Be Like A Duck


I am on my last precepting shift when we got a chest pain call.  We meet fire outside the house as we are about to head in.  ALS (Advanced Life Support, staffed by ACPs (Advanced Care Paramedics)) is on the way.  I’ve been to several chest pain calls, none of which were serious, so I had no reason to expect any different right?  Besides, most calls we go to aren’t serious calls.

I enter the room and look at my patient.  She isn’t sweating, she isn’t pale, she has no shortness of breath, her pulse is regular and strong, but I have a bad vibe by the way she says her chest hurts, the way she’s holding herself, the look in her eyes, the way she grips my hand…I just know something is wrong.

As Fire goes to get the stair chair, my preceptor takes a set of vitals for me, while his partner writes down her meds, I ask her the standard chest pain questions and find:  Localized burning retro-sternal chest pain started while sleeping about 2hrs ago, “very painful” with no relief.  Tenderness on palp, no change in pain on inspiration/expiration or swallowing, history of angiogram…not prescribed nitro…

Damn…she’s having a heart attack.

Me:  “Lets give her two ASAs.  Can you swallow okay?”

Pt:  “Yeah…”

My preceptor pops me two tablets.

Me:  “You need to chew this okay.”

Pt:  “Do I have to chew it?”

Me:  “Yes, you need to chew it, do your best…”

Pt:  “I need some water…”

Daughter:  “She has difficulty swallowing sometimes…”

Her granddaughter hears this and leaves the room to get her a glass.  I notice out of the corner of my eye that Fire is back with the stairchair.  I hand my patient the glass of water, as she takes a couple of small sips.

Me:  “Okay, I’m going to help you up, I need you to stand and just sit on this lovely chair here.”

While Fire and my preceptor help strap her to the stairchair, I ask the daughter a couple more questions that I have forgotten to ask earlier.  I grab the jump kit and the O2 and follow my preceptor and Fire as they carry our patient down the stairs to the ambulance.  I tell the daughter where we’ll be heading.

Outside, I notice ALS have arrived…and it is then that I realize my heart is pounding…I gotta give them a hand-off report!  I haven’t prepared myself in giving a report!  I didn’t have time to think as I spit out what my adrenaline soaked brain can remember:

“This is 87 year old Jane Doe, has chest pain, started 02:00 while sleeping…pain is burning, localized substernal… describes it as “very painful”, has history of angiogram…ahh…gave her 2 ASAs….”

I think that’s everything…what else did I find out?  I can’t remember right at the moment…I hope that’s good enough, I had no time to write anything down…

ALS:  “Okay, we’ll get the rest of the history en route.”

So I hop into the back of our ambulance with ALS, as they pop on their 12 lead for an ECG and I pass the O2 tubing to my preceptor who hooks it to the main tank.  I then see my preceptor grabbing a bag of N/S (normal saline).  Getting the hint, I grab the IV “stuff” as the ambulance start bouncing away.

Me:  “What size?  20?”

I was refering to the catheter size or IV size (the smaller the number the bigger the needle and catheter).

ALS:  “18 please.  Did you give any nitro?”

I stand up, trying to lock my foot under the stretcher carriage and leaning to brace myself in the bouncing vehicle as I tie the tourniquet around our patient’s arm.

Me:  “No, she’s not prescribed nitro.”

Preceptor:  “How’s the veins?”

Me:  “I got a big one on her hand…but it’s rather crooked, I’ll give it a shot.  Not sure how fragile it is.”

I wipe her hand down with an alcohol swab, trying not to fall over in the moving vehicle.

Dammit!  My hand is shaking!  I can feel it, even before I grab the needle with my hand.  I wiggle the cap off the catheter.

Me:  “Sharp out!!”

Preceptor:  “Can you stop the car for a moment so we can start an IV?”

ALS:  “While we’re stopped I’ll print the ECG.”

Stop shaking dammit!  There’s nothing to be nervous about!  I mean, your patient’s only having a heart attack, and it’s just ALS here expecting you to get a line for him…no pressures…

I aim the needle and imagine how it’ll go in.  I muster a confident voice.

