Death

Last week, in clinical, we had an eldery patient with cancer come in - in cardiac arrest. EMS had ROSC (Return of Spontanious Circulation) multiple times, and we lost pulses more than conce. The wife was in another room, and the patient's oncologist talked with him, then came in the room and told us to stop, that the pateint had a valid DNR, and the wife wanted it to be followed at that time, even though she had apparently told ALS to provide care and disregard the DNR.

Odd thing about it was that it was the LEAST sad cardiac arrest I'd ever seen. Everyone agreed that it was sad - but it was an older patient - and he had multiple cancers and was already going down fast. I think it also helped that there was only a spouse (that seemed to expect the outcome), not 20 family members screaming and crying.

Just some random musings.

Musing about preceptors

I’ve been running a lot of clinical shifts with one paramedic. I started running with him at the beginning of class, and I realized that he walked the talk, and actually wanted me to succeed. It hasn’t been all sweetness and light, and we’ve had some rocky times. More than once I’ve had to explain ‘what the heck I was thinking’… but each case has held a lesson for me, and I’ve learned it. I had one shift where we ran back-to-back cardiac arrests… part of my “Angel of Death” period, where I attempted to intubate someone on every shift I ran for a week and a half. We’ve found things I’m good at, and some things I need to seriously improve at.

We’ve also had some rock-star moments. I’m still flying a little high from a call a few weeks ago, where we had a hypovolemic patient with a head injury. First thing he asks me: “Do you want a helicopter?” I hedged my answer and asked for one on standby – meaning I’d do a secondary assessment of the patient and talk with the command doc of the trauma center before I decided to fly the patient.
He tells me “You don’t have that choice – are you going to fly the patient or not!”
Not knowing what to say, I started running through the patient’s condition and verbally rattiling stuff off – he called to me from the other room “So you want to fly the patient!”
I agreed, and he says “Good. Next time, be faster.”
Aeromedical then advised us they were down due to weather, I pushed to go to the closest hospital, rather than drive an hour to a trauma center, because the more I looked at the patient, the more unstable they seemed, and I didn’t want to have them bleed out in our ambulance. I made the call to the Medical Command doc and sold them on it as he sat back and watched. As we were a minute out from the hospital, I couldn’t feel a radial pulse – MAJOR pucker factor. We got to the ED, handed over the patient, and as both my preceptor and I apologized to the doc for bringing them a train-wreck patient, the doc said I made the right call.

I think I’ve found a keeper of a preceptor – he gives me enough rope to let me learn and make mistakes, but he’s also running the show. He challenges me and makes me learn every shift I run with him, and I push myself to impress him whenever I can. I know that he doesn’t give out a lot of praise – and when he does, it is earned – and I get just enough praise to make me want to do better!

And Miles to go before I sleep.

So we use this program called FISDAP to track all of our clinical hours for school. We have 72 hours to enter in all our data, and we also need to turn in a paper form with our clinical preceptor's signature, etc. I was up until 0300 taking care of school paperwork. Today starts at 0500, working 0600-1400, then clinicals 1800-0000.

As I was typing last night, I thought back to a poem I once read... Robert Frost's "Stopping by the Woods on a Snowy Evening". I can appreacate some poetry, and I remember this one from middle school englis

The line that kept running through my head was "And miles to go before I sleep." Given my current schedule, sleep has become the "optional" part of my scheducle. So When I got to work this monring, I took several shorter naps, and probably slept for close to an hour.

Anyway.... I need more sleep.

Whose woods these are I think I know,
His house is in the village though.
He will not see me stopping here,
To watch his woods fill up with snow.

My little horse must think it queer,
To stop without a farmhouse near,
Between the woods and frozen lake,
The darkest evening of the year.

He gives his harness bells a shake,
To ask if there is some mistake.
The only other sound's the sweep,
Of easy wind and downy flake.

The woods are lovely, dark and deep,
But I have promises to keep,
And miles to go before I sleep,
And miles to go before I sleep.
~Robert Frost

PVC Challenge

Clinicals continue to entertain.

