Pink Warm and Dry

From Completely Confident to An..Annn…Anxious pt. II

Here’s the first post in the series… this is the conclusion.  I realize that this isn’t the most interesting post I’ve put up, but it’s one that I’m extremely proud of for some reason.

For those of you medical types who are reading and who have been through (or even teach) ACLS, I realize that it’s been dumbed down (for lack of a better way to put it) and that it was considerably harder to pass for a lot of you.  Others walked through it with their eyes closed.  For my class it had been built up to be one of the most stressful nights of the year.

We sat in the hallway, staring blankly at our notes.  The brown and tan berber carpeting (seemingly laid directly on top of concrete) offered no comfort to our sore backsides.  Any irritation we were feeling at that point would soon be replaced by the pain of the mental spanking we were sure to get from our I/C’s.  The Mega Code was minutes away.

We were quickly joined in the quiet hallway by three or four others, equally as nervous.  Liza, the only other female in the class looked pale.

“How’d you do,” I asked her.

She shook her head.  “What the hell was up with the procainamide questions?  I mean… Procainamide?  Really???  What VW class is it?”

“1a” three of us replied simultaneously.

“Shit.” She slumped down against the wall across from me.  “I knew that.”

“Did Mikey finish yet?” I had to know.  Mikey had spent the first half of the course on my heels in the classroom standings.  He was also dating Liza.

“He’s in the bathroom.” Liza sighed.  “He wasn’t feeling well.”

The door to the skills lab opened up and I/C #2 popped his head out.  “Jeff and Epi, let’s go.”

Jeff helped me get to my feet while our classmates wished us luck.  We passed the two who had just finished testing.  They didn’t look very pleased with their performances.

**********

I/C #2 sat at a desk a few feet away.  Our patient, an adult sized manikin was sitting on a stretcher.  A quick visual survey revealed a LP-12, an orange drug box, collars, IV supplies, oxygen tanks with tubing, you name it we had it.  Most of the contents of an ambulance was in that room.  Unfortunately it wasn’t organized in any way and I was instantly worried that we were going to be wasting time looking for things.

“Are we able to take a few minutes to put things together?  This room is a mess.” I didn’t know if we had what we needed.  Or if we even drugs in the drug box.  Knowing I/C #2,  it was probably empty.

Our I/C nodded.  “Go ahead.  Let me know if you need anything.” His nose was buried in that month’s edition of Fire Chief Magazine.

We had everything we needed.  Except for vasopressin and epi.  A small oversight, I’m sure.  Our I/C immediately opened a drawer to his desk and produced several boxes.  He tossed them to Jeff.

Score one, Team Epi.

When the room was finally set up with some sort of order, we were ready to go.

I was already sweating. My poor partner Jeff wasn’t much better off.

My extremely intimidating (up until this point) I/C shuffled some papers and wrote a note on one of them.  He looked me in the eye and started,  “Epi, you’re up.  Do what you can do with that arm… I don’t want you hurting yourself any more than you already are.   Are you ready?”

I nodded.

I/C:  You are toned out for a 48 year old female c/o SOB and lightheadedness. Family states that they were out shopping when Mom started to feel dizzy, they got her home immediately and now she’s having some difficulty breathing”

Easy enough, yeah?

I struggled with the latex free gloves, putting gloves on with one bad arm isn’t as easy as you would think.  Add in the fact that my hands were a little…er… sweaty (Hey, I was nervous!) and it’s impossible.  Once they are on I start.  “I have my BSI on, is my scene safe?”

I/C:  “It is.”

Epi:  “Do I have all of my resources with me? ” My I/C nods and tells me that I do.

“What kind of help do I have?” It’d be nice if he would tell me that there’s a cardiologist willing to travel with the patient in the room.  Yeah.  Like that’s going to happen.

I/C:  Paramedic Partner, four first responders.

“Ma’am, my name is Epi, I’m a paramedic, can you tell me what’s going on tonight?”  I look to the I/C for his (er, her?) response.

He responds in a not-so-forced effeminate voice, “Well, I was out shopping for a new handbag, (he pauses to breathe) and I just got this (pauses to breathe) jittery feeling. (forced exhale)”

I talk to our patient, “Okay Ma’am, we’re going to take good care of you.   How about I put some oxygen on you, I think it might help you feel a little better.”  I turn from the manikin to my I/C and say, “I’m going to put her on 15L by NRB.”

He nods and makes a check on a sheet of paper.  I hook up the O2 and put it on our patient.

“There you go,” I start.  “Have you ever had something like this happen before?  Do you have any history of or do you see a doctor for any medical problems?”  I find myself already caring about our lifeless manikin.  “Just breathe that oxygen in.”  I turn again to our I/C.  “I’m going to take her radial pulse.  Do I have one?”

Our I/C rolls his eyes.  “Yes, you have a radial pulse, the patient has a history of controlled IDDM.”

I roll my eyes right back at him.  “Can I have the rate?”

“It’s too fast to count.  Over 160.”

Back to the patient, “Ma’am, do you have any allergies?”

“No allergies” The I/C responds.

“Ma’am, your heart is beating a little too fast, which is why you probably feel the way you do.  I can correct this, but there are a few things I have to do.  I have to start an IV and put these pads on you that will take a picture of your heart.  Would that be okay?”  I look to the I/C for our patient’s response.  I/C nods in the affirmative and tells me to “do what I have to do.”

“I’m going to have my partner start an IV and hang a bag of saline…”  And then I drew my first blank of the night.

