My First Kill

They always said that sooner or later, at some point in your medical career, you'd be responsible for causing the death of a patient. Thankfully, my most recent experience doesn't fall into that heading, but perhaps that's up to interpretation.

This past Saturday was an unseasonably cool and rainy day. The first snow of the year had just fallen in the higher elevations, and autumn seemed to have skipped us by in the Northeastern part of the United States completely. It was summer two weeks ago, and now here I am, bundled up in a thick jacket and cradling hot chocolate while sitting in the ambulance, waiting for a call. My partner that day was a nurse/paramedic with about 15 years experience on me, and when we're not doing 911 jobs, we serve as the critical care inter-facility transport unit. I myself have 6 years total EMS experience, with just about a year as a paramedic.

About three hours into the shift that started at 6AM, we're off to a call for new onset seizures. Our system is multi-tiered, and in addition to the Paramedic unit I'm working, every Priority 1 assignment gets a BLS ambulance and the firefighters as first-responders as well. Fire is already in the house when we pull up on scene, but a few moments after the BLS had arrived. When we get upstairs, we find a 62 y/o women tended to by her tall, panicky son, who in my opinion anyway, seemed tweaked up on something. The women is conscious and breathing just fine. My partner starts asking her some questions which she answers without difficulty. She doesn't seem like she had any seizures at all. By talking to some of the family members, it seems that she has a history of asthma and diabetes. She vital signs all check out fine (EKG: ST at 110 bpm, BP: 128/82, Respiration clear at 14-16, BGL: 224 mg/dL). She tells us that she has no pain, but "doesn't feel well." Her son says that she threw up this a couple hours ago this morning, and was in the hospital and discharged for something similar a week or two ago. Other than this, everything else checks out.

In our system, if a patient doesn't need ALS, we routinely release the patient into the care of the BLS and allow them to transport to the hospital. This is what we did in this case. Finding no life-threatening medical problems, or issues that we could care for, we allowed the BLS to take her to the hospital, an eight minute ride away - three minutes farther than the closest hospital. Our field diagnosis was that of either a stomach bug or perhaps the flu.

We return to the station to pick up some supplies and about fifteen minutes from the time we left the patient's home, I get a phone call from the BLS crew.

"Dude! Our patient just arrested in the ER!"

"No!!" I yell into the phone, "That's not possible!"

"Yeah man, they're doing CPR on her right now!"


Out patient died not 30 minutes after I last spoke to her.

I don't know for sure the cause of death, but after we raced up to the ER to find out what was going on, the nurse said she likely had a heart attack. This is something we could have detected. Perhaps not in time to prevent her from going into cardiac arrest, but something we should have known about. We have drugs that could have helped, and we certainly could have treated her.

For the past few days, images from the scene have been replaying themselves in my head. My mind is looped on the assessment we performed on this patient, trying to determine if there was something, anything, that presented itself that would have indicated to us to go a little further and spending more time with this patient - something that would have indicated that we should do an additional test, or look deeper in the patient's situation. I keep coming up dry. Aside from throwing every test we have available to us and looking for an abnormal finding, we performed a prudent exam based on the presentation of the patient. That exam lead us the the field diagnosis that we arrived at.

It's easy to Monday night quarterback these types of calls, and some colleagues of mine have indicated that they would have handled this patient differently, but several others have indicated that they would have probably done the same. It's easy to think about how things would have gone another route, but I continue to arrive at the same conclusion time after time: we didn't miss anything, obvious or subtle.

I'm waiting for the Quality Assurance director to review this call, but I've already approached our medical director and spoken to him about this one. He said that it probably would have been prudent to do a 12-lead EKG or orthostatic vital signs, and I agree, but he seemed sympathetic at least. In the mean time, the images continue to roll around in my head.

