The conference is excellent, just what I need. I attend three classes, all given by dynamic speakers—it is the Harvard of EMS. One session in particular excites me. It is called “The Path to Professionalism” taught by Scott Bourn, an EMT-Paramedic and longtime educator. He poses the question “What is a paramedic?” and talks about how one day on an airplane he was sitting next to a paramedic. Keeping his own occupation to himself, he asked the paramedic what he did, and the answer was, I do IVs, intubations, needle crics, shock people, and give drugs. He says he has had similar conversations with other medics, and that he finds too many people focus on the tasks and not on the roles. He defines the roles of the paramedic as clinician, caregiver, researcher, influencer, teacher, learner, human, and for each, defines what they mean. I take notes furiously. The kind of paramedic he is talking about is the kind of paramedic I want to be. Sure, I want to get the tubes and do needle crics and chest decompressions, but what he is talking about sounds so much more appealing, so much greater. He talks about how in Florida, the EMS community cut the rate of pediatric drownings in half by studying how they occurred—in many cases the parent went inside for just a moment to answer the telephone. By working with the phone company on a plan to get everyone who has a pool a cellular phone, they cut the rate in half in one year. Think of all those kids, alive today, who will go on and have families of their own, and be doctors, teachers, policeman, paramedics, and live and love and play, rather than have their lives ended as they are pulled blue from the pool and a desperate paramedic struggles to breathe life back into them and wakes at night with the nightmares of their dead faces. They cut the rate in half. Imagine being able to say you did something like that. He talks about appreciating the greatness of what we are allowed to do in our job, how daily parents hand us—strangers—their children, what a gift that is, what trust they place in us. How we should be a model by example: walk the walk, take responsibility, initiate change, don’t neglect people in your own life, and know what you look like when you stop caring.
In the question-and-answer session, Marge Leticia, the EMS coordinator at New Britain General Hospital, makes a point about healers and shamans of ancient cultures; in a way that is what, at our best, we are. What a privilege to be able to lay our hands on others and try to make them whole.
Some of the stuff may sound sappy, but it inspires me. It makes me want to be a clinician, a caregiver, a researcher, an influencer, a teacher, a learner, a human. And yes, a shaman. (Though I don’t think the company would let me wear one of those big masks and carry a long bone stick.) I know it will take more than just the talk to get me back, but it is a lift, a small step. It gives me hope.
Payback
I come to work, and there in operations are several students in their white shirts, waiting to hook up with paramedics for the day. When I was in paramedic school I rode with paramedics all over the state. Some were great; others were largely silent, acting as if I was an intrusion into their lives and routine. I thought, How could you not treat a rider well? You have limited time to ride, and it is your introduction to the life. Now that I have been a paramedic for several years, I know how they felt. I remember every medic I rode with, but a student who rode with me last month I might not recognize. Sometimes, you just want to go to work, do your job, and not have to put up with anything. Still, I make the effort, because I haven’t forgotten my own experience.
Today we get a young girl from Massachusetts named Andrea, who it turns out is from the same program where I took my basic EMT eight years ago, and she knows my old teacher, Judy Moore, who so influenced me. Arthur and I make her feel very welcome. She needs to get a field tube. I haven’t had one for a while myself, and I am reluctant to let her do it, if we get one—but I tell her if we do, depending on the patient, I may let her do it.
“I don’t want to jeopardize anyone,” she says.
“Don’t worry,” I say.
We’re just leaving Windsor when the call comes in for a cardiac arrest at a nursing home right off the highway. We’re not two minutes away.
“Let’s save a life,” I say.
We wheel down the hallway into a room where the staff is doing compressions and bagging the patient. “Go to the head and bag,” I say to Andrea. “I’ll pass you the stuff in a moment.” I put the woman on the monitor. She’s in PEA—a rhythm without pulses. I open up the airway kit, and hand Andrea the laryngoscope and the tube with the stylet in it. “Go for it,” I say.
I strap a tourniquet around the woman’s arm and sink an eighteen-gauge in the antecubital (AC) vein. Arthur hands me the line. Andrea is having a little trouble seeing. “You got it?” I ask. I am tempted to take over, but she sticks with it. “There’s peanut butter or something in there,” she says. I push my hand on the woman’s neck to help drop the cords into view. Andrea has a determined look. She sticks with it and passes the tube. I can feel it under my fingers through the thin cartilage. She inflates the balloon and attaches the bag. We check lung sounds. Solid. “Good job,” I say. She beams.
I start firing epi into the IV line, while Andrea bags and Arthur gets the stretcher ready for transport. Suddenly the woman’s eyes bolt open, causing us to jump back. We feel for pulses. “We have pulses,” the nurse says. We all look around, smiling. Andrea is bagging. Art gives her the thumbs-up. I look at the woman’s eyes, shine a light into them. Fixed and dilated.
We wheel her down the hall, get her in the ambulance, and take her to Hartford. She’s got a pulse and a blood pressure but is not breathing on her own. No one is home upstairs. They put her on a ventilator. When I turn the paperwork in, I see her husband sitting in the room with her, holding her hand. The doctor has just told him they will have to wait and see, but I know she’s not coming back. She was out too long. I find Andrea out in the parking lot. “Great job,” I say. “You tubed her like a pro. And a save for your first code. You should be very proud.”
