2 years and counting

I am closing on my second year of being a 911 paramedic in a busy urban/ low socio economic system. Chase cars. MICUs. Dual ALS. Critical Care Fly alongs. A 14 day Critical Care course. Con ed. More Con ed. 16 hour shifts with 9 ALS transports and 11 dispatches. Late calls and late relief. Early calls on frigid mornings. Hundreds of FairLife protein shakes. Missed IVs. Code after code after code. Bed bugs and cockroaches and maggots. Unknown bodies decomposing in forgotten buildings. Shifts I only treated overdoses. Unsafe scenes. Blurred memories of dates and numbers. Lost friendships. A schedule that makes no sense to anyone. SWAT callouts on 2 hours of sleep in 24 hours. Learning how to compartmentalize. Patient care while I battle internal demons. Sleeping sitting up in folding chairs in a ballistic vest. Mastering Google translate. Telling the difference between a Bearcat and MCAT. Where to get the best breakfast sandwich in every local. Fire standbys in July in 100+ degrees. Patients calling me names when I am trying to help. What seems like 10,000 charts. QA Flags. Witnessing my partners skip 0700 coffee and go right to Monster pounders. Trying to avoid overtime. Dismissing sexual advances from patients and coworkers. Watching my boots fall apart but not have enough uniform allowance to replace them. Calls I did all the right things and the patient still dies. No longer having adrenaline when tones drop.

The differences between year 0 and year 1 are drastic. They were noticeable to my peers. I was receiving pats on the back for all my growth. I remember riding in 3 critical patients, a hat trick, to finish my first year. A pt who went UNR (unresponsive) and coded in the resuss bay, a pt in unstable SVT, and a fatal gang shooting.

I recall boldly walking into the ED with my 12 foot ECG tail on the second patient. When I came out, my supervisor and former FTO stood at the back of my truck. My FTO said she was proud of me. My supervisor gave me a smirk and a “good job, Kid”.

My EMT over heard their praise as he was busy restocking the truck. He loudly started cursing my name as “a shit show” and he was never picking up with me again. You can imagine how mad he was on the next call when blood soaked his pants via a shooting victim.

This is how we show affection. He hadn’t had a second to eat his empanadas which he picked up 2 hours ago and were rotting in the un airconditioned truck.

Not going to lie, I felt pretty cool after year 1. I was excited for more growth, for more pats on the back and more snarky remarks from the EMTs. This was awesome.

However, the end of my first year was the last big recognition I ever received. I was in the trenches after that. We do not get pats on the back for doing our jobs unless we give it to ourselves.

The end of year 2 is much more subtle and personal. I find myself looking for loop holes in the protocols, reading pub med and being more curious about what happens AFTER I transfer the patient to the ED nurse. I find that my colleagues now ask my opinion on cases or why I did something a certain way on a call. I have started to develop a “style” or a “practice” as they say in medicine.

I now spend most of my time in a chase car. I noticed the patients I end up treating are much sicker than when I was paired with an EMT on a MICU. I often arrive on scene and do not know the crews. We have 30 seconds to figure each other out and then get on with it. I spend more time at the ceiling of my scope in the cars. I am calmer. I am not surprised much anymore.

Closing on year 2, I have come to the conclusion that my job is much deeper than medical. I have softened to the human condition. I feel myself having more compassion the more I treat. I see that sometimes we are the only ones left to call. We are the last resort.

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Dispatch for change in mental to a multilevel apartment. I am on a MICU and have another BLS truck with 2 EMTs on scene.

31yoM PMH Traumatic Brain Injury (TBI). Bed ridden in a basement. Mother and home nurse on scene.

Pt is laying supine. Bilateral radial pulses strong, regular, equal. Skin warm, dry and true to skin tone. No adventitious breath sounds. Bilateral chest rise and fall. PEERL. Unresponsive to verbal or painful stimuli. Bed sheets are clean.

Patient (Pt) was struck by a car in February down south and was transported to a Level 1 trauma center in that region. Pt’s mother spent 8k (her life savings) to have him moved up here in May.

I ask my EMTs to get vitals as I talk to the family.

It is now the end of June.

She is crying. The home nurse is quiet but responds to questions. He started last week with this patient.

First, I am a detective.

“Ma’am, I understand this is a lot but please stay focused on my questions. I need to figure out the story and game plan.”

She nods as tears continue to vacate out of her eyes.

Pt has been having more recent periods of lethargy and going unresponsive. His eyes are always open. He just “checks out”. This recent episode started on Sunday. Today is Wednesday.

“Is he taking all his medication?”

Mother responds with “yes, he has a feeding tube. I do everything for him. I promise he gets his medication.”

She says it defensively. I let it go. It is okay. It is normal for people to be on the defense with us, especially in the beginning as we gain rapport on scene. As previously covered, people can be at their wits end when they call 911.

Two playful cats dart up and down the basement stairs. They are having the time of their lives with all this activity. All these new people, smells and equipment.

The pt is in a cervical collar. His mother states this collar has never been changed. It was placed by the treating hospital down south months prior immediately after the accident. This pt needs repeat scans of his cervical spine. He has not had any scans since the initial imaging after his accident. He has a C1 break.

I have no other information but am handed a med list along with feeding tube instructions.

I inquire, “What is going on with these scans?”

The mother breaks down further. She shakes when she speaks.