Essay

So I decided to try to go back to college, and eventually medical school. Here is the essay I wrote for the admissions folks about my decision (some information redacted!):



The decision to change careers was not an easy choice to make, yet in a way, it was the easiest one I’ve ever made. During my undergraduate work at [some NYC school], I had one main goal: obtain my engineering degree then find a solid and stable position to begin my professional career. I succeeded in achieving that goal and for the past two years, I’ve been happily engaged as an engineer working for the government [doing stuff] in the City and State of New York. My work is secure and interesting. It is challenging and often rewarding. However, I feel that my career is just a job and I quickly realized that I could never, truly be passionate about engineering.
In retrospect, it probably should have been easy for me to listen to my passion from the beginning and set goals that were worthier than simply trudging down a career path that lead only to job security, but no zeal about my future or my work. In fact, all along I’ve been walking down two paths simultaneously. These paths led side-by-side for a long, long time, but when they finally diverged, I realized I was stuck on the path that led to the place I find myself now, a comfortable but unfulfilling existence.
It wouldn’t be accurate to say that I “suddenly realized” the path that I wanted to follow, or that I had a “revelation,” because I really knew the truth all along. I knew that I wanted to enter the field of medicine, go to medical school, and become a physician for a long time. Starting from the first semester of my first year in college, I have been involved with EMS, the Emergency Medical Service. By the end of the term, after taking the class on campus, I was certified as an EMT. My involvement with EMS has been a large and constant part of my life ever since. I started as the low man on the totem pole at my college’s volunteer ambulance, and upon graduation, I had achieved the highest rank there was in the Corps: Crew Chief. But it went beyond that – during my summers off, I worked as a volunteer from my parent’s house in Upstate New York with the local fire department. I also became involved as the [big-wig? no thatr's not right] for a non-profit organization: the [some EMS organization].
After I earned my degree, one of the first things I did was to enroll in Paramedic school, an intense 12-month educational experience. The process of becoming a Paramedic was eye-opening. I learned to practice a new level of clinical medicine and I loved it! I did observations in nearly every department in the hospital, and learned skills like starting IVs, intubation, reading and interpreting EKGs, treating heart attacks, and giving medications in response to a patient’s distress. It was also during this year in Paramedic school, through interacting with doctors on a regular basis that I finally knew that I could never work as an engineer for the rest of my life.
My current place in life has me again walking two paths. I now work full-time in my regular and non-changing engineering job. I am also working part-time in [hem, ahem!] in the dynamic setting of a Paramedic. I enjoy being a Paramedic, but I am eager to learn and do even more. There are now people alive on this earth that would not be here today if I hadn’t been beside them. There are also people who have died because I wasn’t able to intervene, because the training of a Paramedic is limited and the skills and procedures that we perform do not address every situation.
Becoming an engineer was difficult, and an arduous journey itself. It was difficult deciding to turn my back on a promising career. I am aware of the challenges that await me. I know that a high-level of academic achievement is required. However, I will succeed. I have never felt more determined and eager for the future. It is time for me to leave the path that is warm, comfortable, and smooth all the way to retirement, and return to the path full of potholes, challenges, and excitement – the correct and true path. I know that every obstacle I overcome is a step in the right direction.

Happy Birthday!

My Dad turned 58 yesterday. He’s an engineer and currently works apart from the family in Saudi Arabia. I remember when I was a lot smaller we were all sitting down one weekend afternoon for a nice lunch of hot dogs. I started choking. My Dad called 911, started the Heimlich Maneuver (abdominal thrusts!), and a minute or so later, out popped the chunk of meat that had been plugging my trachea.

So, Thanks Dad: Not just for giving me life, saving my life, and raising me into a man, but thanks for just being here. Happy Birthday!

'THE' EMS Convention. No, not that one.

This weekend I had the opportunity to participate in the National Collegiate EMS Foundation's annual conference. As one of the mid-level volunteer administrators for the Foundation, I had an very interesting and very unique view of the event.

NCEMSF is a group formed nearly 20 years ago to address the specific needs of an under-served part of the EMS community: the scores of volunteer first-response and ambulance corps that operate on our country's college campuses. This year, nearly 900 participants traveled to our nation's Capital to attend lectures, participate in discussions, and learn how to advance each individual group's missions.

The college-based EMS group is unique. There are very few ALS providers, and the majority of providers are new to the field. Almost all are volunteers, and for many, participation on a college EMS squad is their first exposure to the field of EMS.

Campus squads also face many unique challenges: money is certainly an issue. Very few receive federal or state grants. Training is another concern: with the high level of turnover associated with graduating students, experienced providers often barely reach an level of excellence before leaving the scene. Also associated with this transient group are issues of recruitment, retention, and motivation. Myriad other challenges also stand in the way of the success of a campus EMS group.

