The MacMedic

It was probably a good thing that I only had one call today. The cluster headaches that dogged me for several days last year have returned and almost right on schedule I have had the sudden onset of a searing headache in the late afternoon every day for the past three days. I hope that I can get them under control faster than last time. These headaches just take so much out of me that I am useless during and afterward.

I was supposed to be working a 24 hour shift today with one of the few partners that I enjoy working with. It’s not happening, the headache that started last night continued throughout the night and by 0300 I had had no sleep and was feeling generally worse than before. No way I can work feeling like this, I called in sick.

Tonight I lectured about airway management to an EMT-Intermediate class that is being put on by the volunteer ambulance. I love teaching airway management and my recent airway management nightmare was included as a teaching point about being sure to control your environment while you work.

There were 10 students in the class and all but one were on the ball and interested in the topic. The remaining student had the “been there, done that” attitude of someone who had taken the course before. Problem is that he had taken the course before, and then proceeded to fail the National Registry exam a total of six times. While I couldn’t say it I certainly was thinking it, a little less attitude and a little more learning would go a long way.

The only thing that was bad about the whole evening was the ripping headache I had by the end and still have.

I had absolutely no interest in going to to work. None at all. I was still fuming about my last shift and not looking forward to working my 12 hours of indentured servitude in theED. All I can say about the night was that it was more of the same. More IV starts, more blood draws, more take this patient here and that patient there.

The only high point for the night was hearing from the EMS Medical Director that he would back me if anything came of “The Incident”. He felt that once I was on scene none of the doctors that were there had any right to expect that they would be in charge or be performing any procedures.

The past 24 hours were less than spectacular between the hours and hours of boredom, the seemingly endless cancellations, and what will certainly be one of the most outstandingly frustrating calls of my career I was quite ready to forget the whole day.

Up to 2100 the day had been spent running from one cancellation to another, never seeing a patient, and helping out in the ED. Then everything changed, just as we were getting ready to be released to quarters we were dispatched to a “woman down possibly not breathing” at a country club in the next town over. Every minute or so the dispatcher would call us with an update from the 911 operator who was on the phone with the caller. “Not breathing, CPR in progress”, “AED in place no shock advised”, “physicians on scene requesting EMS to expedite”, and finally “physician on scene requesting intubation equipment stat”. It just sounded ugly right from the start.

We arrived three minutes after the ambulance to find a rather large party in full swing. After driving across the grass to right next to the ambulance we were directed to a corner of the room where an elderly woman was supine on the floor with a crowd of well dressed people around her and the ambulance crew standing nearby with the “deer in the headlights” look. A well dressed woman approached me yelling that she needed intubation equipment and grabbing at my bag. Not knowing who she was I elected to hold on to my equipment and attempt to get through the crowd and actually lay eyes on the patient.

What I found was an unresponsive elderly woman lying on the floor with agonal respiratory effort. An oral airway was in place and she was being bagged by a man who identified himself as a physician. An AED was in place that kept stating “no shock is advised” and the patient had been placed on an Autopulse. Fortunately the Autopulse had not been turned on. I disconnected the AED and placed the patient on my monitor which yet another physician correctly identified as showing sinus tachycardia. One of the bystanders mentioned that chest compressions had been done manually and at some point a large food bolus had been removed from her mouth.

By now I could at least understand some of what was going on with the patient and could formulate a plan of what needed to be done. Airway first, I suctions a large amount of secretions from the patients mouth and then opened the intubation kit to set up to intubate her. It was not a difficult tube, I needed to suction her some more but I was able to pass the tube easily. With the tube in place I put down the laryngoscope and reached for the capnography probe to confirm placement only to feel someone pushing me to the side while saying “I need to check lung sounds”. A second later I found myself pushed over onto my right elbow with the capnography probe in one hand and the, now displaced, tube in the other. OK, replaced the oral airway and continue to bag.