“I….I don’t know why he did not get them down south. I…I am so sorry…I don’t know…I had him moved here…I have not been able to get him out of this basement. He has no doctors and no one will help me move him.” (help move him to get him to the hospital)

The home nurse chimes in: “we have prepping to try and get a home doc in here but it has not been successful. I suggested we call 911 and get him to a hospital.”

The patient is in a well kept, clean basement that doubles as the apartment kitchen. He has his eyes open but he does not respond. He appears to have some voluntary movement of his extremities but limited and not all the time.

“He needs rehab…I think- he needs better care- he needs these scans”

His vitals are text book.

Mother reports that on most days he can speak short sentences, softly, to her. She smiles at me. “He says he loves me”.

He hasn’t spoken to her since Sunday. He now just stares off into nothing.

“Okay Ma’am here is the game plan. We are going to carry your son up these stairs and get him out of here. We are going to the ER. I will talk to the doctors. He will likely be admitted for repeat scans and a thorough work up. They will get a short and long term plan together for you.”

She is nervous but shakes her head yes as she wipes away more tears.

I turn to my EMTs, “however you want to do this is okay with me. I am going outside to call command.”

My BLS crew radios for the fire dept to help with an expedited lift assist. My supervisor is also dispatched.

“Med Command Dr. X”

“Hey Doc. This is PM on truck Y. I have a complicated one for you…TBI in February. Struck by a car. Has not had repeat scans. Originally happened down south. Transferred up here via family. Vitals stable. Pt has been AMS since Sunday. We are getting him out now. It’ll be about 15 min before we are to you.”

“Okay got it. See you then”

Fire arrives. They don’t acknowledge when I say hello and thank them. Love me a grumpy group of wackers. Sorry to interrupt your paid shift of binging youtube fire videos.

Our patient is carried up the stairs to the stretcher via the reeves, secured and loaded into the ambulance. My supervisor flies out of his car. I tell him it’s cool and we don’t need him. He is relieved but hangs out for a few minutes, like most attentive sups.

My EMT asks me if I am riding this in.

“Yeah, I got it”

The mother asks me if she has time to take a shower as she hasn’t showered in over a week. I tell her to take her time and he will be at the hospital when she is ready. The barometric pressure raised a few bars with her sigh of relief.

My EMT goes back to our truck. He will meet us at the ED and pick me up. See, I am the medic in this local but everyone wants their cut. I hop aboard the other ambulance, since this the local for their ambulance. They bill for the transport. My company bills for the medic. One call. One patient. Two trucks. Three EMTS. One Medic. One transporting unit. Welcome to logic. I don’t make the rules.

I grab more vitals and a 12.

I have an EMT in the back with me. I tell her to expose the pt and we are going to to a thorough physical assessment. I turn to the pt and tell him we are going to look at him and to let us know if anything hurts.

An instructor in medic school told me once, “They can always hear you”.

I truly believe that.

He is well taken care of, globally. His skin is clean and soft. He is well groomed. He looks to be a strong young man even after months of being bedridden. He has no bedsores or rashes or bruises or signs of abuse or neglect. His feeding tube is is secured with a clean device and is flushed. He has no signs of infection (such as heat, redness, discharge, swelling) or complication with the tube. He has no bad odors and a clean diaper. We look for pain triggers as we work. I find that universally, pain presents in a patient’s eyes.

As we assess, he starts to make eye contact with us and track our movement.

I tell the EMT I am going to get a line and grab labs to jump start everything for the ED. I take the patient’s hand and tell him “I need to start a line okay?”

He squeezes my hand tight which took me off guard.

I ask the EMT to come sit with me and hold his hand while I grab the IV. I talk to him. I know he can hear us.

He Squeezes his eyes tight as I place the IV.

My EMT and I each hold a hand in transport and talk to him. Women seem to be better at this part of patient care. I think if I asked a male EMT to hold a patient’s hand they would scoff and refuse. I learn my EMT is a mom. She affectionately tells the patient and I about her kids.

Upon arrival at the ED, our patient whispers “Thank you” and it stops me in my tracks.

It does not take medical training and 30k of student debt to see the struggle in someone’s eyes.

Upon entering the ED, I ask to give report to the MD and assigned nurse before handing the pt off. It took me 2 tries but the charge realized I was not messing around.

I told them what I knew. I gave them the packets. I told them I am running this as AMS. Which, I know, one could argue, was overkill.

However, one could also argue that this is the job…

We arrive on scene and assess. This patient deserved scans. He deserved care. His mother deserved to have help. I will advocate for AMS knowing it gets this patient where he needs to be. The system had failed him. Call this person. Get this script. This transfer form. Come up with this amount of money. Try this department. Hold please. We can’t help you. Call this other doctor. Maybe maybe maybe. A whole bunch of mazes that result in dead ends. This was all in my verbal report.

I told them this pt should be admitted in my lowly paramedic opinion. The MD appreciated the report and attention to detail despite me capitalizing their precious time.

This patient needed definitive care. My job is to get patients to definitive care. This corn maze of fuckery ends today.

Was this a sexy call? No. Will my coworkers ask about this case? No. Will this end up on 911 on Fox? Trick question. None of our calls end up on that show. The kids game “Operation” has more medical accuracy than that dumpster fire.

However, in my experience, these are the calls, that make a difference. As cited by a mentor of mine, “Do the ordinary extraordinarily well”.

Know the system. Know your protocols. Know your patient. Always do what is right for the patient and advocate like hell. That is the job.