She smiles. I remember how good I felt after my first tube. You can’t let the patient’s ultimate outcome bother you too much. You did your job. She’s on her way to helping the world.
Though I didn’t get the tube, I helped somebody take a step forward. I grew beyond myself. I have started to repay those who helped me. I feel good.
I look around at the other medics I know, some I am in awe of, some great generous teachers; others are burnt, with broken greatness, what they had once to give now gone. I wonder what will happen to me? Will I be a good teacher? Will I be someone to look up to? A holy shaman? Will I soar above the city or will I crash in flames?
Rebecca
The company has a new batch of just-certified paramedics who need to be trained. Daniel Tauber, the chief paramedic, and Debbie Haliscak, the EMS coordinator, ask me to precept Rebecca Drotch. I like Rebecca and eagerly agree.
“This will be good for you,” Debbie says.
I think it is just what I need. Maybe it will recharge me. Give me perspective. New life. A return to the basics. Break me out of my funk.
Daniel Tauber tells me, “Rebecca’s going to need someone with maturity, someone who will instill some discipline in her.” They have changed the rules of field training since I was precepted. Now the preceptee must ride as a third so the preceptor can sit with them in the back on the calls, rather than driving and coaching through the rearview mirror. He says Arthur and I are the right people.
Rebecca, while much younger than I was when I precepted, has some advantages I didn’t. For the last year she has worked regularly with paramedics. Some have even let her run calls under their watchful eyes. I have worked with her myself several times. Her IV skills are excellent, and her assessments are strong. We have a good time together and joke easily with each other.
* * *
Rebecca will be the first person I have precepted, and I have to admit the night before I feel a bit of nervousness. What if we get the really bad call? How can I teach her if I myself am being taxed? I don’t know everything, and I think maybe
that will be my approach—what I know I can teach her, what I don’t we can learn together. The morning we start I tell her what my preceptor, Tom Harper, told me, that whatever happens is between us, and I will never say anything bad about her to anyone.
“Thanks,” she says. “I know you wouldn’t.”
The truth is she has little of the fear about failing that I did. She’s worked around medics enough to see the good ones and the mediocre ones, and she knows she will be at least as good as some.
“How long do you think it will take?” she asks. “I’d like to get done in six weeks. Four would be better. It can’t go over eight. That would be awful.”
I tell her it all depends on what kind of calls we get. We need to do a cardiac arrest. Other than that, all I am really looking for is to see that she is comfortable and that her thought pattern is working the right way. I will not be a drill sergeant. I hear of another preceptor who tells his preceptee, “Two rules: first, the preceptor is always right; two, see rule number one.” I do not want Rebecca to be a robot of my own making. I want her to find her own style; I want her to have confidence. After she has finished her first checklist, I say, “Let’s go out and do some good.”
Our first call is for an unresponsive man at a nursing home in East Hartford. We find him sitting at the nursing station, being held in the chair by a nurse. His eyes look glazed. His forehead is cool and clammy. Rebecca asks the nurse what he is like normally. She replies that he’s normally alert and oriented. Rebecca looks at me for a moment. I give her a you’re-the-boss-don’t-look-at-me look. “Why don’t we get him going?” she says.
“Sounds good.”
We put him on the stretcher, and put on an oxygen mask. In the elevator, she feels his pulse. “He’s bradycardic.” In the ambulance, she gets a pressure of 60. He is in a junctional rhythm of 40 on the monitor. His pulse saturation is in the 60s, but it could be because his pressure is so low, he’s not perfusing to his extremities so we are getting a bad read. “What do you want to do?” I ask.
“Start a line.”
“Good idea. Why don’t you look on that arm and I’ll look on this one?” I find a vein that looks good and say, “I got one.”
“I got one, too,” she says. “Give me an eighteen.”
She makes it clear that she is going to do the IV, so I stand back. Nothing wrong with aggressiveness. I keep my eye on the vein I found in case she misses, but she gets it right away and draws up the blood. I hand her the line, and she says, “Open wide?”
“Yup. What else do you want to do?”
“Give him a bolus?”
“How about something for his rate?”
“Atropine?”
“Good choice.”
I open the drug box, hand her a bristojet and a vial of atropine. The bristojet is a special syringe the vial screws into. She looks at me, and holding one in each hand, flips the yellow tops off with her thumbs, like they used to do on the old TV show Emergency, which I saw when it was first on and she has only seen in reruns. She smiles. “I had to do it,” she says.
“High marks on your technique,” I say. It is a rite of passage for all paramedics, flipping the tops and sending them spinning through the air.
She pushes the atropine. “Fast,” I tell her.
We are crossing the river now, headed to Saint Francis on a priority two. The man’s rate jumps up to 112. She checks a pressure and hears it well at 130/70.
We both look at the patient. He is still unresponsive. His blood sugar checked out fine. His respiratory rate is about ten and shallow. I look out the window. We’re about six blocks from the hospital. I am thinking I wish we were ten blocks away. I look at Rebecca. “Do you know what I’m thinking?” I see a gleam in her eye.