Yet, this past weekend was inspiring. As facilitator of the skills competition, I saw providers struggle with some very challenging scenarios. Some failed miserably, others were competent, but many rose to the occasion, and probably provided care that would be unmatched elsewhere. In the ten minute time window, I was groups recognize immediately a case of possible bacterial meningitis; something I myself probably would not have done, even with my ALS qualifications and six years of experience. On the ALS competition, the rare and tricky beta-blocker overdose provided a challenge, but many treated the patient successfully.

Collegiate EMS is not really an end in itself. It is really just a beginning. A nation of healthcare providers and leaders grow out of this one-of-a-kind community. Being a part of this community and helping nurture it was a rewarding and significant personal experience. I received my start in EMS as a freshman in college back in 2003. The ability to begin to serve not just my patients, but now the next generation of EMS providers is truly special.





PS, Congratulations to my alma mater for winning this year's Collegiate EMS Organization of the Year Award!

We've all been there

The job is for an 'altered mental status' at a local nursing home. The BLS gets there first and radios us to set up in the back of their bus. As they're coming down the elevator, they again radio us that this "could be cardiac related."

Relaxed, my partner throws a few new stickies onto the 12-Lead wires, and I continue scribbling the location details on the chart. As if by magic, the EMTs appear when they throw open the rear doors. "Nursing home staff found her this morning at 10AM, but they thought she just wasn't speaking because she was in a sullen mood, I couldn't feel a radial pulse or get a blood pressure" the quite petite and quite cute, young EMT tells me: Mr. Medic.

I glance at my watch: 4PM.

My partner puts the EKG leads on, and we both look at the monitor at the same time -- idioventricular beats only, at a rate of 20 bpm. Not good. In case you haven't guessed yet, this patient is completely unresponsive. Here we have the 85 y/o female who waited six hours for medical attention, and all of a sudden, now we are all springing into action. My partner and I move with the certain speed and grace that only a life hanging in the balance can instill in a man.

Oxygen. Intubation. Intraosseous Access. Assisted Ventilations. Fluids. Atropine. Pacing.

Our first line medical treatments... not a dent, not a change. We've run out of Standing Orders.

We call the doc and and let him know what he's about to get hit with. By this time we're racing away with every light and every siren blinking and yelping at full bore. "DOPAMINE!" the doc yells over the din. Barely time to look at the drug and we're pulling into the ER. A flock of nurses, a young, quiet Attending, us - the medics, a mass of people. More medical procedures the do, more hands flying around in a blur. Then calm. Order sets in. The routine kicks in again...
A nice stable blood pressure gradually sets in. The ventilator is hooked up, blood work gets sent, the medics go on their next job.


The following day I speak with the quiet young Attending physican. " A Save!" says he, but to what end? Only a stopgap in death. A crumbling levee against the tide of the inevitable. The doctors, can't wean our patient off the dopamine. Physically, she's probably moderately strong, but too long a hypoxic brain. Too much injury. The family makes their grandmother DNR. Six hours.

Green Medic

This just in! New medic in town! Oh baby, going to hit the streets!

After a year of classroom study and clinical rotations, I am a fully certified and rip-roaring, ready to go, brand-new Paramedic. The new gig is a very busy urban EMS system in the most densely populated county of the most densely populated state (New Jersey). I started last week and tomorrow is the last day of orientation. Since I'm a per diem, my first official tour of duty will be six days from today.

Now, you may ask, "Why cross the mighty Hudson River from your beloved City of New York for a job? You have five years experience as an EMT in your fair city, and trained as a medic in the same?" The most honest answer is "Uhhhh...?" So, with that affirmation in the hopes that I know what I'm doing, I embark to work in the Garden State twice a week; and for twelve hours on each of those days, 'County of 1,000,000 people': I will be one of the only six paramedics here to come at your call (assuming the dispatcher decides you need ALS attention!). Good luck crazy county, to the both of us!

Ho, crap!

Wow, what happened!


Paramedic school really beat the piss out of me. But at least I can now call myself Polarbear, NREMT-P!

With medic school over and done with, I think it's time to get back to this blog. New posts coming soon!