Just a Paramedic

Baby Medic asks in his most recent post Routine about the frustrations of the mundane in EMS:

I would like to know how those who have been doing this job for a long time are able to withstand the mundane. Do they no longer live for the exciting calls? Are they content to relax in the routine, or have they a way to find interest in the subtleties that I may perhaps miss in my eagerness for something new?

Am I missing something?

I’ve been in EMS now since 1989, a medic since 1993, and a full-time medic since 1995. Here’s my take:

I do share the frustration of the mundane to a degree. I have had days where I am doing multiple codes and months where I never touch my laregnyscope. I’ll do back to back trauma room calls, and then not have another trauma for three weeks. I’ll do ten ALS calls in a row, but none of them more advanced then simple IV, 02, monitor, and transport non-priority.

I guess I manage through the dry spells because for me it has never been primarily about the medicine. I have come to enjoy and appreciate the challenges of the medicine and, as much as anyone, I relish an opportunity to solve a medical puzzle or perform a difference-making skill. But the fact is we are somewhat limited in our diagnostic abilities. We can venture guesses, but often without labs, x-rays and imaging tests, etc, we can’t really tell what’s going on, and often not knowing, keeps us from taking a stab at treatment(And we really should never be stabbing at treatment unless the situation is quite dire).

Recently I had another patient who’s internal defib was going off. The last time it had happened, he had hypomagnesium. I carry magnesium, but there is no way for me to tell that this is why it is happening again, although I can guess it might be. I have amiodarone ready if he goes into a v-tack and starts getting shocked repeatedly as well as some versed to ease the jolts, but his defib never goes off again and we have a nice easy ride in with pleasant conversation.

Working primarily now in a town with a huge elderly population I am constantly faced with the CHF/COPD/Pneumonia conundrum. Some cases are clear cut, but in many in order to determine what is really going on, I need an X-ray and a BNP test. The doctors have that at the ED and I don’t so my care is far from definitive. I’ll withhold the Lasix, and give them NTG if I feel I have to do something.

The challenge for me then when I am not medically challenged is trying to do the part I can do as well as possible. Yesterday we had a stroke patient, and I judged myself on how well I was able to get the full story of the patient’s norm, what happened, etc, collecting all the clues to present to the doctor. The call went okay, but there were some frustrations. I couldn’t get a good medical history because the man was visiting relatives and not at his home where his medicine was kept. I had radio problems and so couldn’t give a patch to the hospital, and then in transferring the patient over to the hospital’s bed, the tape on his IV got caught on his pants and ripped the IV out when we moved him over. Oh, well.

I’ve had a number of IVs get pulled out in this way over the years. Now whenever I bring a patient to the trauma room, I always wrap kling around the IV site to protect it because they are notorious from yanking out IVs as they try to help you transfer the patient over. I am going to start working on a new method of better securing my lines on all patients and see how long I can go before I get another one yanked out in transfer.

What I like about the routine of the job is the chance to try to do calls perfectly. Even the simplest calls are hard to do perfectly, but I try. I grade myself in many categories from courtesy to the patient, family and staff, efficiency of time, proper gathering of history, getting the patient into a johnny if necessary and putting their removed shirt and jacket in a plastic clothes bag, full assessment, doing a 12-lead, gaining IV access, getting the blood sugar, dotting all the i’s and crossing all the t’s, limiting time on scene, completing all care by arrival at the hospital, as well as writing my trip card, and cleaning the back as I go, so that when my partner returns the stretcher, there is little to do, but change the sheets. And of course, saying goodbye and wishing the patient well.

If I can do weeks of simple calls as close to perfectly as possible, then when I get the big bad one, I might do it just a little better than I otherwise would have.

For me, though, the biggest thing that keeps me sane through the mundane is the people, the human contact and the stories. That’s why I got into this in the first place. If I can come through a day with one good story or moment I can tell about when I get home, then I am happy.

For me yesterday, it was at a retirement home where our patient, a woman with a skin tear on her leg, sat watching the Red Sox game on TV — unbenownst to her it was a cable rerun of the game the night before. It was now the seventh inning and the pitcher for the Oakland A’s had a no-hitter going with one out in the 7th with David “Big Papi” Ortiz up for the Red Sox. We were trying to get her on our stretcher, but she wanted to see how Big Papi was going to do. “I know the way its going, he’s going to make an out, but I just want to see him bat,” she said.