Me:  “You’re just going to feel a small poke…”

I went in, got flash, advanced the cath, pull back the needle.

Me:  “We’re in!”

I breath a sigh of relief as my preceptor places the tegaderm on for me.  I feel the ambulance shift and start moving again.

Me:  “Okay, lets see if this flows…”

My preceptor starts the line…

Preceptor:  “It’s not flowing.”

Me:  “Okay, I’ll pull back a bit…how is it?”

Preceptor:  “Okay, it’s going good.”

Still struggling to maintain my balance, I rip off some tape to tape the IV in place when I notice swelling just distal to the catheter.

Shit!

Me:  “Uhh….it’s going interstitial.”

My preceptor stops the line.

Preceptor:  “Okay, look higher on the arm.”

He drops me a couple of gauzes.  I pull the catheter out, placed it in the sharps container and tape the gauze in place to stop the bleed.  As the vehicle swing me sideways, I tie the tourniquet higher up on the arm.  I find a decent vein on her forearm…not the best vein, but good enough to fit an 18.

At this point, my confidence is slowly going down the drain.  I can feel ALS’s eyes on me.  What is he thinking?  What does he see on the ECG?  Does he need to give meds?  Stop, just fooocuuuussss….I take a breath.

You got this one, you got this one.  I didn’t believe myself but I didn’t let that show.

ALS:  “Can you get the nitro?”

My preceptor grabs the nitro from the cabinet, primes it, and gives it to me.

Preceptor:  “Here, you can give it.”

I think he said that partially because I’m being precepted and partially because he is standing by the captain’s chair behind the patient.

Me:  “Can you lift up your tongue for me?  I’m just going to give you a little medication under the tongue.”

I thought I might miss in the rocking ambulance and spray my preceptor instead, but the spray went in nicely.

Preceptor:  “Found a vein?”

Me:  “Yup.”

I felt the car stop…

Partner:  “We’re at a red light…”

I’m not going to wait around, I got the needle in, but for some odd reason I shifted a small tad, and I see blood coming out.  Crap!!!

Preceptor:  “Keep on going, it looks good.”

Ignoring the bit of blood I kept advancing.  Come on flash, where’s the flash?

Partner:  “…yellow…”

I advance it a bit more.  Walla!  Flash!  I advance the cath and pull the needle back.

Me:  “Got it!”

I can feel the ambulance move forward, my preceptor goes off balance a tad while giving me the tegaderm and accidentally shoves the catheter slightly out and I see more blood flow out.  Argh.

Preceptor:  “It’s good, push it back in.”

So I did.  He tosses me a couple more gauzes.

Preceptor:  “Sorry about that.  Here, clean it up.”

I quickly wipe the site off as much blood as possible.  In the background, I can hear ALS giving the hospital a notification.  Darn…I still need a hospital notification competency!  My preceptor places the tegaderm on and occludes for me as I take the bloody sharp out.  I look around and realize I can’t put the sharp in the sharp’s container or I’ll fall over from lack of balance in the moving vehicle.  Hesitantly I place the sharp (the needle is contained inside a plastic container) on the blanket covering the patient’s lap and connect the IV tube.

Preceptor:  “It’s running good!”

God, that was the worst IV start ever…I tape the IV down, toss the sharp in the sharps container, and dump the bloodied material and glove into the garbage.  I look at the first IV site, a big bruise is forming, I apply pressure to it and look at my patient with apologetic eyes.

ALS:  “Can you pass me some gravol from my kit?”

He pushes gravol in through the IV port, then turns to me.

ALS:  “You’re giving the reports when we get to the hospital.”

Me?!?!  What?  I didn’t expect this.

Me:  “What did you find?”

ALS:  “You know as much as me.”

I wonder what he got on his ECGs, which he didn’t tell me.  He did call to notify the hospital, so there must be something going on in the ECG.

ALS:  “Do you use LOTARP or OPQRST?”

