Big decisions ahead

Well… As of early Monday morning I am no longer a paramedic student, nor will I be testing for my National Registry Paramedic anytime soon. My preceptor felt that my assessment was too rough and unorganized, and my ‘scene presence’ was not good enough, to be turned loose as a practicing paramedic. To say that I feel like my life has just been turned on it’s head is an understatement.
One thing I’ll say for my program’s faculty is that they have been the best since this happened. Another reason I am very glad I started with the program that I did. They have offered me the ability to test for my intermediate licensure at the national level (I85, which will turn into EMT-A) due to the fact that my medic program covers every facet (clinical, skills, and most certainly knowledge) needed for that licensure level. I’m making sure to test for Intermediate mainly so I can get a job for some 911 experience (which I’m thinking might help my deficieits during internship) and to be able to move down to the ED at my hospital job and get the pay raise for that. I think all in all I’ll be happier doing the above than I am right now… Not that it takes much to make me happier at this point.
The other thing I need to think about is that I just had my 90 day eval at the hospital. They are very impressed by my performance and have offered to pay 100% of all my nursing school expenses, along with helping me have the state pay for it so I can basically get a stipend to help cover whatever in addition to my salary. This all sounds like a good thing to me, and they would want my commitment to work in the ED as a nurse for 4 years after I graduate with my BSN, which is also the time the state would require me to work in-state to pay off the state for whatever they give me. Doesn’t sound like too bad of a deal, especially since I can get a contract stipulating 2 years ED then move up to ICU.
So now I need to decide if I want to redo the medic chohort to be able to redo my internship and then go for nursing after that, or if I want to get my BSN and then challenge the medic testing process. Right now I have no idea which one would be better. I’m kinda leaning towards nursing first, but I love working on an ambulance and don’t know how well it would go working as a nurse and going to medic school… I might at that point wind up working so much as a nurse that I wouldn’t have time for medic.
My eventual goal is still the same. To fly on either rotor or fixed-wing aircraft. Not picky if I do scene response or IFT. I just want to work in flight medicine, as that branch appeals to me most of all.
Well, that’s all I have for now. Time to get back to work I guess. It’s time for another round of vitals on my 10 patients.

Why am I doing this?

“3027, we’ve got a code 3 two blocks from you,” a radio crackles from the cab.

I look up from my paperwork and sit bolt straight. Time to stop being the box troll and actually get to do something.

“27, responding to address,” my preceptor calls in as the MDT shows the location. “Any info on type of call?”

With this I perk up, picking up the handset in the back to listen better to what is going on.

“Working code. PD states scene is secure, officer performing CPR. Fire is five out, Engine and Rescue 12 responding with you,” the usually demonic box blurts out.

Hearing this I start piling the gurney with our bags and monitor. I look up and see us pulling up to the address stated on the monitor. Jumping out of the module, I notice a chaotic scene already. Multiple police units on scene blocking off traffic. We get to the wreck of a vehicle, or what had once been a vehicle and take in the area.

A blue Land Rover, brand new from the paper plates on the back end, somehow wrapped itself around a light pole in a residential community. Usually a quiet section of town, everyone seems to be out rubbernecking. The front end of this SUV seems to be pushed all the way into the passenger compartment, with the engine no where in sight. No glass anywhere in the vehicle, the rear end shatter with wheels pointing in opposite directions.

We rush over to where the cops are all gathered in a huddle and ask what is going on.

“Kid was racing some friends down this road, lost control and then over-corrected, looks like he rolled it once or twice and then smacked right hard into that pole. We found the kid laying right here,” the shift Sgt tells us as I look at the distance between the wreck and the body on the road. A good 20 yards or so.

I look at the mangled form lying before us. He doesn’t look a day older than 16, wearing the colors of a local high school. Blood coming from his nose and one ear, a leg that is bending in a way it shouldn’t, bone coming out of his left wrist… This kid is not doing good. The cops have him hooked to their AED and are doing CPR, for once good quality, and bagging the kid. I quickly remember that being the box troll means I’m in charge of the scene.

“Get our monitor on him, grab the airway kit and O2 tank. Lets get him exposed,” I start barking out orders as I get set into motion. “We need someone to hold him C-Spine and then get IV access. Two large bores if we can get them.”

As I’m saying this the engine and the rescue pull up onto scene. I yell at the oncoming crews to being a board, block, and straps. Quickly looking at the monitor I see a flat line where we should be seeing beats. It turns into a mess of jumbles when the cops finish their bagged breaths into the kids and start compressions again. I look at the fire medic and tell him to get me some lines.

With that I grab the intubation gear and move to the head. 7.0 tube, stylet, 10cc syringe, laryngoscope, and tube tamer all in my hands as I get set up. I look up as I get ready and see two lines in place from the fire crews.

“Push a mg of Epi now!” I shout out towards the other medic. Then I turn my attention back towards the head. They have just finished bagging him again. I lay on my stomach with the scope and tube in my hands. Feeling the gravel cut into my chest, I go in and take a look. I ask for suction and start to clear away some of the bloody secretions I’m seeing. I think I’m seeing the white lined hole of the vocal cords. I push the tube through and pull the scope out. Pulling the stylet out and inflating the syringe I hold the tube steady. I quickly attach the inline capno and the bag to it and tell the firefighter to give it a few good squeezes.

