High Stress, Low Class

When the adrenaline is flowing, it is more than a challenge to keep my cool at times.  I’m not a confrontational person, but when a person interferes with my patient care, I can be a little hotheaded.  I’d love to be able to say I am the calm in the stress induced storm of an emergency, but I’d be a bold-faced liar.  I don’t know of a single person who hasn’t let their frustrations show in the heat of the moment. I’ve certainly borne the brunt of others’ rage in times of high stress on more than a few occasions.  Now that I’ve grown into the paramedic role, I’ve found that I’m no different.

Historically, I haven’t always been diplomatic when people interfere with my patient care. As it stands, I’m the only person I know who threatened to kick a police officer in the face, albeit in a joking tone, and didn’t get arrested.  I’ve doled out more than a few empty, ridiculous threats to get my point across.  I’ve said plenty of other things I’m not proud of, but I probably shouldn’t admit them publicly.

In paramedic school, we were put through the proverbial ringer of high stress situations.  We had airway obstacle courses, in which we had to perform under strobe lights and loud music.  We had impressive mock MCIs: a meth lab explosion, a train wreck with hazmat qualities, a house fire with multiple patients, multiple patient farming accidents, a building collapse with fire and trapped responders, swift water rescue, high angle rescue, and many multiple vehicle accidents.  We had complicated scenarios, in which we performed demanding tasks like CPR, controlling difficult airways, and handling multiple critical patients, while reciting acronyms and definitions.  I still recite drug dosages, classifications, indications, and contraindications while I jog out of habit.  My instructors tried their hardest to prepare us for the worst by exploiting our weakest points.  They’d make us overcome various states of equipment failure, force us to become skilled in the art of adapt and overcome, stress us out, and push us to the limit.  They even stole my equipment once because I left it unattended.  Despite all that preparation, I can sometimes feel my heart try to beat out of my chest on calls when the stakes are high.

Recently, I had my first pediatric code.  It’s no stretch of the imagination to state a child in cardiac arrest is one of the most efficient ways to induce a big, fat adrenaline rush for any emergency responder.  Everyone on scene was frazzled.  No one likes a dead kid.  I couldn’t get first responders to cooperate on even the smallest things very well, like moving the patient from a cramped bedroom into the spacious living room.

The problem wasn’t that they were bad at their job or that they were dealing with a female paramedic arriving to take control of the scene; the predicament was that the gravity of the situation was downright distracting.  I tried to be calm and collected, to keep my thoughts straight and my voice level, but when everyone else in the room is tense to the point of disruption, it is easy to become irritated.   My heart may be beating at SVT worthy rates, but I try like hell not to show it, which is not always successful.

I intubated the toddler with a small endotracheal tube and tied it down with twill tape.  A fireman was ready with the BVM to resume ventilations.  I told him to place his free hand over the child’s mouth to hold the tube in place, to keep it from dislodging.  I turned away to give a dose of epinephrine, and looked back to see he had let go of the tube and had accidentally pushed the hub of the tube to the patient’s lips.  *Gasp* My tube! Checking breath sounds, I found the tube was lodged in the right mainstem of the lungs, so I readjusted it.

I said, “It is really important that you hold the tube in place with your hand right here.  Remember the airway is paramount with pediatrics, and it is very easy to slip downward or out because there isn’t much room for error.”  I turned away to give a dose of atropine, and looked up to the same problem as before.  Holy crap!  Do not slap this man.  Good paramedics do not abuse their first responders. Again, I readjusted the tube, insuring it was in its proper position.  I tried to will myself to grow more functioning arms like a Hindu goddess, but that was unsuccessful.  Why can’t I have more arms? I said, “I really need you to hold this tube in place, because this tape isn’t working worth a crap.  You are doing a very important job, and if you need someone else to take it over, we can do that.  This tube may be this kid’s only real chance for survival.”  He said he was fine, and I believed him.  A few seconds later, I turned around to see him start to grab for something again, but he looked up at me and mouthed “Sorry.” Do not make me a murderer today, sir.

Walking to the ambulance with the stretcher, while first responders were doing CPR and ventilating, I held the tube in place at the patient’s mouth.  Within earshot of the five people surrounding the stretcher, I told the fireman in a semi-joking tone, “We’re all jazzed up here, but if you let go of my tube one more time, I’m going to kick you in the solar plexus.  If you don’t, I’ll be your best friend and send your kids birthday and Christmas presents.  If you need to switch out, tell me now.” He said he was fine; it was just his first pediatric code and he was understandably a little “freaked out.”  I didn’t tell him it was mine, too.  We loaded the patient in the ambulance, and I checked to make sure the tube was still in place before allowing him to hold it again.

On the way to the hospital, I noticed the hub of the tube was almost in the patient’s mouth, and I finally lost my cool.  I listened for breath sounds and heard nothing, but I did hear epigastric sounds.  He lost my tube. I transformed from a stressed paramedic to a pissed off megabitch in a nanosecond.

