. The minus side is that once again the number of paramedics on the shift was double the number of nurses so it was pretty clear early on that we, the paramedics, would be doing a lot of nursing work.

I was right, sort of, we did have two calls and both of them ended up being ALS but because we were so close to the hospital there was not much time to provide a lot of care.

The first call was for a man in his mid-sixties with emphysema who had been developing cold symptoms over the past day or so. Tonight he started to get very short of breath and his wife called 911. When we arrived he was tripoding over a sofa in moderate distress. He was febrile, had wheezes in all fields and a productive cough. While my partner went down to get the stair chair and set up the stretcher at the bottom of the stairs I applied a nebulizer with Albuterol and Atrovent and got a baseline set of vital signs. He was pretty sick but responded well to the nebulizer.

Once downstairs we loaded and started the five minute trip to the hospital. I barely had time to refill the nebulizer with Albuterol and get an IV started before we were backing in. So much more I would have like to do but with the short transport times it just wasn’t going to get done.

The other call came in half an hour before shift change. Everywhere else I have worked in the past fifteen years a call at this hour meant that you would have no chance of getting out on time. This patient woke up this morning with nausea and abdominal pain and was waling out to the curb as we pulled up. She complained of lower quadrant abdominal pain and nausea. No other complaints and although she had extensive history none of it was relevant to this complaint. Her belly was soft and her pain did not change on palpation.

From here the transport took about four minutes and I felt rushed to get my IV started and some Phenergan on board. Once again we were backing into the ambulance bay as I was just finishing up. Somehow I felt cheated by not having the chance to see the medication take effect and the patient show some relief.

On the brighter side I was still out on time.

Out of all the services I work for here this one is the hardest for me to adjust to not only in hospital but out as well. So far the shifts I have worked have not been very busy in the field but the pace on scene always seems very rushed and a total “load and go” mentality. I have worked in busy systems before and even busy urban systems before and never felt this rushed. I really hope I get a better feel for the system here and can find a way to fit my style into the services culture. I don’t want to feel like I am always being rushed to do a quick assessment and bang out the treatment in the shortest possible time nor do I want to feel like I am dwaddling on scene being unnecessarily long. I just want to feel like I have been prudently thorough and given the patient the best possible care that I can.

It seems like forever since I have been on duty for a night shift and assigned to the intercept unit. Well, OK, it is my first time at night. Usually the intercept shifts are 24 hours long and I was only covering half so instead of being able to sleep tonight I would be staying in the ED while my partner headed off to bed shortly after I arrived.

As nights go it was not very exciting. The ED was steady but not very busy and non of the patients were very acute. The only two calls that came in were before midnight. Since my partner was already in quarters for the night this meant that I had to leave the ED, swing by the night quarters for the paramedics and pick up my partner and respond. It added a minute or two delay to our response.

The first call was for a patient with difficulty breathing. A young woman in her late teens who happened to be pregnant. The EMT-I level ambulance had already administered an Albuterol treatment before we got there and the patient was back to her norm. I suspect that the fact that she was pregnant effected their decision to keep us coming instead of beginning transport and intercepting or canceling us outright. No big deal, we hopped into the ambulance did a quick assessment and assured the crew that they didn’t need our help.

We had just left that scene when the next call came in for chest pain. in a town even further out than where we were. I was actually looking forward to it, I really was a bit bored and wanted to have some patient contact time. No joy, we were cancelled when the ambulance signed on at the paramedic level and our total time on task was 2 minutes. I was disappointed.

After dropping my partner back off at his quarters I returned to the ED to the slow but steady pace of non-critical patients that were coming through. No more calls for the rest of the night, no matter how hard I wished for them. The call volume here is killing me.

The ED rocked for most of the night, lots of patients but only a few that were complex. A sobering experience for the night was the trauma patient that came in via ambulance after a high speed rollover on the highway. The patient was an obese woman in her late forties who was the unrestrained driver of a compact car which drove off the side of the road and rolled over several times. The other occupant of the vehicle fled the scene leading to a drawn out search and strangely enough leaving the patient, his fiancee, alone in the vehicle injured. I don’t even want to try to figure out the dynamics of that relationship.

The patient arrived via the career fire department ambulance service from the town where the hospital is located and their care did little more than meet the minimum standard. In and of itself this was not out of character for them and I was not surprised. What was surprising to me was that as soon as the ED knew they had a trauma coming in the only change from the norm that they made was to call X-Ray to have a portable machine and a tech standing by.

The patient rolled through the door and was put in one of the “major rooms” and the trauma team consisted of me, two nurses, and the doctor. While all of the elements of an advanced trauma assessment were done it took considerably longer than I expected and the decisiveness of the team was not what I would have hoped. The patient did get all of the same exams I would have expected with multiple x-ray studies, a CT scan, labs, and the like but care didn’t flow from one step to the next.

As this was my first trauma in this ED I wasn’t really able to help facilitate the flow very much. The procedures were new to me, the protocols were new to me, the situation of not having a trauma center available within 30 minutes was new to me. I did what was asked of me and what I thought would be expected of me but in the grand scheme of things it was not enough to keep things rolling at a quick pace.

Later in the shift I ran the situation by one of my colleagues and he concurred that this hospital was not a leader in trauma care. On the other hand, he reminded me, neither were any of the others in the area and he figured what I saw tonight was probably a typical trauma response for this or any of the surrounding hospitals.

Talk about culture shock.