What’s next?  Why is my instructor rolling his eyes again?  Why am I flipping out?  I know this!  Why did I bother with explaining everything?  It’s an effing manikin for crying out loud.  Shit shit shit shit shit.  This room is the temperature of the sixth level of Hell.  Okay, Epi… Let’s get back on track.  Airway is clear, the patient is breathing, the patient’s pulse is sky high, but she’s stable so far.  No allergies (thank GOD), what’s next?…  Monitor?

“I’m going to have a first responder get a baseline set of vitals, BP, pulse ox, while I get her on the monitor.”

My I/C nods.

I fumble with the packaging to the electrodes.  It’s already open, but my fingers can’t quite get to them.  I hand the package to Jeff and ask him under my breath to fish them out while I take my sling off.  I can’t work with it on.  Jeff hands me the stickers, one by one, and I put them in their proper place on our patient.

“IV’s in.  18 in the left AC”  Jeff is proud of his taping job, I can tell.  It consists of four or five wraps around the arm with two inch tape.  That IV’s not going anywhere.

I work to untangle the leads and manage to finally get everything connected.  I turn on the monitor and am rewarded with a nice clean SVT in lead II.  “I see SVT on the monitor, my leads are all good, correct?”

I/C:  Yes, your leads are good.

I can see her rate is at 170-ish.  “What are her vitals?”

I/C shuffled a few papers and reads them off.  “BP is 110/78, respiratory rate is 22, pulse ox is 92.”

“Ma’am, we’re going to hook up just a few more wires here to get a better picture of what your heart is doing.  Are you doing okay still?”

I/C responds, “I’m *takes a breath* doing okay.  *takes a breath* Go ahead.”

I attach the 12 lead patches and hook the leads up in record time.  An accomplishment for the one-armed medic student.  I print the 12-lead and decide to go with adenosine.  What kind of person has a favorite cardiac drug?  A geek.  This geek.

“Ma’am, I’m going to give you a little medicine through your IV… It’s going to help slow your heart rate down…. Uhm…  You might feel a little discomfort.” I turn back to the I/C.  I’m going to give adenosine, 6mg rapid ivp with a 10cc flush.  First I’m going to check the drug for the six rights, right patient, right route, right drug, right time, right documentation, right… right… Dammit.”

I/C:  Excuse me?

I was wracking my brain for the sixth right… “Uhm, Right dosage?”

I/C:  Are you asking?

I wiped the beads of sweat from my forehead.  “No, Sir.”  I can feel my heart beating in my chest and wonder if maybe I might need a little adenosine myself.  “It’s right dosage.”

I/C:  Okay, continue.

Another check in my favor.

“I’m going to push the adenosine fast and follow it with the flush.  I’m watching for conversion from the SVT.”  I know it’s not going to be that easy.  I hold my breath and wait to see what button on the simulator my I/C is going to press.

The rate drops from 170-ish to 120-ish for a brief few seconds… It skyrockets back up to 220-ish and holds.  I curse under my breath.  “Okay, we’re going to try a second dose at 12mg.  Again, confirming my six rights.”   I push the second dose, flush it, and watch and wait.

Asystole.  We have a winner.

I hold my breath and wait for something close to NSR to march across the LP screen.  Thirty seconds later we’re still in asystole.

Fantastic.  I killed her.  With my favorite cardiac drug.  Effing wonderful.

“Okay, we’re in asystole.  Are my leads still good?” I/C nods.  And yawns.

“We’re going to…”  I couldn’t make up my mind… Pacing or CPR…  Pacing or CPR… “I’m going to start compress–”

A bleep marches across the screen… then another.  Then another.  “Okay, I’m not going to start compressions…” I reach down to check the patients radial pulse again.  “Do I have a radial pulse that matches the rate of … 43.  Or so???”

I/C nods.

“Is my patient conscious?”

I/C channels his best female patient voice yet again.  “Don’t you ever do that again, that hurt like hell!”

“I’m sorry ma’am.  How are you feeling?”

I/C:  “I’m a little bit dizzy… and my chest hurts something awful.”

I’m staring at the screen again… I can’t quite figure out what the rhythm is.  I have p waves, I have QRS’s.  They’re not matching up.  Could be 3rd degree HB.  Could be Wenckebach.  QRS to QRS almost line up, and the p waves almost line up.  Almost but not quite.  Because our patient has chest pain (I realize she just had two hits of adenosine) and everything isn’t lining up exactly I have to go with 3rd degree HB.

“I’m going to have my first responders repeat a set of vitals, please?”

I/C nods.  “You have respiratory rate at 20, BP is 92/62, pulse rate is 40.”

I decided to pace.

**********

In the end, my patient died.

She pulled through the SVT, and the 3rd degree HB, but went downhill quick with the bigeminal PVC’s, the STEMI, and the whole Asystole debacle.

I gave drugs, I paced, I shocked, I intubated,  I did CPR, I gave more drugs, I did more CPR, I gave more drugs, I did more CPR. I gave more drugs, I did more CPR, I gave more drugs.

In the end it didn’t matter.  It didn’t make any difference.  My patient was dead and I was a sweaty mess with an aching fractured recently reduced shoulder that begged for narcotics.

Who knew that doing what you were supposed to do, and doing it correctly, could be so painful.  (Okay, I’m sure a number of you just raised your hand.  You know what I meant.)

The patient died, and I still passed.  Funny how that works out.