Grabbing the stethoscope from it’s place in my right left pocket, I take a listen. It’s hard to make out, but I hear air movement in the left and very little in the right. A quick glance at the capnography shows that we’re in. Thinking quickly I reach over to the airway kit and bring out some iodine and a very large fourteen gauge catheter. Swab the betadine and stab the cath into the right side of the chest. We get a large rush of air and the firefighter tells me that the bag is easier to squeeze now.

“Squeeze that bag about 15 times a minute and tell me if it gets harder to squeeze again. Don’t stop while he’s doing compressions!”

I go to the med box and start handing my fire medic drugs as I want him to push them. A mg of Atropine, then another mg of Epi. We alternate until we have all three of Atropine on board. Then it’s just straight Epi. Amp after amp of the drug is pushed into this kids body. We don’t seem to be making a difference. I decide on a Hail-Mary and toss the other medic an amp of bicarb. We push it in along with another 500cc’s of fluid. Still nothing. I tell everyone to stop what they’re doing. Looking at the monitor reveals no change. They resume.

I ask for the hand-held from my preceptor, about to call the hospital for orders to terminate efforts when we stop and I see a lot of random squiggles on the monitor. V-Fib!

I reach over and crank the monitor to 200J, and yell out to everyone to clear.

“Everyone clear! Shocking!” The monitor hums as it builds energy. When it stops and the button flashes I hit the button, kindly marked with a lightning bolt for those firefighters who can’t read (I kid I kid, but we do call it firefighter proof). And then the sound. The sound that only a defibrillator can make. The patient gets a good jolt as 200 Joules of electricity get pumped into his body. The person doing compressions, now my units driver who happens to be an EMT-Intermediate, starts up as soon as the shock is delivered. I take the bag and start squeezing, trying not to go so fast, and knowing I’m failing at it.

When we end our set of compression I look again. This time it’s a more regular set of squiggly up and down waves. Ventricular Tachycardia. I reach towards the neck and am rewarded with a weak and thready pulse. But it’s a pulse!

I give the bag to another firefighter and reach back to the med box. I draw up 1.5mg/kg of Lidocaine to try and get his heart under control. No more compressions and he seems to pink up a little. The Lido is in. We quickly get him boarded and in my truck. The rhythm is still V-Tach, still has a weak pulse. I flip the monitor to sync cardiovert as I feel us get moving.

“Code return!” I shout up to the front. Grabbing the radio I give a quick report, “Male, late teens, was pulseless and apneic on scene. Tubed on scene. Worked him for twenty. 3 of Atro, 3 of Epi on board. 1 of bicarb. Went into V-fib, shocked once at 200 then into V-Tach with a pulse. 1.5 of Lido on board as well. Running hot to ya’ll, be there in five, see ya in the trauma room. BP is 70 palp. Getting ready to sync him.” I try my best to keep it short and give them all the info they need.

I charge the monitor to 150 and ensure it’s still on sync. It is, marking the peak of each QRS. “Everyone clear!” I yell out.

I let it charge and listen to the whining sound it makes. Then I press the shock button. The patient jolts again. I quickly look at the monitor and feel for a pulse. Monitor is showing a sinus rhythm with multiple PVCs. Pulse is now
stronger.

We get to the hospital and have a team of techs and nurses waiting for us in the bay. We get the gurney out and rush him into the trauma room. “Late teens male, was pulseless and apneic on scene. 7.0 22 at the teeth, good waveforms on the monitor. Apparently ejected from vehicle. 3 Atro, 3 Epi, 1 of bicarb, and 1.5 Lido on board. Converted to VF, one shock at 200, converted to VT with a pulse. Low BP. Sync’d at 150 converted to Sinus with multiple PVCs. A liter and a half in so far.” I watch with fascination as the trauma team takes over from here. An art line, blood hung on one of our lines, ABG drawn, fractures assessed.

We get the kids wallet out of his tattered pants and give the unit coordinator the info. I look at the date of birth… The kid is seventeen a couple of days ago. Seeing that I walk out to the bus, and look inside. It’s a mess. Almost like a tornado hit it. I suddenly feel dizzy and sit heavily on the back bumper. I feel my breakfast coming up and the next thing I know I’m staring at it in a puddle on the sidewalk.

I feel arms help me up and someone putting a mask to my face. I see my preceptor smiling and telling me that I did great for my first code. I’m not really hearing it. I just keep seeing that kids birthdate floating in my head.

—————————————————————

I have been asked, since this is my extension, why I want to do this. Why I want to be a paramedic. To run the streets and help people. I’ve never been able to come up with a good reason. It really boils down to the fact that nursing school was full and had a long wait list. Now it’s become something else.

I can’t imagine doing anything else. The street has an allure that is not easily turned down. And when you have that good call it energizes you. Calls like the one above. My first code this internship. My first field tube. My first shock. My first save. I can’t get the memories of that call out of my head even now, a week later.

I’ve been told that I have all the knowledge I need, but now I just need to show I can use it in the field. Calls like this help with that. It shows I can think on my feet. I know what needs to be done so I do it.

And for anyone wondering what happened to us after this call… We were out of service for almost an hour, and I was sucking down O2 for a good half hour trying to calm down. It feels good to get it on paper though.