Hospital Clinicals - A Million Hours of Misery Or A Million Chances to Become an Excellent EMT?

Hospital Clinicals - A Million Hours of Misery Or A Million Chances to Become an Excellent EMT?

You remember your hospital clinical hours, right? Maybe you're doing them now. They never seem to end. Back in the dinosaur days of EMS when I was in paramedic class, the only place we did clinicals was in the ER, because the emergency room is the most like EMS, right? And back then, EMS wasn’t exactly taken very seriously. Appreciated, yes, maybe even commended, but seldom taken seriously. Most of our clinical time (two hundred forty hours!) was spent watching the nurses start IV’s and push drugs, watching the doctors intubate patients and helping fetch and carry things thither and yon. Few of the nurses trusted us enough to actually stick a patient with an IV. We only practiced intubation after the patient was pronounced dead. 12-lead EKG’s took the same place as Egyptian hieroglyphics in our curriculum. At best, we might inspire enough confidence in the staff to allow us to give a pill or rub some ointment on a rash.

Nowadays, the curriculum includes over four hundred hours of hospital clinicals spanning not just the emergency department, but the ICU, med-surg floors, labor & delivery and surgery. On the surface it seems like the ways to be bored have increased exponentially. And if you’re looking for something to do, you may find yourself in the same predicament we did back in my class, when the Tyrannosaur was the king of the earth, and go look for an empty patient room to nap in.

One thing is for certain, when you take your hospital clinicals you’ll be a newbie. A “lowly” EMT (actually, you’ll be worse- an EMT student!), so judged by the nurses and doctors on the floors who don’t know you from Adam. You may be able to run circles around any other EMT, but there’s no way you’re going to prove that to crotchety old Nurse Ratchet. And she won’t care if you did.

So is there any benefit to the spectrum of torture your instructors are putting you through? If you want to be an excellent EMT, there most certainly is!

Maybe, just maybe, you’ll get to stick an IV. The CRNA or anesthesiologist might let you intubate a real, live person. Good, you need that. But it’s no big deal. Why? Because you can teach a monkey to intubate or start IV’s. All that takes is training. As an excellent EMT, you need to seek out education. And the hospital environment provides you with multiple opportunities to do so. Training teaches you how do do stuff: “Is my scene safe? I put on universal precautions. How many patients do I have?" Blah blah blah. What to do on every scene you’ll ever have. What education does is teach you how to think critically about your scene, especially when your scene is one of those “what if...” situations that EMT class can’t prepare you for. A great deal of education can be gleaned in the hospital.

Let’s look at some examples. One thing you’ll have to do on every call is write a run report. “Nobody’s gonna read this thing besides a lawyer,” you say to yourself. On the contrary! Many, many times the very first thing a physician or nurse will do when initially encountering your patient is read your run report. Your run report stays in the patient’s chart until he or she is discharged. It is referred to nearly every time a new doctor or nurse has any interaction with your patient. Even if they’ve been in the hospital for months and you’ve long forgotten about the call, your words are still being read and taken into consideration. If you are doing clinicals, try to take note of how often EMS reports are read. Now imagine those are your words being read. Is the report clear? Is the mechanism of injury and pertinent history accurate? What did you do for the patient? Why or why not? And be assured, your spelling, grammar and penmanship are under keen scrutiny. It is those words that will make the difference as to whether we EMT's are to be taken seriously by the medical community!

Speaking of what you did or didn’t do for the patient, another valuable lesson you can learn from hospital clinicals is the concept of continuity of care. Though your responsibilities may end when you hand over the patient to the emergency department staff, the patient’s care does not. More importantly, what you did while the patient was in your care has repercussions long after you’ve gone home and forgotten about the call.

Did you intubate the patient? Once your patient is intubated, you’ve assumed responsibility for the airway & breathing - two of the cardinal aspects of the ABC's. By intubating them, you’ve effectively made them vent-dependent. Once the body realizes it doesn’t have to breathe, many times it doesn’t start again. In your hospital clinicals, take a look at the patients who are intubated, particularly by EMS. A week or two after you’ve patted yourself on the back for “getting that tube” while hanging upside down in an overturned car in a ditch at night, that patient may well be getting a tracheostomy. That sweet grandma with CHF might not ever be able to speak the words to thank you for “saving her life” because she’s dying of ventilator-acquired pneumonia. Are you SURE you absolutely NEED to intubate that patient? Is there anything you can try to prevent an intubation and subsequent vent-dependency? The chest decompression you performed, the perhaps-less-than-aseptic IV and the hypotension you induced by walking your patient to the ambulance also all create a huge change in the continuing course of care for the patient.

