Self Mutilation 1/2

Self

Pronunciation: \self, Southern also sef\

1: a person’s particular nature or personality

2: the identity, character, or essential qualities of any person or thing

3: the union of elements (as body, emotions, thoughts, and sensations) that constitute the individuality and identity of a person

Mutilation

mu·ti·la·tion

Pronunciation: myü-tə-lā-shən\

1: an injury that deprives you of a limb or other important body part

2: to physically harm as to impair use, notably by cutting off or otherwise disabling a vital part, such as a limb or vital organ.

As a paramedic intern I have three states of mind; call anticipation, call anxiety, and post call critical evaluation. During my 48 hour shifts with my preceptor I cycle between the three in a never-ending manic loop.

I’m standing in the kitchen of our quarters making coffee for the crew. It’s my routine after checking out the rig each morning.

The tones go off on the portable radios and the dispatcher comes up telling us the nature and location of our first call of the day; chest pain in the corner of the county at the far edge of our response zone. Unlike my current county which is mostly urban with a dozen hospitals, the county in which I interned was mostly rural with only three hospitals. Parts of that county were over an hour away from the closest hospital, and possibly even further from the closest most appropriate hospital. At least we’ll have coffee when we get back to quarters.

Siren wailing, strobes muted by sunlight, we speed across the two lane rural highway towards the water. I’m sitting in the back of the rig. My preceptor, Tony, is in the front holding the map book and directing his partner to the call.

Tony tells his partner to take the side entrance to the mobile home park by the water. With my call anxiety in high gear I look up through the windshield to see the BRT (big red truck) parked next to a mobile home, and neighbors in bath robes standing around the truck taking in the commotion like a Jerry Springer dinner theater. It’s a new experience for me as I can’t remember ever going into a mobile home park. Little do I realize how often this exact scene will repeat throughout my career in EMS.

Ambulances are drawn to mobile home parks by the same electromagnetic waves that draw ships into the Bermuda triangle. The same mysterious phenomena causes ambulances to be drawn to Walmart more so than other retailers.  I’m thinking there’s a correlation here…

Walking into the mobile home I see my patient sitting at a vintage 1960’s folding card table in the dinette; a bottle of cheap red wine sitting on the table, almost empty at 0915, and an ash tray overflowing with butts, one still giving off a slight stream of smoke.

The BLS (basic life support, meaning EMTs only, no paramedic) fire crew is finishing up a set of vitals and gives me a quick report as my preceptor becomes a fly on the wall giving me enough leash to run the call, but ready to cinch the choker if I screw up.

The patient presents with sudden onset crushing chest pain of 10 out of 10 severity, associated diaphoresis, non-provoked. Except for the cigarettes and wine.

James, my patient, is sitting at the table in boxer shorts and flip flops. His chest is scarred down the middle with an eight inch fresh surgical scar held together with staples. I will later come to recognize this as a “cabbage” (CABG – coronary artery bypass graft).

At this early stage in my experience I have to ask what it is. James tells me he had quadruple bypass surgery last week. The pain he’s feeling is exactly like the heart attack that led to the surgery.

As James is now on the heart monitor I print a strip: ST segment elevation in two of my three leads. I reposition the leads to get two additional views from S5 and McL1 as my preceptor taught me just last week. This rural county hasn’t adopted pre-hospital 12-lead ECGs so we have to do the “poor man’s 12-lead” by moving electrodes around the chest. More ST-segment elevation.

I may be brand new to the field but even I can do the math well enough to see this is a probable MI (myocardial infarction, also known as a heart attack).

We load James into the rig and start transporting. As with many other patients, we’re over twenty miles away from the closest hospital so we apply the common practice of “load and go” – start driving and treat en route to save time.

I run through my chest pain treatment protocol with staccato starts and stops. After running similar calls a few hundred times it becomes second nature, but the first few times it’s a conscious effort to remember everything. I ask about aspirin allergies before giving him an aspirin. I hold the nitroglycerine spray up to his mouth then quickly pull it back to ask if he’s taken Viagra recently. My hand fumbles while screwing the morphine vial onto the hub of the IV tubing. I have to do contortions to read the slash marks on the vial while cautiously pushing the drug into his vein. It comes loose from the hub so I have to screw it back on.

I also ask James how he could possibly keep smoking and drinking like he does after having heart surgery. “Don’t you know that your heavy smoking and drinking probably caused the heart attack that led to your surgery?” I asked. “Yeah, I know. But I just couldn’t stop.”

None of this goes overlooked by my preceptor. Sitting behind James in the captain’s chair I’m not really sure he’s even awake. He seems to have the uncanny ability to sleep through the siren noise, the bouncing of the rig, and the enormity of the fact that the cardiac tissue in James’ heart may be slowly dying. But of course he’s watching every move and saving his thoughts for the post call critique. Again, just enough leash and no choker yet so I must be getting it right – or at least I’m not getting it terribly wrong.

Arriving at the ED (emergency department) I stutter through a hand off to the RNs and MD that are waiting for us. They realize I’m an intern by the conspicuous lack of county patches on my uniform. The RN looks over at Tony silently confirming my report. He nods letting her know she has the full story.

Tony takes me aside after the call and runs down the entire event from start to finish. He gives praise on some aspects and well-meaning criticism on many others. Study points are identified and on the way back to quarters I practice with vials and syringes in the back of the rig to try to build the muscle memory.

Back in quarters I’m finally able to have my morning coffee. It’s two hours old and condensed to a bitter lukewarm shadow of its former self. I stare at the portable radios quietly sitting in their chargers and wonder when the tones will go off again.

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~ by KC on June 25, 2010.

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