Resolution

At the nursing home I get a quick report from the nurse (who is running the other way down the hall when we come in) which makes me think the difficulty breathing we have been called for is a patient with pneumonia or sepsis. The vitals she tells me are BP 83/34, Sats in the 80’s on a cannula, and a temp of 102.8, on a patient with increasing confusion.

The patient’s family is in the way and are rude to my partner when she drops a woman’s sunglasses while trying to hand her her bag off the patient’s bed, so we can get the patient — a 55 year old female — onto our stretcher. There is an overall bad vibe with the family. I decide to just get the patient out to the ambulance and do everything en route.

In the ambulance, reading the W10, I discover the patient is on renal dialysis, but now I don’t have the answer to the question I am later asked — When did the patient have dialysis last? I see the patient has some communicable diseases and since we are going to a hospital that doesn’t take our blood draws I am thinking I may just BLS the call in. Then I decide that would lazy and irresponsible.

Our SAT won’t read, and then it comes up in the 70’s. The patient’s fingers are in poor condition so I don’t know how reliable the SAT is. Still I put the patient on a nonrebreather to be safe and also put on the ETCO2. I’m concerns when I see it is 53, which indicates the patient is hypoventilating(or possibly it could be due to the fever and increased metabolism). Regardless, it is not a sign of pristine health.

I see what looks like a dialysis catheter under the patient’s sweater as I attach electrodes to her chest. I listen for lung sounds. I hear no rhonci, no rales or wheezes, but it is hard to get the patient to follow commands enough to take deep breaths. I check her sweatered arms for a shunt and then put an IV in her left wrist and start some fluid.

At the hospital when I try to convey my sense of the patient’s level of sickness — she doesn’t know where she is, her SAT is low and her ETCO2 is up, she’s hypotensive, although our reading at 100/50 wasn’t as bad as the nursing home’s, tachycardic at 112. The nurse then asks the patient how she’s doing. The patient answers in gibberish, which doesn’t seem to register on the nurse. Over the phone, the triage nurse tells the room nurse who will get the patient that the patient is not tachypnic and responds to her. She apparently didn’t hear me say or understand about the hypoventilating.

In the room I give an admittedly meandering report to a young doctor I have never seen before, making a poor impression for myself. I’m caught a little off guard because she has come into the room while we are trying to move the patient over, so I am talking and moving the patient at the same time sort of like walking and chewiing gum — hard for some people, particuarly me today. I am unable to answer what the patient’s normal mental status is nor what their daily activity is. All I say is, “I don’t believe this is the norm. they said increasing confusion today.”

I am feeling slow and stupid — like my four days off have robbed me of any sharpness. The new doctor now recognizes the patient as someone she has treated before and declares this is, in fact, her norm. In the EMS room, I finally see written on the W10, the patient is normally alert and oriented and ambulatory. Do I feel dumb. I wish I pointed that out to the doctor, who apparently was mistaken.

When I return to the room with my written report, the nurse announces that I have put an IV in the arm with a shunt in it. I apologize and say I didn’t feel it there, plus she gets her dialysis through her chest catheter anyway. You can feel it, she says, squeezing the patient’s arm. Sorry, if I’d known it was there, I wouldn’t have put it there, I say. I’m kicking myself for not undressing the patient at the home, taking her thick sweater off and putting on a Johnny. I almost always do it, and then I don’t, it bites me. Dumb. Lazy.

Another young doctor I have never seen before asks the nurse what were the patient’s SATs. I don’t know, I’d have to check the notes, the nurse says. I pipe up then, “They were in the 80s in the nursing home – we were getting in the 70’s.” The doctor is not looking at me, but continues talking to the nurse. I feel like saying what am I invisible? I continue, “In triage after she’d been on the nonrebreather for about twenty minutes, her SAT was 97. But we were also monitoring her ETCO2 and we were getting 53 for a reading, which is high. She may be hypoventilating.”

The doctor turns to me then and snaps, “Well, she doesn’t need to be on a nonrebreather then.”

I don’t say anything. A look of puzzlement comes over me. ???? There is no COPD here. No question of a hypoxic drive. Her SATs were in the 70-80 range before the non-rebreather. Her ETCO2 is 53. Besides she looks really sick.