The drugs you push have effects beyond the ER doors, too. Educating yourself about them can make the difference between an EMT who can pass his test and an excellent EMT. If you’re in clinicals, take a look at how the course of care is altered by drugs the EMT’s gave. Did EMS max out the patient on Atropine? The care changes. When EMS pushed labetalol on the hypertensive crisis, did the patient’s asthma kick in and now they have to be intubated? Another detour in the path of care. That patient with eclampsia - why is the ER giving them levophed after EMS pushed the magnesium sulfate? All those drugs have side effects, some of them deleterious. What may make you seem like a hero at the moment may cause an unnecessarily extensive hospital stay for the patient, added expense for insurers or taxpayers and a negative outcome in general.

In the hospital, you’ll encounter equipment that you’ll believe you will never have to think about again. Wrong! Many patients are discharged to home care with a variety of medical devices. As was stated earlier, the emergency room is the most like EMS right? Well, that’s no longer the case. A huge part of EMS calls nowadays have to do with ongoing care. That’s right- home health. People call EMS when their home oxygen machine breaks or their premature infant’s feeding tube is clogged. Imagine going to the home of a chronically ill patient who’s receiving tube feedings. The feedings are still running to the PEG tube and you have to disconnect it to package them for transport. How do you disconnect it? How do you flush it? Use your hospital clinical time to find out. Some patients go home with a Wound-Vac device to remove exudate from a surgical wound or pressure ulcer. When and how should you disconnect it? How long can it safely remain off? What should you do if it is accidentally dislodged? Again, pay attention and ask questions in the hospital. Some patients have a PICC line (Peripherally Inserted Central Catheter). Can you use that for IV’s? How should you access it? If it starts coming out, what should you do? There is a cornucopia of devices that you may not feel you need to know about, but in reality you will have to deal with frequently. Quinton cathers, Foley catheters, suprapubic catheters, colostomies, home ventilators, home CPAP and BiPAP machines and tracheostomies are only a few of the things you have a golden opportunity to learn about while doing your hospital clinicals, and you will be glad you did when you encounter them on scenes.

You can take note of other things too. True, cleaning a patient isn't a priority in EMS. But try to assist the nurses to turn and bathe that 600-pounder in the ICU. Help them keep the combative head bleed still for a minute during the CAT scan. Feel the soreness in your muscles the next day. The nurses will acquire a newfound respect for you and you will appreciate what they do when they have to do it without your help.

Use your hospital time to really learn about patient care, not just the bare minimum of EMS training. Understanding that what we do in the back of the ambulance has a lasting effect on our patients’ outcomes will make the difference between you being an adequate EMT and an excellent EMT. Remember, any trained monkey can start an IV and memorize ACLS algorithms. Being an excellent, educated EMT is not only what makes you stand out, but is also what truly makes a difference. And making a difference is one of the reasons we all started in this field, isn’t it?

Adoption

Preface: I was adopted by my parents in 1965 as a six week-old infant. I’ve always known I was adopted, as have my two eldest sisters. There are six kids in our family, three of us adopted, three of us natural-born. I’ve never had any sort of a complex about being adopted; I deeply love my parents and my brothers & sisters. I’ve never been interested in finding my “birth parents;” I’ve never thought of my Mom and Dad and family as anything else but my family. Life goes by for forty-four years. And then...

There I was at work in my ICU, doing my little nursing thing, minding my own business. I get a new patient admitted from the emergency room. He’s had a stroke and is intubated and on a ventilator. He’s awake but the bleeding inside his head makes it impossible to communicate or recognize what’s going on. We’ll call him John (not his real name).

Anyway, I admit John and do my thing. I tried to find his family in the waiting room to find out more about his medical history, medicines, allergies, that sort of thing, but his wife had already gone home. No big deal. A while later the wife calls up on the phone to ask how he is, what are the visiting hours and so on. Before hanging up I say, “All right ma’am, my name is Sean, I’ll be taking care of him.”