I planted my feet and took a stance I learned from playing too much Mortal Kombat in my youth.  With a punch square to the jaw, blood and two teeth flew across the ambulance.  I landed an uppercut to his chin and followed it with a right hook to the kidney when he doubled over, both solid hits.  The words “BAM!” and “POW!” appeared in the air in jagged bubbles of sound effect.  While performing CPR, the other responder in the ambulance announced in a low pitched, demanding voice, “FINISH HIM!”  One solid round house kick to the solar plexus sent him flying through the air, pushing the back doors of the ambulance open with force, and he flew out of the ambulance and onto the highway at 75 mph.  At least, that’s what happened in my head.

In reality, I took a moment to yell something that sounds an awful lot like mother trucker in addition to a string of expletives, while stomping my feet hissy fit style and grabbing a new BVM out of the cabinet, because we’d left the mask on scene.  I reassembled the intubation equipment, choosing a slightly larger endotracheal tube that I hoped like hell would fit.  I re-intubated the patient, forcing the larger tube in, as the correct sized tube was no longer useful. I said, “I don’t have the *BLEEP*ing dexterity in my toes to push drugs, so you’re going to have to hold this *BLEEP* *BLEEP* tube in place like your life depends on it. I don’t have enough *BLEEP* on this truck to intubate this kid again.”  And let go, he did not.  He even looked over at me for approval before releasing the tube in the hands of hospital staff.

Upon arrival at the hospital, the physician was “beyond impressed” that I’d managed to secure a 4.5 size ET tube.  I told him I had a little help, while glancing over at the first responder, who looked like a hurt puppy.  Afterward, I apologized to him for behaving like an asshole.  I finally told him it was my first pediatric code as a paramedic, and it took just about everything I had to hold myself together and put my training to use.  I told him I know what it’s like to be in his shoes, and while it will never get easier, he’ll have a better hold on the situation next time.  I assured him that despite the snafus, we did everything we could for the child (a mantra I had to keep repeating to myself as well).  He accepted my apology very well, and I truly hope he doesn’t hold my behavior against me, or other paramedics for that matter.  Granted, he doesn’t know that in my head, I beat the crap out of him.

For both of us, it was a horrible notch under our belts.  Perhaps next time each of us will be better prepared.  I’m certainly not the only responder who can be affected by what we encounter on the job, and I was the new EMT with the deer-in-headlights look in this very situation once upon a time.  The first time I saw a child in cardiac arrest, I was completely distracted by the one thought that kept circulating: This isn’t supposed to happen. I think we both learned a lot from that call.  I learned to trust my instincts a little better, make people trade positions when they show signs of insufficiency, and that I need to be much more civilized under pressure, while he learned paramedics can be jerks when you lose their tubes.


  • Para3medic says:

    Glad to hear that your first pedi code went… Well, that it went. Firefighters are curious creatures; they frequently don’t register the politely phrased directions, but are attuned to “sentence enhancers” as indicators that the directions are important. I have had similar issues in giving essential directions in high stress situations (with drivers trying for NASCAR, responders assisting with care, etc) and even have the benefit of a baritone voice and testosterone to get the point across.

    I’ve found that the ones that don’t register the polite directions respond well to the “enhanced” directions, threats of bodily harm optional. Yelling is generally not necessary, but the extra words do seem to help drive home the gravity of your instructions.

  • Timothy Clemans says:

    Wow talk about owning your mistakes. If every person was this candid about their mistakes the world would be a better place. On the bright side that responder will probably never lose another tube.

  • People think I’m weird b/c, no matter how much stress mounts up in an emergency I remain calm.
    One guy even mentioned it as if I were subhuman to be so cool as a cucumber in certain situations.
    I can’t help it, and it didn’t come from a noble place. I watched my sister dying in front of me, and saw paramedics save her life.
    They were calm and kept us calm, and I still believe if they hadn’t been there helping me, I would have gone crazy from what I was witnessing.
    I don’t just know how important staying calm is; I feel it to the core of my being.
    I can’t forget what I saw and I can’t forget how important it is to stay calm.

  • Chris Sterricker says:

    Pup, I give you credit for apologizing. I don’t know that I would have. Let’s face it, it goes A, B, C, for a reason. Granted, you can BVM too but a tube is much better. Without some form of A and B everything else really isn’t doing much good. Snapping at something like that is beyond forgivable, if it were over handing you a cannula instead of a non-rebreather, well, maybe I’d say you have issues. Mad props for holding it together as long as you did on one of the worst scenes we can face.

  • Christopher says:

    We’ve gone to cuffed tubes on pedi’s along with commercial devices to hold it in…but I’m with you: if I got it once, I really don’t want to do it again.

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