I'm way behind in my clinical paperwork... as soon as I finish posting, I've got to work on my charts for my ED shift last week, as well as my prehospital shift on Sunday. If I get all caught up, there is paperwork from the L&D rotation to do, too.


Anyway... the other night was a pretty busy shift. Started off with a major trauma after an MVA. BLS onscene called for us to assist. Patient had a femur fracture and signs of a head injury... so he got himself a ticket for a helicopter ride to the nearest trauma center.

I had a few other calls, but the last one was the most serious:

Dispatched for a CVA (Stroke). On arrival, the usually calm cop was a little panicked. PD said that the patient had just gone unresponsive on him after exhibitng sudden-onset, stroke-like symptoms.

The patient wasn't breathing well... fast, shallow, irregular respirations. We laid the patient down and he wasn't moving air and had signs of a brain injury, so we went for the airway.

After ventilations with a BVM, the patient started to look better. Gag reflex was intact, so I intubated nasally. I'd always head how easy it was... but I didn't really believe it. I had a little trouble at first, because I had to remember to push the tube BACK, not up. I was using a BAAM (a whistle that fits over the end of the ET tube), and all of a sudden, it started whistling. I checked lung sounds and secred the tube.

I was a little protective of the tube... because I didn't want to lose the tube.
Part of that reason was that I'd pulled a medic's tube out on my last prehospital shift... the tube just popped out... and I wanted to make SURE it didn't happen to me.

So... I got another first in the class. Someone else got the first oral tube... but I'm the only one with a nasal tube.

Tuesday - Post 1

So... I'm sitting at work. Working 2 hours overtime to cover a hole in the schedule. I'll take the money.

I'm about a month into medic school - and we've got some form of mid-term tonight. There is a study group gathering before class... and I might stop by.

I've been running myself ragged between work and school. I need sleep. I need a day off. I'm also sick - had a sore throat start last night during clinical, runny nose today, and I feel miserable.

I had 3 calls so far today at work - 2 were cancelled before getting to the scene, and the third was a moderate MVA - high speeds, limited injury.


Last night at clinicals was cool. I had the first shift of the class in Labor and Delivery. That meant that I was the guinea pig. I stood around looking a little out of place (6'3" big guy in gray shirt and blue pants surrounded by female RN's in green scrubs. Then they realized that I needed to get into scrubs - which I did.

I don't like wearing scrubs - at least not in public. My scrubs at home are reserved for around the house and use as pajamas. I'm used to having pockets, and thicker fabric. I feel so out of my element in scrubs. No trauma shears, no key ring, no glove pocket.

I got to observe a C-section last night. C-sections are WAY out of the paramedic scope of practice, but it is intresting to watch. Because I went through a different paramedic program already, but now get to start over from scratch, I'd actually already done a few shifts through L&D, but at a different hosptial, in the City. So I actually had seen one before... but it is still intreesting to see. I also spent a lot of time talking with a medical student doing his mandatory OB rotation. I learned some from him... and even more from watching the attending teaching him. I also spoke with a PA in the OR.

I've been in OR's before. I understood what was sterile, and what wasn't. I had to ask where I would be able to stand out of the way... but otherwise, stayed back and watched. The procedure seemed to go without any trouble, and the NICU folks were there to resusitate the baby, but didn't have to do much. Initial APGAR was 9. I had a discussion about that, too. Although the perfect score would be 10, they only usually get 9, loosing a point on color.


Anyway - it was a good experience. But I really hope to keep my rig "life-neutral"... no one dies in my truck, and no one is born in my truck. I've done pretty good on the second half, lately. OB was a great change for me - in my previous 2 clinical shifts, I'd worked 3 codes... 2/3 were unsuccessful. The 3rd one we actually got ROSC (Return of Spontanious Circulation)... AFTER we started working the code, the nursing home gave my preceptor the patient's living will, which called for no heroic measures. By the time we got this, we were transporting - so we kept going, consulting with the hospital staff. So we walked in the door and got a pulse back - but the patient didn't want to be there... now what? I'm not sure if the ED staff continued mechanical ventialtion, as the patient had no spontanous respirations. I'm going to guess that that patient died, too... making me 3/3.