Paramedic In Paradise

I am lucky enough to have traveled a bit in my life. I have been to and lived in some pretty amazing places. My current home, in Hawaii is one of those places. But no matter how amazing a place, or an experience is, its always taken down a notch or two when you involve work into the equation.

Lets take my “2nd” job as a scuba diving instructor for example. Getting paid to scuba dive! sounds pretty amazing right??? But when you add the “getting paid” part to that, it now becomes work, because as we all know, work is trading your time for money. So now, something that I LOVE to do, has become a chore I have to do, because I agreed to trade my time for money. I have done far less scuba diving while living in Hawaii than I ever imagined I would… Why, because I don’t want to spend my whole life working… and I already have a full time job as a Paramedic that occupies 40+ hours of my week, and that is all of the time I am willing to trade away for money. So that brings up the question, well, why don’t you just go scuba diving for fun, and not for work. Seems easy enough at first… But remember that I live in Hawaii, and everything is expensive, especially the tourist stuff like scuba diving. So now instead of getting paid to do something I love, I would have to pay for it, and that would mean trading more of my time for more money to spend on diving. Its a vicious circle… But this entry is supposed to be about being a Paramedic in Paradise, so lets get to that…

Working as a Paramedic in Hawaii is kind of the same thing. at least is it for me. What I mean is that because we decided to LIVE in Hawaii, that means I have to WORK in Hawaii. I know someone is reading this and saying, O, you poor thing… you have to live and work in Hawaii while I’m sitting here in BFE dreaming of living your life. Well, if I were just here on Vacation, of course I wouldn’t be working, and I could spend all time time living the dream! but as Ive mentioned over and over, the dream is expensive. So, its off to work I go.

Forgive me on this part if your not a “medical minded person”… it might get a little technical…

Hawaii is a unique place to live and work as a Paramedic. As far as medical technology goes, it seems as if were about 15 years behind the rest of the country. We are also isolated on a tiny island in the middle of the ocean. Do we have Doctors and Hospitals, of course we do, and we have brand new ambulances, and decent equipment. But what we don’t have is advanced or updated prehospital protocols, availability of resources, and a modern EMS system. We have ONE trauma center for the entire 8 Island chain that makes up Hawaii. Fortunately for me, its on MY island… But I spend a good chuck of my shifts picking up patients from the airport, from life flights from neighbor islands to transport them to the trauma center… This also goes for Pediatric patients, complicated L&D, surgical cases,  and just about anything else that can’t be handled at a “community hospital.” Then that leaves the 911 calls and other IFT calls that happen on my island, but don’t happen “In Town.” (Where the big hospitals are)

I had a call a while back that was supposed to be a pretty routine IFT (Inter-facility Transfer) of a patient from Hospital A (A small, limited resource hospital) to Hospital B (more advanced hospital) for a guy with impending cardiac tamponade (Compression of the heart caused by fluid collecting in the sac surrounding the heart.) When I arrived on scene, I took at look at my patient and had a chat with the Doctor and Nurse about his current condition, history, expected complications… The regular stuff… and I noticed that he just didn’t look good to me. I had that gut feeling something was bad on this call. I quietly pulled the Doctor aside, and explained that I was at least 30 minutes away from where he wanted me to take him, and I asked point blank, “does this guy have 30 minutes left”. The doctor honestly answered “Im not sure”. Not exactly the reassurance I was hoping to get, but hey, at least he was honest.

With a little closer exam of my patient I noticed that his breathing was rapid and shallow, and his heart rate was high and his blood pressure was low. None of this was making me feel warm and fuzzy about this call. I asked the Doctor to do me favor, and intubate (place a breathing tube) before I left, so I wouldn’t be forced to try to do it in the the back of a moving ambulance, by myself,  driving down the road at a high rate of speed. He agreed with my recommendation and started the intubation. This is where it gets really fun. It apparently was not, as we say, “an easy tube” to get. And after having to jump in and do it myself, we finally got that done. One less thing to worry about during transport! Awesome!

Well, then I noticed that the heart rate was dropping from the 130’s to 100’s to 80’s then 60’s….. tried to get a updated blood pressure with no luck… and now our patient is in cardiac arrest. We had already confirmed “our” tube placement and were confident that it was not the cause. I assigned my partner to start chest compressions and I felt for a pulse with each push to assure high quality CPR. At this point, the Doctor is quite literally standing in the corner watching this happen, I told the Doc, I have NO PULSE with compressions. (Indicating that the cardiac tamponade had reached the point where the heart was so compressed by fluid built up around it, that it could no longer function as a pump) – I told the Doc, you need to do a Pericardiocentesis NOW! (a procedure in which a needle and catheter remove fluid from the pericardium, the sac around your heart).  The reason the patient was being transferred to Hospital B, was to have the Pericardiocentesis preformed in a “Cath Lab” by a cardiac surgeon. But that ship sailed and it was now do or die time for our patient. The Doctor told me, “I don’t know how to do that, Im not a cardiologist…”

At this point, I know that emergency Pericardiocentesis is still taught in Hawaii Paramedic Programs… and the equipment was in my ambulance, (Although I have never done one, or seen one outside of a classroom) I sent my partner RUNNING to the ambulance to retrieve “the biggest, longest needle you can find, and the biggest syringe you can find”. My partner must have had wings, because I would swear he was back in under a minute. and by now, the attending Doctor from the ER had come to the bedside as well. I updated her on the situation and asked her if she could preform the procedure. She said “I did it once in medical school”. and I told her that I had just done it on a mannequin last week during an update training… So we decided that together, we could get this done! So, we set up our LONG 14 gauge IV Cath, and got the syringe from the King Tube Set (60CC) and we went to work placing the needle, blind. Once we had a good “flash” we secured the syringe and pulled… Much to both our surprise, we got a return of bloody fluid. We removed approximately 300cc of fluid and I assigned my partner to resume compressions. He jumped right in, and I felt a strong pulse with each of his compressions. We pushed our standard ACLS Protocol drugs, and 2 rounds of CPR later, we have ROSC (Return of spontaneous circulation). Meaning our patient had a heart beat, a blood pressure and was ready to go! Having a secured airway, and a good blood pressure and heart rate, we quickly moved the patient to my ambulance gurney, attached my portable ventilator to manage the breathing, and got ready to go. I grabbed the nearest RN and said, “your coming with me… if this goes sideways again, I’m gonna need some help back there”. So we packaged up our patient, and took off for hospital B. In case you were wondering what happened to the ICU Doctor, he’s still standing in the corner… The rest of the transport was relatively uneventful and we were able to deliver our patient to the cath lab where the awaiting cardiac surgeon was thoroughly impressed with our attempts to save this man.

In this rare situation, I was able to follow up and was pleased to learn that this patient survived his procedures and was recovering in the ICU days later. I don’t know the final outcome of this patient, like all my patients, once I drop them off, thats often the last I hear of them. Its one of the parts of this job that haunts me the most. Not knowing if what I did actually made a difference. Not knowing if my patients ever made it home. In this case, I know we bought him a few more days, past that, I have no idea. I also wonder if that ICU Doctor is still standing in the corner.

Now Im sure this type of thing happens to lots of Paramedics around the country and around the world. But for me, coming from the super structured, infinite resources, advanced hospital systems of Southern California… This was something I thought only happened in movies and TV. But I’ve learned that in Hawaii, on this little island, you make due with whats in front of you. You learn to adapt and overcome. Its not something that I am comfortable with yet, but its just part of being a Paramedic in Paradise.

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