I want to point this out to the new doctor — and say if she is hypoventilating and has low SATs off the mask, and doesn’t have COPD, she really needs the oxygen — but when you do poorly on a call – meandering through it, and even putting an IV in a shunt arm — when you appear so stupid yourself — what do you say when someone says something so stupid to you.

I just turn and leave the room.

Maybe she knows something I don’t know. Maybe I know something she doesn’t. They’ll come to the right answer soon enough.

The thing about medicine is – you can be great on one call, and then the next be an idiot – paramedics and nurses and doctors, all of us. You have to prove yourself patient by patient. You won’t bat 100, but you need to try.

In the coming year I resolve to try to do my best on each call and not to judge anyone, high or low.

5 Comments

  • Brendan says:

    A perfect example of “What do they call the guy who graduated last in his medical school class?”

    As for your performance, don’t worry about it. Everybody has days where they can’t get out of their own way.

  • Jamie Davis, the Podmedic says:

    Tough call, Peter. We all have days when we seem to be missing our edge. Don’t sweat it. It’s important to remember that one of the key places where the ball gets dropped in medical care is the hand off to another provider.

    This is why nurses get annoyed when they are interrupted during shift report.

    We see it everytime we hand over a patient and the nurse seems to not be paying attention.

    We hear it when we consult by radio or cell phone and the doc doesn’t give us orders for what we need to help our patients.

  • Anonymous says:

    During my paramedic internship, I had a particularly challenging preceptor. A guy that I always learned a tremendous amount from and who encouraged good critical thinking skills and the importance of a really in-depth assessment. He was a good preceptor, but intimidating as hell. He stressed the importance of good IV skills, but with him, I could never get an IV start. I kept blowing one after another. It was killing me on my evals.

    When I’d ride with another crew, I nailed every IV. I think with other crews, I was probably at 95-99% first time success rate. With this guy, it was always around 25-50%. Horrible. I was always second-guessing myself. That was most of the problem. I doubted my own abilities. I tried to compare myself to what the medic was capable of. He’d been doing it 8 times a day, five days a week, for years. Over 1000 patients a year. I’d been doing it for two weeks.

    I wish it wasn’t that way, but some people just have that effect on me. Some hospitals, some doctors, some nurses, I always ended up looking like a fool. Some radio reports were fantastic, but other times I just mumbled through them and the receiving facility would rip my report apart on the radio — an open channel and a recorded channel.

    Some days, thing would go really well. But it was the days when things fell apart that I always remembered. The full arrests where someone forgot to attach the pads correctly. The chest pain patient where the EKG leads were attached backwards and not noticed. The IV done in haste that blew through the vein. Forgetting to check the pupils on an unresponsive patient and not doing the CPSS with altered LOC. Not checking the o2 level in the main tank in the truck, only to find it empty when it was needed most. Starting an IV without having the tubing attached or the line flushed, then fumbling to hold the IV with one hand while trying to everything else with the other hand.

    But I know I’m not alone in making these mistakes. Nurses often forgot or didn’t even realize that starting and IV in a moving truck, on a black person with long-standing diabetes is extremely challenging. Not everyone remembers to ask about a DNR when running a code, and then finding out later that their intubated patient on a vent in the ER is in fact a DNR.

    I hate making mistakes, but I always try to reflect on what I’ve done, and what I’ll remember for next time. When I listen to stories from other medics, like the one you mentioned, it’s a good reminder for me to avoid the same mistakes. I’ll make different ones, but as time goes one, I hope I make fewer and fewer.

  • Anonymous says:

    We learn more from when we do things wrong than when we do things right.

    I think some of my best habits have come from making a mistake and then consciously making a note in my mind to not repeat it and to improve myself.

  • fiznat says:

    I wonder which is better: to remain convinced of your infallibility, or to be constantly reminded of the opposite. It seems that given the opportunity for mistakes on both sides of the fence, at the end of the day the doc will always be right, the EMS provider will always be wrong.

    Strength of character helps people like you pull through the adversity and come out still self-assured and confident. Still, is it worth the constant battle? More letters after your name wouldnt relieve you of mistakes, but I imagine (at least from this perspective) that it would spare you from full face public acknowledgment of them. It must feel good to be correct by default, wrong by exception.

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