The ABCs

As I mentally prepare myself for the biggest transition of my medical school career- from pre-clinical to clinical student- I can't help but be reminded of my humble beginnings in EMS.

For the past two years, I've been sitting in a classroom with 160 other students and an "even" playing field- most of the classroom knowledge is so specific that no one really goes in with an advantage. But as I review my schedule for orientation week, I cant help but fixate on the Wednesday afternoon CPR class.

I'm sure that most of my classmates have taken the class, but I wonder how many of them have had to put it to use. Not only that, but frequently be in situations where the life of a patient depends on the split second decisions and actions of a 20-year-old paramedic.

Driving today, I reflected on some of the calls that have heavily shaped and influenced my "clinical personality." For some reason, a call that I hadn't thought about in years kept replaying in my head.

Returning from Duke University's ER after one critically ill patient, I vividly remember the dispatch to another ambulance for a pedestrian struck on a highway. I was trying to get back to my district before letting the dispatch center know we were available, and we weren't there yet. But we were, by far, nearer than the next-closest ambulance.

I immediately weighed the options in my head: keep going, and avoid a messy call, or go the ethical route and handle the call. My EMT partner, who was driving, looked at me as if to ask me what I wanted to do. I know she wouldn't have judged me if I had ignored the call, but I knew I couldn't live with myself if the patient died. I would always wonder if the extra few minutes could have saved him.

I picked up the radio and notified dispatch of our decision. Later I realized that I could have been reprimanded for not alerting them I was available, but at that time, that was the last thing I was thinking about.

I was a new paramedic- I think I'd only been "fully released" (allowed to function without another medic) for a few months, and with no other scene information, I had no idea what I was walking into.

We literally pulled up on the scene within a few minutes, and it was something I'll never forget. It was a huge highway (540 for those of you familiar with Raleigh), with four lanes on each side. In one of the middle lanes I saw a heavily clad African American man (it was the middle of summer) lying on the pavement. The speed limit in that area is 65mph. A few cars had pulled off to the shoulder- out of the corner of my eye I noticed a few hysterical bystanders.

To this day I have no idea what possessed this man to try and cross the highway at rush hour, but the woman who struck him (purely by unavoidable accident), believes he had dropped some sort of tool and had run out to retrieve it. She was clearly upset but talking to her for any longer would be futile, so I turned to the patient.

We strategically parked directly behind the patient to protect us and the patient from traffic, but the entire time I was on the scene I couldn't help but think about all the passing cars going 65mph inches away from me.

As a crew of two females, we had little choice but to stay put. My poor partner had to endure my frantic demands- radio for help, get a backboard, get the EKG monitor. First responders, usually on scene before us and better equipped to deal with heavy traffic, were several minutes away. They were also coming from the other direction on a divided highway so I had to watch them drive by my scene as I helplessly pushed on this poor man's chest.

While it seems impossible to survive such an impact, I could not find any actual injuries on the patient, as desperately as I searched. Based on that alone, I made the decision to work the cardiac arrest- in other words, attempt to resuscitate him.

Between the two of us (my partner, aptly named Angel, was truly was an angel that day), we managed to have the patient packaged for transport by the time help arrived (which is a feat, just take my word for it!). He didn't have a heartbeat, but there was still electrical activity in his heart, so I did my best to jumpstart it. Since I couldn't defibrillate him (PEA for medical geeks!), I did CPR for about 10 minutes. If anyone had ever done CPR, you know that it's exhausting. It's recommended that you switch people every few minutes in order to maintain adequate technique.

With help, we loaded him up and went back to Duke. I felt so ashamed pushing the stretcher into the ER. He had no IV, no endotracheal tube, nothing. I basically just ran a BLS code. I had one fireman to alternate CPR and ventilating him and that was all I could manage.

Looking back, I realize that I did the right thing. All my decisions were sound and logical. I could defend any one of my choices in court.

In medicine, you always start patient care with the ABCs- airway, breathing and circulation. Truly, the basics were this patient's best shot. I could have stopped CPR to intubate him so I wouldn't be humiliated by the doctor, but that would've been for my ego, and not the patient's best interest.

The team of doctors and nurses who took over had just seen us leave and knew our time limitations.  They even commended our efforts. They continued resuscitation efforts briefly, but everyone knew it was futile.

I learned a lot that day. A lot about myself, and a lot about sticking to my guns. There wasn't anything I could've done differently (I believe) that would have saved this man's life, but I did the right thing. I gave him the best shot possible.

I still don't know why he died; I can only make the assumption that he had a traumatic brain injury with severe hemorrhage. I also don't know why he ran into the highway, but it must have been something important that led him to risk his life.

I'm really dreading this CPR class next week with a hundred fellow students who don't know what it's really like, but I know that as I sit there I'll be reminded of the countless patients who did (and some who did not) survive because of my basic skills from training at the beginning of my career.