While the patient was bagged the ambulance crew had brought in the stretcher and had it place beside the patient. I took a moment to intubate the patient again, still a fairly easy tube. Capnography probe was placed on the tube showing good waveform and confirming the placement. All that remained was to secure the tube. I looked to my right to see where the tube holder had gotten to. Imagine my horror when I felt the patient moving and turned back to find 4 well dressed people picking the patient up by her arms and legs and literally hurling her onto the stretcher. Sigh, here we go again. The capnography wave form disappeared and the patients stomach immediately started to inflate.

This time I removed the tube, replaced the oral airway, and had one of the EMT’s return to bagging her and said “let’s get to the ambulance”. I figured it would be better to be on our turf where we could close the door and leave all of the well meaning physicians and bystanders outside.

The patient was put in the ambulance and I made ready to intubate the patient for the third time only to find the female physician that had been demanding intubation equipment to be standing half in and half out of the side door of the ambulance saying the “she wasn’t leaving until she was sure we had a secure airway”. This time the tube was a little tougher, her airway was getting a bit swollen from all the manipulation. I needed to stop and bag the patient some more and listen to the physician tell me to “get out of the way, I do this all the time”. Now I still have no idea who this doctor is, what kind of doctor, and what makes her more qualified than I am. I said “I have this under control” and proceeded to finally place the tube, confirm placement, and secure it without incident.

At this point I said just three words. “We’re leaving” to the doctor and “drive” to the technician driving the ambulance.

About halfway through the transport I called the ED on the cell phone. On paramedic working in the ED answered and took my report. “We already knew that. Dr. So-and-so called to give us report and file a complaint that you wouldn’t let her intubate.” That was not what I needed to hear, I was already frustrated and angry and this just made me even more so.

The patient had remained unchanged throughout the transport with only agonal respiratory effort and stable vital signs. We arrived at the ED a few minutes later and I gave my report to the ED physician and the ED staff. I made sure to give the full report including the entire incident.

I was about ready to just go home. It took me a little while to calm down enough to sit down at the computer and write the patient care report. I was fuming and even an hour later when we were finally cleaned up and finished documenting (including an incident report to my boss) and released to our quarters I was still to wound up to actually go to sleep. I finally managed to get to sleep about 2 hours later and slept fitfully for the remainder of the night waking up and not feeling the slightest bit rested.

I drove home still totally frustrated and disgusted with the whole day. It was made worse knowing that I would have to come back at 1900 tonight for my ED shift.

Another dreary night in the ED. I am really becoming quite disillusioned with my job. The entire night was spent running from one room to another doing IV starts and blood draws in addition to the myriad of orderly type tasks that seem to always be the paramedics job.

By morning I just needed to get out, I was feeling like I truly accomplished nothing at all during the night that required my unique skill set and that the hospital might have been better served by a less trained, less expensive technician. I suppose that as long as the paycheck keeps coming I shouldn’t complain too much but I long for a job where I can feel challenged regularly and where I get up looking forward to going to work.

I continue to believe that I am way too old to be doing 24 hour shifts. Partly because I recognize that after 16 hours (sometimes more, sometimes less) I start to be less sharp than I would want to be, partly because I still do not sleep well at work, and partly because while it may be pleasant to have a good partner, working for 24 hours with a partner that you don’t enjoy makes it unpleasant. All of these came into play for this shift by 2200 I felt wiped out, had a feeling that I wasn’t going to get any restful sleep, and was so irritated with my partner that I really wanted to just hang it up and go home.

My partner was one of the newer hires here, newer than me at least, and so far has done little to impress any of us with anything except his slavery to his two addictions, caffeine and nicotine. I can’t speak to the caffeine addiction what with my Diet Coke habit being what it is but after 12 hours I was pretty annoyed with his nicotine habit as he spent pretty close to 20 minutes out of every hour outside smoking, well over a pack by 1900. Only a couple of those times were in a place where the smoke was blown into out unit and he did move when asked without hesitation. What had me so annoyed was that with the ED hopping all afternoon and him MIA for a third of the time I ended up having to pick up the slack and I felt it was quite unfair.