“How do you spell your name?” she asks.

A lot of people ask me that. I’m very happy to spell it. “S-E-A-N. Spelled the right way,” I joke.

She continues: “This may sound strange, but how old are you?”

I raise my eyebrows, though this is a pointless action since I’m in a phone conversation. “Well, I’m forty-four,” I reply. “Why do you ask?”

She answers with what I interpret as a wistful tone, “It’s just that I had a son named Sean that I gave up for adoption. His birthday was 11/11.”

I stopped typing on the computer charting her husband’s assessment. “What did you say?” I asked.

“I had a son with John (the patient) named Sean. We gave him up for adoption. His birthday was November 11th.”

I said with a somewhat incredulous voice. “November 11th? Um, that’s MY birthday. What year?”

“November 11th, 1977.”

I breathed a sigh of relief, though I wasn’t entirely sure what exactly I was relieved of. I explained “That’s pretty wild, but it couldn’t be me. I was born in 1965.”

“1965? You know, it was so long ago, I may not be remembering right, and I’ve been so worried and tired with John in the hospital. It might have been 1965. We gave him up to Catholic Charities. Were you adopted, Sean?”

“Yes, I was. From St. Vincent’s.”

“St. Vincent’s? On Magazine Street? That’s who we gave him to!”

“Holy crap!” we both said simultaneously. She continued “Were you raised in a big Irish family?”

“Yes,” came my stunned reply.

“Did you grow up in Louisiana?” she asked.

“Yes.”

“Do you have blue eyes and dimples in your cheeks?”

“Um, yes.” I felt as faint as her husband must have.

“Do you have a full head of blond hair?”

“Y-y-yes,” I stuttered.

“Oh, my God!” she exclaimed.

I sat back in my chair, unable to move or speak. After a while, I collected my jaw off the floor and managed to bark out “Will you be here in the morning?”

“Yes,” she said. “I’d like to meet you.”

“Yes,” I agreed. “I want to meet you too. I’ll be here late after my shift for a class in the morning and I’ll come back to the ICU to meet you.”

“OK. I really want to meet you to,” she said, not saying the words we were both thinking, and hung up.

Could this be my birth mother? Could the guy in the hospital bed be my birth father? Is it possible?

I got up to take a closer look at my patient. Are there any resemblances? Does he look like me? As I examined him, I found frustration. I looked at his face and body. But he had been in a fire some time ago and was heavily scarred. His fingers had been burned off then and they were mostly nubs. He had pale, featureless skin grafts over most of his body and face. It was difficult to imagine a resemblance to anyone. He was sleeping. With my fingers I opened his eyes and gasped. The were the exact same blue as mine! I had explained my lengthy phone conversation to the other nurses. Two of them joined me in the room.

One of them said “You two have exactly the same nose.”

I looked closely. We did. And neither of them could deny the similarities in our eyes. A little while later I got him into a hospital gown, as the emergency room had stripped him naked. I noticed the pattern of the hair on his chest was the same as mine.

I needed some air. I had to take a few minutes to breathe, to sort out the storm of thoughts raging in my head. I went downstairs to have a cigarette.

I checked my own memory. I was born in 1965, right? I remembered the house on Chapelle Street we lived in till I was three. I remembered Vietnam, Watergate, the Apollo moon landing, Elvis and disco. I remembered the birth of all my brothers & sisters, all born before 1977. Yes, I couldn’t question my own memory. But I could question hers. Even she questioned hers.

I tried a different line of reasoning. What did I know about my birth parents? I had seldom asked, uninterested as I was in the subject. The only thing I know was that my birth mother was fifteen or sixteen and my birth father was seventeen. How old was my patient? When I admitted him, I had glanced at his hospital armband to verify his identity. It had said he was sixty-one. OK, so his age in 1965 he would have been... what? I couldn’t think enough to do the simple math. I pulled up the calculator on my phone. His age minus my age. Sixty-one minus forty-four. I punched in the digits and looked at the result. I blinked. I punched in the equation again. Seventeen.

Holy shit.

When I arrived back on the floor upstairs the phone was ringing. “ICU; this is Sean.”

“Hi Sean, it’s me again,” came the now-familiar voice of the wife. “I have to ask you, were you a blond baby but bald-headed? Did you used to walk around in a sort of circular stroller thing? With a round plastic thing around it that had toys attached to it?”