“He’s going to lash a single up the middle,” I said.

Sure enough the next pitch, Big Papi broke up the no-hitter with a single up the middle to the woman’s great delight.

“You should be a fortune-teller,” the woman said.

“No, no, I’m just a paramedic,” I said, pleased I had my story for the day.

6 Comments

  • RC Huder says:

    When I look back now after retirement on twenty six years as a medic. It is not the complicated that come to mind first. It was young single mother at 3 am with a baby and no one except us to help here. The baby simply had a cold we made sure she got him the care he needed. The look of thanks still resonates. It was a young man with a debilitating disease that was watching his life slowly ebb away and he began taking it out on his mother the only person in his life. We got them the help they needed. Nothing big just got them to the hospital where they hooked up with a social worker. My partner was stopped by the mother weeks later. She told him we had changed their lives, seeing the social worker had helped. It was the code where everything was a struggle and nothing seemed to work but we delivered her to the hospital breathing and with a heart beat. She died a few days later but the family sent us a basket of fruit in thanks. Those days had given them time to say goodbye. You don’t know. I came to believe it was not about the medicine as much as it was about helping people.

  • Anonymous says:

    Once you get your line in and tegaderm applied, I like to go around the arm with 1″ tape. It’s technically a no-no but it really keeps your IVs from pulling out and it’s quick.

  • RevMedic says:

    Peter – I too grew frustrated with ripping out IV’s. Now, whenever given the opportunity, I start my line with only an extension set in place, rather than fluids and a long admin set. Do you have that opportunity? If your agency does not stock them, perhaps you could ‘borrow’ them from the hospital – it would probably benefit them too.

  • Rogue Medic says:

    On the AICD patient, amiodarone is a fairly useless drug, but magnesium might work. Call medical command and see if they agree with the treatment. The worry about side effects is not significant in an awake patient.Nobody NEEDS a chest X-ray and BNP to identify CHF. That is an excuse given by poorly trained residents. A good history and assessment provides more information. And Lasix is not a good EMS drug for CHF.BNP less than 100 means that it is less likely, but far from certain, that the patient has CHF. BNP over 500 means it is more likely, but far from certain, that the patient has CHF. BNP 100 to 500 means you don’t even have that much information, not that it is much or that the information is worth anything. A CXR provides more useful information, but is also far from definitive.Some doctors feel the need for objective tests that will clearly identify the patient’s condition. If we have these tests, who needs the doctors who rely on these tests? If only they could come up with a test that works as well as a good assessment and history.

  • PC says:

    Thanks for the comments,We do use the saline locks/extension sets. My problem comes from the commercial “Venaguard” tape I use often catching on clothes or sheets and pulling the IV out, although I have also suffered the trauma room pulls on the IV line. I have started trying what anyonmous suggests with the tape. The Venaguards are quick and easy to use, but lack the security of the old “chevron” method. The tape will help, but I maybe should consider going back to the chevrons (cutting thin tape and sliding it under the catheter and then doubling it across).RC, thanks for the comments. Well put, I agree with you its those moments that make the difference, its what we are about.Rogue medic, again great comments, but this time I have to disagree with you about amiodarone. I have had success in a couple of patients who were having VT causing their defibs to fire. The amiodarone stopped the ectopy and stopped the firing.Also, its not just untrained residents who feel that way about xrays and BNP for cases of questionable heart failure. There are obviously many patients where good assessment reveals what is going on, but there are also many patients where the assessment is not definitive, and inappropriately treating them can cause problems. There is a place for medical tests to supplement and confirm or aid diagnosis. I would agree with you that they are often overused or used as a crutch when the diagnosis should be clear.I agree with you about Lasix. I know many services have removed it from their kits. I use it only rarely now. NTG and CPAP are the future of EMS CHF treatment.Thanks again for all the comments. By the way I started reading your blog and enjoy it very much. I’ve added it to my blogroll if that’s okay with you.Best,PC

  • Rogue Medic says:

    PC, Thank you for the link and the kind comments.I will write a post about amiodarone, soon. The research on it is not very good, as in the studies are not well done and the results are not positive for amiodarone.One of the reasons the research is hard to do is lack of sustained stable VT.For hypertensive CHF, we generally use far too little NTG, when we do use it.Another drug that is not used enough in EMS is enalapril (Vasotec). If I recall correctly, ACE inhibitors are the only drug class shown to improve survival in acute CHF.

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