Stress in EMS

Based on my twenty-five years as a full-time street paramedic, here are the five most stressful situations in EMS (for me, at least).

5. Pedi Codes. There are two kinds of pedi (pediatric) codes. Those were the patient is dead and is not coming back and those where you have a chance. The second are obviously more stressful than the first, but even the obviously dead kid is a highly stressful situation. The family is largely hysterical. You new partner may be freezing because she has never seen a dead baby before, and you have to manage it all. I usually always pick up the baby and do CPR all the way out to the ambulance. I have had quite a number of calls where the pedi was already cold and as stiff as mannequin baby. While we presume many of our cardiac arrests dead on scene and do not transport, it is uncommon to do so with a child. We usually show our best efforts and get everyone to the hospital where there are grief counselors and more staff to handle the collateral issues. If the baby is workable, that is hard too, because despite all the PALS classes, it is not as usual for us as when we do adult arrests. The tendency is also to just get the baby out to the ambulance, but I still believe in working them right there – or at least until you can get them stabilized. I can’t do as good CPR walking with the baby as I can when I lay them on a table or counter. The sad fact is most of the time a baby is in arrest it is for a reason that you cannot reverse. I have done too many of these calls and they are always sad, although with time I have learned how to disassociate myself from the chaos both of the scene and of my emotions. These are the calls that remind you of what you asked to do as an EMT or paramedic.

4. COVID patients. This is a cumulative stress of having to gown up and then trying to take care of a sick person who is vomiting or gasping for air with PPE that doesn’t fit. It’s hard to see through a fogged up face shield, hear through masks, maneuver with gowns, deal with the roaring sound of the exhaust fan, and all the while worrying that the germ is going to somehow slip through your defenses and find purchase in your lungs, and every time you get a sniffle or an ache or irregular bowels, you worry its COVID and then in two weeks you’re going to be in an ICU, and listening to a nervous doctor tell you need to be intubated. It’s the unrelenting nature of these calls that frays and exhausts the nerves. I knew I would have to do pedi codes, but I never imagined having to deal with a pandemic like this one.  A quarter million dead and rising.

3. Legitimate obstructed airway calls. We get called for choking all the time and usually by the time we have arrived, the person is breathing fine. The object has been removed or it was a false alarm in the first place or the person says they ate some fish and feel like they have a fish bone stuck in their throat when most likely it is just a scratch there. I am talking about the turning blue, losing consciousness. If you can’t get the airway cleared with the Heimlich or with your McGill forceps, the person is going to die. You only choice is to cut the neck, and you know there will be blood, and you know it may not work, and if it doesn’t, you will be questioned why. Others will question you and you will question your fitness.  These are the calls that end medic’s careers.

2. Vent transfers and vent transfers with IV pumps. Most of the calls I do are emergency 911 with a few transfers thrown in. Every couple months, I get called for a vent run taking a patient out of an ER or ICU going to another ICU. We have a vent that I have been trained on multiple times (I got to every vent training they offer), but every time I use the vent, I feel like I have never used it before. I nervously review the manual on the way to the patient’s room. The problem is the patient who may be very stable on the hospital vent has difficulty adapting to our vent. I always try to transfer them to our vent while they are still in their bed. I wait at least ten minutes before leaving with them. Despite that I have had numerous episodes where they suddenly desaturate, and I end up having to play with the vents dials (and our vent has a ton of them and lots of flashing lights and alarms –not like the simple three dial one we had when I first started). My adjustments don’t always work and I  end up having to manually ventilate the patient the patient with a bag-valve mask. Add to this meds pumps that also malfunction and beep for air in the lines or other problems (I once had an old med pump that malfunctioned and the messages it flashed were all in French), and some of these meds need to be run constantly at a steady rate or the patient will crash. Their pressure could tank; if they are sedated, they could suddenly wake up in a rage and pull their ET tube. I am sometimes all alone in the back and quite far from the destination hospital or you are in a driving rain storm or both. I don’t do enough critical care transports to be at ease.  I have finally learned to refuse transfers that I consider unsafe.  Sometimes the ERs or floors just want the patient gone and they will pressure you to take them, but I will no longer do it, and our training backs us up.  Never take a critical patient you are uncomfortable with.  When I was newer, I took everything for fear of being judged.  I took patients I had no business transferring.  I took them and prayed nothing went wrong.  No longer.  Give me another medic, another set of hands in the back or call us back when the patient is stable.  I’d rather being doing a cardiac arrest in the field than doing vent runs. Maybe that’s just me.  I can’t take the stress of it.  If all I did was critical care transports, I would more comfortable.

1. And the number one stressor. .. If you are not in EMS, you may find this hard to believe, but if you are in EMS,  you likely understand. It’s waiting out the last fifteen minutes of your shift. You’re in the bone zone, and you’re just hoping, please no late call, don’t call my number, please tones don’t go off. After twelve plus hours at work, you’re already half home. You have plans, things you need to do. Dinner’s on the table, your daughter’s softball game is starting, the gym or the liquor store (your preference) are closing, you want to go for a run before the sun sets, whatever it is you do after work, you’re not going to be able to do if they give you a late call. Please no. Don’t get me wrong.  I like doing calls.  I bust it all day long, but when its time to go, it’s time to go.  I hate being held late and I hate late calls.  The dispatcher calls your number with urgency. F—! Is he toying with you? Is he going to say, “Never mind, head on in.” Or is he going to say, “471-Priority one. Main Street for the unconscious.” Even if dispatch does send you in, those fifteen minutes of waiting it out, the constant stress of not knowing if you’re going to be able to make your plans, get your few moments of nonEMS time to yourself before having to come back to work the next day and do it all again takes years off our lives. Years. That’s the street truth.