I thought back to my toddler days. I have an extraordinary memory for such things dating back to even before I could talk. It’s not quite a photographic memory; it’s called an eidetic memory. Images, the place of words in a book, the exact words of a conversation - all rattle around in my head with nowhere to go. I cross-referenced my own memory with the memories of photos I had seen of my own childhood. I clearly remembered my round walker/stroller thing. Some of my siblings had used it too.

“Yes, I did,” I answered. “How did you know?”

“Catholic Charities sent me a picture of Sean after his family had adopted him. I’m trying to find it now; I’m tearing up my house,” she said.

“That’s unbelievable!” I exclaimed.

“I know!” she said, also in disbelief. “I can’t believe I just called to see how John was doing and this happens!”

“Yes!” I replied. “I feel the same way!” I thought back to some of the information I didn’t have in my medical assessment to ask her, trying to seem a little bit professional, though all my emotions and thoughts were long gone. I could have asked about his immunizations, his prescriptions, his family medical history, social habits, anything. Instead I asked, “How tall is John? What’s his height?”

“He’s six foot one,” she answered.

It took a moment before I could say anything. “That’s my height.” I took a deep breath. “Ma’am, tell me your name again.”

(Again, not her real name) “My name is Beth. Beth Green Smith Brown.”

I insisted “Miss Beth, I know it’s four a.m., but would you be able to come down here to the hospital right now? I need to meet you.”

“I’ll be there in a few minutes,” she asserted.

Ten minutes later, the nurse I had informed of my experience told me, “Mr. John’s wife is in the waiting room. Are you nervous?”

“Yes, I’m very nervous,” I confided.

I met Beth. I won't go into a description of her so as to protect her privacy. I guided her to John’s room, holding her hand. It felt... I don’t know how it felt. Once in his room, I stalled. I tried to explain John’s medical condition to her. I stammered and choked. She said to him “It’s me John! And look who’s here! it’s Sean! Sean’s here!” John, with his swollen, bleeding brain, couldn’t comprehend.

Finally I decided I had to get down to brass tacks. “Tell me about this birth you gave up for adoption,” I instructed her.

She dug in her purse and pulled out an assortment of photographs. The first one was of a man in his thirties and a woman. His girlfriend or wife, I assumed. “That’s Brendan (not his real name). He’s my son. Or maybe, your... I don’t know, maybe he’s your... stepbrother?” she suggested. “I tore my house apart trying to find the pictures I have of Sean but I couldn’t find them.”

“Well, before we have a family reunion, let’s dig a little deeper. How long have you and John been together? I inquired.

“Since 1964,” she said.

The math fit perfectly. Crap.

“How old were you when you had this baby?”

“Twenty-four. I’m fifty-eight now.”

“And when did you have this baby you gave for adoption?” I pursued.

“1966,” she answered.

I paused. “I was born in 1965.”

She took a deep breath, sadness in her eyes. “Oh. I thought you had told me 1966.”

The math no longer worked.

“When was Brendan born?” I asked.

“He was born in 1971. He’s 38.” she answered.

“And was he your first child?”

“Yes,” she said. “It was my second child I gave up for adoption.” She went on to describe a conversation she had with Brendan in 1977 when he was very young, along the lines of Brendan asking her ‘why so-and-so’s mom can keep their baby, but you can’t.’ She gathered her thoughts. She knew that I had found the truth, that her second baby had indeed been born in 1977, not 1965. I suppose she had altered her story, errantly changing the year to 1966, having mistaken what I had said over the phone, in the hopeful desperation of locating her other son, and in her sad pursuit had altered the year to fit with my own life, though it would have made her pregnant at seven years old at the time of my birth. “I gave him up because I wasn’t going to be a welfare mom!” she asserted with a degree of pride in herself. I silently admired her desire for independence and self-sufficiency, even though her perception of time was somewhat… deluded.

“Do you think they might have lied to you about when you were born?” she asked with a shred of hope.

I pitied her for her husband’s illness and her lifelong desperation to find her lost child. I silently prayed that she would find some peace in her life, or at least that John would adequately recover from his stroke. I said to her, “No. I vividly remember being alive between 1965 and 1977. I’m sorry, but there’s no way I can be that son.”