Me:  “I use both…”

ALS:  “Which one would you like to use?”

Me:  “LOTARP.”

ALS:  “Okay, so what’s the LOTARP?”

So I tell him the LOTARP I got on our patient (LOTARP is used to get a better understanding of pain and stands for location, onset, type/pn scale, alleviation/associated symptoms, radiation, provocation/precipitating events).  I learn a couple of useful questions from him and how to better phrase certain questions for a patient with dementia and a relatively poor historian.  We are just pulling up to the hospital when he gave me the nitro spray again.  Has it already been 5 minutes?  I’ve totally lost track of time.

I prime it and give the patient another spray.

ALS:  “Did you ask about Viagra, Levitra, and Cialis?”

Me:  “No…I assumed you two did because you gave it to me and told me to use it…”

I look from ALS to my preceptor who had a smirk on his face.  You gotta be kidding me!!!

After that scare they pulled on me, it turns out that it was all good for me to have given nitro afterall.

The ambulance doors swing open and we unload our patient and roll her inside.

Triage Nurse:  “Who’s giving me a report?”

The triage nurse goes to ALS as he shakes his head and points to me.  The triage nurse looks at me with a face that said seriously?  I ignore the expression and is confused because he has a lab coat on and I thought he is a doctor.  Anyways I utter about a sentence:  

“87y/o female having chest pain.  Started at 02:00 while sleeping, describes it as burning/heavy retrosternal…”

He cuts me off and says okay, grabs my patient care report out of my hands and looks at it.  It is blank.  He looks at me.

Me:  “Didn’t have time to fill it out…is there anything else you’d like to know?”

Triage Nurse:  “Any allergies?”

Me:  “Penicillin.”

Triage Nurse:  “Okay, go to 371.”

While waiting for the nurse, I start filling out my paperwork.  My hand is still a bit shaky, but I got it pretty well controlled now.  Damn adrenaline!  I give another two reports, one to the nurse, another to the doctor, and then started another 18g IV on my patient’s other arm.  I find out our patient shows elevated T waves on ALS’s ECG, and my preceptor tells me the lab tech who just ran another ECG says the patient has an inferior MI (heart attack).  Before leaving, I give my best wishes to my patient.  She returns a smile to me and her daughter and granddaughter thanks me.

Preceptor:  “Good job on the call, it flowed really well.  I don’t know if you were nervous or not, but you ran the call really calmly and …”

Me:  “You kidding me?  I was so nervous!  I don’t know if you noticed, but my hands were shaking when I was starting the IVs!”

Preceptor:  (Chuckles)  “Well you hid it really well.”

One of my paramedic teachers once told me:  

“Be Like A Duck.”

 I guess if anything, I mastered being like a duck.  It was the first time I was so nervous on a call.

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Comments
2 Responses to “Be Like A Duck”
  1. Ken says:

    Good story! Sounds like some good ALS… its not everyday you go with them for an inferior M.I, I’m going to suggest its because you were being precepted 🙂 I’ve known lots of Paramedics that have had difficulties with I.V’s for various reasons, and a little trick I find helps is that ; when you get flash, continue to advance the catheter another couple of mm’s, this allows the plastic sheath to pass by the lumen.The flash is from the very tip that is not covered by the sheath and has passed the lumen, while the sheath is still in the lumen. Most missed I.V’s that show initial flash is because they haven’t advanced the cath far enough and it piles up in the vessel wall. Another good one is NEVER let your hands cross each other while you have an exposed sharp in one of them. It is virtually impossible to jab yourself if you follow this simple procedure. Sounds silly but I have seen numerous needle sticks due to not following this concept. Never have had one myself ><

    • PocketMedic says:

      Hey Ken,

      Good tips! Learned those from my preceptors/mentors as well and very useful. I also find how they teach you at school to go in at 30 degrees don’t work well…I find going in at 10 degrees (lower angle) work better.

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  • Courage is the discovery that you may not win, and trying when you know you can lose. -Tom Krause
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