“Tube him?” she says.
“Go for it.”
I almost tell Arthur to swing around the block a couple times. She opens the airway kit, while I get the ambu-bag out for her. She goes in with the laryngoscope, and I press down against his Adam’s apple to try to bring the cords down into view. “Only do it if you see them,” I say.
I am thinking, she’s not going to get it, but at least I’m letting her try.
“If you don’t see them, pull out, and we need to bag him.”
“I got ’em,” she says. She has a look of fierce determination on her face, as if she’s about to get into a fistfight. She goes in with the tube. I can feel it pass beneath the skin under my fingers. “I’m in,” she says. She pulls out the stylet.
We are in the driveway of the hospital now. She tapes the tube down, and we check for placement by listening to lung sounds. “You’re in,” I say. “Congratulations.”
She beams.
“First call, you get a tube,” I say. “Too much.”
When we pull him out on the stretcher, other medics and EMTs who have been standing there all stop talking to watch us. Everyone watches a new preceptee, everyone wants to know how she’s doing. Here’s Rebecca on her first call, bagging the tubed patient. She is smiling, her face flushed as if she was just named woman of the year. Afterward people will come up to me, ask if she was the one who got the tube, and I’ll say yes, she did. I brag about her for the rest of the day. I didn’t get the IV or the tube, but I helped her. It may take getting used to, but it feels good.
The first week goes well. Rebecca is comfortable in the job, and has a good knowledge base. She needs little help from me, doing all nine IVs by herself without a miss. I get after her to be more thorough with her morning checklist and try to teach her there is a higher standard of conduct now that she is a paramedic. We bring in a fifty-three-year-old man with chest pain radiating down his left arm since last night. His vital signs are okay, but he appears scared, and when we put him on the monitor, he has ST elevation, which is a good indicator he is having a heart attack. Rebecca gets the line, puts him on oxygen, gives him some baby aspirin and a nitro.
When we wheel him into triage, the triage nurse is taking a report from another paramedic. An ER tech sees Rebecca and gives her a hug, then says he has to tell her something and pulls her into the EMT room just a few feet from the triage area. I look at the patient and see the fear in his eyes. What she has done—forgetting about her patient’s emotional need—is something I have also done in the past, but now standing against the wall I recognize this failure. When Rebecca comes back a moment later, I glare at her, but she doesn’t notice.
Afterward I scold her. “I’m upset with you,” I say.
“What’d I do? I didn’t do anything wrong. I didn’t miss anything, did I? What? Tell me.”
“You abandoned your patient. This guy was having an MI. He was scared and frightened, you were joking around with the tech, and you abandoned him.” She looks a little stunned. Everything has been going so well, and now the first criticism.
“I didn’t mean to, but he pulled me away.”
“It was unprofessional. You’ve got to just say no. You’re a paramedic now. Take care of your patient.”
“But I didn’t mean to.”
“No buts. Don’t do it again.”
She frowns, wounded.
I feel like a preceptor now. I have found fault, but I can’t keep up the heavy role. “Look, you’re doing great, just remember not to do it the next time. You always need to be aware of your patient.”
We get sent for chest pain to the state capitol, where a protestor has experienced some chest tightness in the heat of a rally. I always feel a little uneasy going into the capitol on a call, because there is a crowd of people watching you, and I wonder how many recognize me from when I used to work for the former governor and wonder what I am doing. We take in all the equipment and are led to a room off the main corridor, where the man sits in a chair. He looks a little ashen, but says he is all right, his heart is just beating a little fast—he has a problem with that. His pulse is too fast to count. We put him on the monitor and he is going at 240.
“What do you want to do?” I ask Rebecc
a.
“Adenosine,” she says, lighting up.
“You want me to do the line for you?”
“No, I’ll do it,” she says, and pushes right by me.
With adenosine, you need to get a good-sized vein as high up as possible because of the short half-life of the drug. She gets the line and tells the patient he may feel something unpleasant. He says he’s had it before, but it hasn’t worked. He says the first time the paramedics had to shock him. I am thinking, as much as I want Rebecca to get her skills, I hope not. I have seen conscious people shocked; it is not pleasant to watch.
The first six doesn’t touch him.
I draw up twelve and hand it to Rebecca. This time it does the trick, and his rate converts to 112.
“You saved my life,” he says, looking at Rebecca as if he is in love with her. “You’re the best.”
She is smiling; Arthur and I are standing around like big lugs.
We get the stretcher ready, and I pick up the trash, the IV wrappers and empty drug vials and needles.
Suddenly the man says, “I’m not feeling so well.” His head drops face forward onto the desk. We both look at the monitor. He is ventricular tachycardia—a lethal rhythm. I reach for the fast patch pads and am considering just punching him in the chest to set the heart back to a sustainable rhythm. I am cursing that we don’t have him on the stretcher. He’s a big guy; it’s going to be hard to manhandle him from behind the desk.
He lifts his head up. “Wow,” he says.
I look back at the monitor. He has broken back on his own.
“You all right?”
“Yeah, I just went out.”
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