We had little conversation after that. I was still distracted by the notion that I might have accidentally found my birth parents. After all, there was the incredibly identical story she had told me and there was the uncanny, unsolicited description of a child who sounded just like me. And there were John’s eyes.

I’m still not interested in finding out who my “birth parents” are. I’ll always have only one set of parents. But for the rest of my shift, I took care of John with, well, the kind of attention I’d take care of my Dad with. Good luck, John. And good luck, Beth. I’ll always remember you.

Metaphor Madness

Most of us like to try to sound marginally intelligent in our conversations with others. Not all, but most of us. Even when we aren’t trying to impress someone, we don’t want our friends and acquaintances to think “God, I can’t stand listening to him!” This is one of the reasons that cliches are unacceptable in scholarly papers, news articles and any form of writing that is designed to be of a professional ilk. Likewise original thoughts and metaphors carry a heavier weight in verbal intercourse than tired-out cliches.

Nevertheless, worn old cliches and metaphors do serve a purpose. Some are so aptly put that it is difficult to come up with a better phrase to illustrate one’s point. “Between a rock and a hard place” is one metaphorical cliche that comes to mind. It carries an indefatigable image to which anyone can relate. The circumstances it describes are immediately understandable. And you and I both know that no amount of learning or eloquence will eradicate tired cliches and metaphors.

Therefore it seems time that rather than declaring a moratorium on such phrases, it is time for a quick lesson on their use and structure. As stated, no one wants to seem unintelligent in front of anyone. The act of using a cliche or threadbare metaphor treads thin ice (there’s one!), so let’s make sure that you know how to properly use them.

Let’s look at a few examples. “It’s six of one and a half-dozen of the other” is a benign starting point. If you are going to use this cliche, go to the trouble of actually saying “it’s six of one and a half-dozen of the other.” A popular bastardization of this phrase lately has been expressed as “it’s what and what.” Remember, we’re trying to sound marginally intelligent. Abandoning the imagery that “six of one and a half-dozen of the other” carries just sounds stupid. To say “what and what” simply portrays the speaker as one who rummages around in his brain for a simple thing, a thing that should be right there on top of everything else and, being unsuccessful, asks the listener two questions “what?’ and “what?” because he can't even finish his own thought. Do you want to be the type of conversationalist that your listener thinks of you: “Jesus Christ, he can’t even come up with a tired old metaphor! I don’t want to listen to someone who can’t even find his conversational ass with both hands.”

Here’s another one. “God-given” and God-forsaken” are NOT interchangeable. "God-forsaken" is a description of something that even the Creator of all things has left alone. If you have a God-given right to something, do not say it is God-forsaken. This will have the rest of us picturing you finding something after digging through a dumpster of hazardous waste and horrible, rotting garbage in the effort to cling to that thing which even the homeless would throw out. If you believe that you have a “God-forsaken right” to something, then by all means, indulge in it, but don’t whine to anyone that no one else wants to be around you. Even God would ask what that smell is.

Do you you have a girlfriend? A boyfriend? Significant other? Life partner? Mistress? Sweetheart? Fuck buddy? Then please let the world know this relationship! Do not refer to them as your “boo.” It sounds as if you were going to say “boyfriend” but then got tired mid-word and just left it at “boo” because you were too lazy to finish the syllables. At best, describing someone as your “boo” sounds as if the individual in question is the person who scares you every Halloween.

Do not try to improve upon cliches and well-known metaphors. If you must describe yourself as being stuck between two difficult, if not impossible obstacles, then say that you were “between a rock and a hard place.” Do not tell your audience that you were “trapped between a cliff and a mountain.” Nor should your say you were betwixt “a concrete wall and a cement rampart.” Your metaphor may be amusing to the odd geologist or structural architect, but for the most part, we will think of you as someone who has clearly never gotten laid.

One more tip, because I’m tired and I want to go to bed. Avoid dogs in your metaphors. Utilizing the imagery of a canine is confusing, and can make you look like more of an idiot. The common phrase “working like a dog” is not consistent with the also common phrase “it’s a dog’s life.” If you describe someone as working like a dog (rough, sweaty, difficult work) then how will we reconcile the leisurely, lying-around-but sometimes-licking-my-butt imagery that “a dog’s life” conveys? Are you “dog tired” because you were working “like a dog” or because you laid around in the sun doing nothing on a “dog day afternoon”? Yes, dogs in conversation are inconsistent, confusing and often embarrassing. Avoid them. You don’t want to give your friends the wrong impression when you greet them with “Yo, dawg!”

