Shaky Hands, Part 3

Shaky Hands, Part 1
Shaky Hands, Part 2

For the next two seconds, I internally panic. I honestly think the only thing that didn't stop me in my tracks was that we were wheeling Wendy out to the ambulance. I second guess myself. Maybe she didn't have a pneumo. Maybe my needle placement was wrong. Maybe I should have been more aggressive up front. I debated whether or not I should intubate her. RSI would take too long. We're two miles from the hospital. Finally, I think back to the paperwork the med-aid handed me and that Wendy was very clearly a DNR patient. What will I do if she arrests? Will it be because of something I did or didn't do?

My internal conflict is over by the time we reached the back doors of the unit. I outlin my hasty plan to my partner. "Set me up a BVM. I'm gonna take one more listen to her left side, then I'll assist her on the way in. We don't have the time to intubate her. Let's just get going."

I put my ears on as my partner whips out the BVM. Terese, one of our Basics that's working an extra shift with me, moves swiftly in the ambulance, securing the equipment for travel and setting up the BVM. I listen to Wendy, no improvement in her lung sounds, but as I watch her breath, her work of breathing seems to have eased some.

"Wendy?" I ask. "Does your breathing feel any easier?" She looked up at me, desperation and fear in her eyes, and shakes her head no. She still can't talk, but at least now she's responding again to my questions. My tension eases, ever so slightly.

My partner is up front now. She places the ambulance in drive then flips on the lights and we start transporting. My hands are still shaking and now that I'm sitting in the airway seat, my legs have started to shake, too. Another nervous response of mine, both my knees are pumping up and down rapidly as I bounce my heels off the deck of the ambulance. I'm trying to take deep breaths, to be calm and cool, but it's not working well.

I have the BVM over Wendy's nose and mouth, her eyes are pleading up at me to help her. He jaw is so narrow and slight that I can't make a proper seal. Even in my attempt to assist her breathing, I can't seem to do it right. I'm forced to supplement her rapid breaths with puffs from the bag. I try to coach her, "breath in with me on three. 1, 2, 3... 1, 2, 3..." God I wish I could do more, I think. My hands are busy, so I tell my partner to give a report to the hospital when we're only 60 seconds out. The ER staff doesn't like it, but I can't effect how close the care centers are to the hospitals.

Terese unloads the cot by herself while I try to hold the bag in place over Wendy's face. We roll her through the ambulance bay doors and into the ER bay. The ER doc doesn't look happy to see us. The ER is full and they've had to clear a bed in a rush for my patient. The doc is smirking at us as we roll in, a tired, haggard and almost hateful smile. I can see it in her face, why the hell did you bring me this?

I should have taken another deep breath before starting my report, but the words just started tumbling out of my mouth. I couldn't even make sense of what I was saying and the nurses had to stop me a few times to clarify a point or ask me a question. I was ashamed as I take pride in having good turn over reports. The RT has arrived now and has taken over bagging the patient. Wendy is more alert now, tracking movement and responding to stimuli. Her work of breathing has improved considerably, but she still can't talk. I leave her side, slowly being pushed to the back of the bay as nurses and techs step in to assume care. The ER doc, standing at the back of the bay turns to me. "Why did you decompress her?"

Away from the patient's side, away from the immediacy of her care, I'm able to take a deep breath and calm myself. The doctor can see the stress in my face, the sweat on my brow, and gives me a knowing smile as I start over from the beginning. Eventually, I get to where I can answer her question, "I decompressed her because she could no longer breath adequately, her lungs sounds on the left had disappeared, she became lethargic, and subcutaneous emphysema developed all in less than 10 minutes. I did it because she needed it and I thought it was the right thing do to."

The doctor looked at me for a few long moments, then gave a knowing and reassuring smile. "Okay," she said then continued with her assessment. The doctor would later tell me that she now faced her own dilemma: whether to place a chest tube in this elderly woman with a DNR and send her to specialized care in Portland, or keep her under observation at Providence's own ICU where she would receive a lower standard of care, but be closer to home and adhere more closely to her DNR.

I now had paperwork to complete, demographic information to collect, and an ambulance to put back in service. But I was awash with emotions and couldn't focus too well. I was still anxious and nervous about whether I'd done the right thing, I was tired physically and emotionally exhausted, and I was excited and enthusiastic--I'd never done a needle decompression before and now I had a story to tell.

During the next 30 minutes while my partner and I attended to our tasks, I would poke my head into Wendy's ER bay. She was on a nasal cannula now with oxygen sats at 100%. Her heart rate and respirations were down. Her work of breathing had greatly improved. But best of all, her look of fear and desperation had disappeared. She was anxious, I could tell, but she knew she was being taken care of.

My partner and I returned to quarters after collecting my paperwork. I wrote my chart and had dinner while we waited for the night car to start its shift. I felt that I had done good work. My partner told me how impressed she was with me, that she knew I was one of the few medics in the company that would have decompressed her. She felt like we truly made a difference in the patient's outcome. With the shakiness gone, the anxiety and adrenaline subsided, I had to agree. "We did good work," I told her, shaky hands or not.

Wendy went to Portland with Medic 7 roughly 4 hours after arriving in the ER. She was diagnosed with a tension pneumothorax and subcutaneous emphysema extending along her entire left side and up into the left side of her neck. Her outcome, beyond that of being stable when she left Providence hospital, is unknown.