When I broached the subject with him he was quite incensed and assured me that I was the only one to ever complain. By this time our time in the ED was over, I was so frustrated I wasn’t going to be able to continue the conversation without getting angry and decided that I would be better off if I just went to bed. Four hours later I lay awake in my bunk tossing and turning unable to get to sleep and feeling mentally and physically wiped out. I really just wanted to go home. I finally did fall asleep and slept uninterrupted for about three hours but, as usual, it was not a restful, restorative sleep and I was looking forward to getting home to bed.

Outside the ED it was not a very busy day with only 5 calls in the entire 24 hour shift and only one of those had any patient contact at all.

We were dispatched to assist a fire officer who had come upon a motorcycle accident that had occurred moments before. The initial report was three patients, 2 with minor injuries and 1 with serious injuries. We arrived on scene right after the first due ambulance and I was directed to the patient that they determined was most serious.

The patient, a female in her mid-twenties, had been the unhelmeted passenger on a motorcycle that had been struck from the side at unknown speed resulting in the bike being knocked over and sliding along the pavement for 40 or 50 feet. She had some really impressive road rash on all of her extremities and the second mid-shaft femur fracture (this one open with some moderate bleeding) I had seen in a week as well as an angulated, open fracture of her lower leg. No loss of consciousness or other significant injuries were found and she had no entanglement so we were able to get her immobilized and ready for transport rather quickly.

I had started one IV while the ambulance crew was splinting her leg and started a second while we were enroute to the closest ED. We had some real difficulty getting her to stay still on the back board. Every time she moved her torso the movement of the muscles in her leg caused a significant increase in pain in her leg. Once again Dr. Feelgood comes through, and after some big doses of pain medication she was much less uncomfortable by the time we arrived at the ED and able to stay reasonably still on the board without moving her injured leg as much. We managed to slow but not totally stop the bleeding from her open fracture site but her blood pressure was holding and her heart rate was down.

In an ideal world I much rather would have traveled to a trauma center but with the nearest almost an hour away and a helicopter at least 25 minutes to the scene once the lifted off it made more sense to head for the closest and have them arrange transfer. In this case I really wish I could have gone directly to the trauma center. The quick and dirty x-rays they did in the trauma room were all unremarkable except for the femur fracture, tib-fib fracture crossing the joint area of the tibia, and the dislocation of her, now free floating, knee joint. Each of these was a significant fracture in its own right but taken as a combination this had the potential to be a debilitating injury requiring multiple surgeries and possible a total knee replacement.

The frustration? Multiple causes, foremost the hospital I work for simply sucks at doing trauma. It’s not that they don’t try hard. It’s simply a matter of not enough volume, not enough practice, not enough support staff, and no easy availability of a surgeon that is willing to take a trauma case to the OR or even consult. These causes lead into the next thing, missing somewhat obvious tasks that need to be accomplished. After we returned to the department after paperwork, fuel, and restocking nobody had actually done anything beyond what had been done outside the hospital to control the bleeding from her leg. By now there was a rather impressive pool of blood on the end of the stretcher and her pressure had gone soft, hovering on the high 90’s and low 100’s with a heart rate in the 100’s. The final straw for me was when I learned that they had made arrangements to transfer her to a larger facility that was capable of dealing with her injuries but 2 and a half hours after arriving she was still here as the staff was waiting to hear from the helicopter service that the weather had cleared enough for them to lift off to come transport her. A transport that was only a little more than an hour by ground. She was only then getting ground transport. The only question now was when the patient was going to crash on the paramedic doing the transport. When, not if, when the patient was going to crash.

I am really wondering if my patients wouldn’t be better served if I could convince the ambulance to make the hour run bypassing 2 other hospitals to a trauma center rather than just heading for the nearest ED providing that the airway was patent. I suppose that this would not go over well and would violate several different rules and regulations. Still, I wonder if it wouldn’t be better for the patient.