Stay tuned for more metaphor madness in days to come. In the meantime, try not to sound like an idiot. Yes, this may mean you might actually have to use your brain when speaking. But then, isn’t that what you want to sound like you’re doing?

The Science of Apathy (Or Maybe the Science Fiction of Apathy)

The Science of Apathy (Or Maybe the Science Fiction of Apathy)

I love sci-fi. I love real life too. It’s always so much fun when I watch sci-fi movies about aliens and space travelers and such. They’re always trying to blend in with their disguises and their shape-shifting ways, only to be foiled by keen-eyed civilians or “the government.” Earth survives another day. Yay.

But then it comes down to real life. I’d love to believe in actual extraterrestrials. But I don’t. Why? I haven’t seen any. Nor have you. Or have we? How many times have you seen someone on the street that was just so ugly or deformed or unearthly beautiful? Did it ever cross your mind that they might be an alien? Of course not. Me neither. But here’s a fun thought: what if they are? I’m sure psychologists would say that our minds simply try to incorporate the unusual into our usual frames of reference. For example, a time-displaced caveman might refer to a helicopter as some sort of bird (remember that movie?). Likewise, we would probably just think of an alien as a different-looking human. We’d just say “Oh, they must just have Down Syndrome,” or “What a an unfortunate birth defect, having a head shaped like the Sydney opera house. She should get surgery for that.”

Which brings me back to sci-fi. Remember when Captain Kirk and crew returned to the 1980’s to retrieve their humpback whales? The Shat ordered his crew to remove their Starfleet insignia. Why? Who would care? Mr. Spock wore that bandana thing to hide his ears. Really? What was the point? (Pardon the pun.) I’ve seen lots of people with weird-shaped ears but it never once entered my mind that they might be an alien. I’d venture to say that you, dear reader, have done the same.

I’ve been a paramedic and a nurse for nearly twenty years. Many, many times I’ve listened to patients’ chests and heard heart tones on the right side as well as the left, or heard breath sounds when listening to an abdomen. Breath sounds in a belly or heart tones on the right side are exactly what you shouldn’t hear. But I never suspected that they might be a timelord like Dr. Who or other such alien with two hearts or otherworldly arranged internal architecture. I just figured that my stethoscope was really sensitive or the patient’s chest was particularly resonant.

The sci-fi show that I think strikes the nail on the head psychology-wise is “Invader Zim”, a Nickelodeon cartoon that only ran for a couple of seasons. In it, Zim is a green-skinned alien with no ears and pink eyes who lives in a freakish house. He goes to great lengths to disguise himself as he plots to annihilate the world. Zim needn’t bother. The only person who believes he is an alien is Dib. Everyone else is convinced Dib is insane. All the rest of humanity is completely apathetic about the unusual happenings surrounding Zim.

That’s pretty much how humanity really is. I don’t think that there are extraterrestrials living among us; which, if you’re an extraterrestrial, is the perfect disguise. The folks that believe in aliens are the “fringe” people, and they proclaim their stories of abduction and insidious alien plots between doses of Seroquel behind the revolving door of their psychiatric facility. What if they're actually right? Like I said, I’d like to believe in aliens, but I don’t. Does that make me as apathetic as the rest of the world? Probably, but I don’t particularly want to spend my days behind that revolving door in a Seroquel happy place.

So is there a happy medium? Can a normal person find a compromise between boring, sane apathy and the men in the white coats? Just for fun, next time you see someone unusual-looking, imagine that they might actually be an alien, instead of an unfortunate soul whose eyes are too far apart or in need of a good plastic surgeon to take care of that tail or proboscis. Just the other day, I saw a man who was odd-looking (I say he was a “man,” but who knows?) His eyes were really far apart and his skin was an odd shade, sort of like you would get by putting too much butter on burnt toast. His ears were odd too, almost star-shaped. My first thought? Some black guy born with fetal alcohol syndrome. My second thought? He could be an alien and no one else realizes, or cares! The second thought, that he might be an alien, was so much more fun than the depressing disease process thought! Try it! Just be careful who you talk to about it.

See you in the asylum!