When you graduate from paramedic school, the protocols that were in place for your initial certifying exam will be the ones you remember forever. So much depended on knowing those procedures and the orders in them, the drugs, the dosages, they all stay ingrained in your memory. You might develop dementia 50 years from now and forget addresses and birthdays but you’ll still remember every sedation drug and dosage from your graduation date, at least I will.

But the world of medicine is an ever changing landscape of innovation. New drugs come on the market replacing old ones, philosophies change regarding telemetry contact, and every once in a while considerations are given towards changing methodologies that are problematic. Thankfully the ones involving patients who are actively seizing were included in that. Giving medications though an IV to people who are violently flailing their arms about has always been near impossible but it was the only available way we were able to manage it. We old people like to pat ourselves on the back for dealing with these situations professionally, without all the fancy changes that have made things easier but the truth is, we cursed the protocol committee MD’s that seemed to encourage our high rate of getting stuck with random needles. Another issue was that the main drug of choice is a narcotic and all narcotics required physician pre-approval for administration back when I carried a drug pouch. This was causing delays during life-threatening events, so today they can be given as a standing order and the physician contact, still required, can be handled after the call.

At one point the regional MD’s approved an additional drug option for active seizures, one that could be administered through a needle to the shoulder. It didn’t require physician approval prior to giving it, either. The new drug was called Versed (Midazolam) and it came out with great fanfare. It could be used in other protocols but its much touted usage was for actively seizing individuals that you couldn’t obtain IV access on. When our Advanced Life Support Coordinator came to the stations to stock our narcotic lockers and drug pouches, he went through the new protocol changes with us and notification bulletins were xeroxed and hung up on walls everywhere. For some reason, no one made a notation in the little mini protocol books we all carried. Most of us probably trusted our awful memories that were locked onto the rules at our graduation dates.

Eventually more new changes came out. Other procedures and operational notifications got tacked up to the walls, covering up the old things tacked up on the walls. Given the constant influx of notifications over the fax machine the Versed notice was probably six pages deep when my partner and I were sent to that awful housing project.

It was a newly designed complex built by architects that hated paramedics and the handicapped. Stairs are no friend to either and they were all over the place. First you had to go down a set of steps to get to a courtyard and then after a walking a bit you went up another set of stairs to get to a lobby area. Then you had to go either left or right down an open air pathway and if you were lucky you just went up another set of stairs to get to the first row of apartments. Since we were never lucky, there was another long open pathway, like a balcony, to get to anther set of stairs and up to the second row of apartments. We did this carrying our 80 pounds of bulky equipment. We were worn out before we even rung the doorbell.

The door was opened by a teenager who told us his aunt had a seizure. He then left the apartment, leaving the door open, which we assumed meant he would be back. We went in to find the aunt, a large woman with an elaborate hair-do involving bobby-pinned curls, laying on a couch. She was awake but disoriented, which is common after a seizure. Usually the patient will come around without any intervention. We knew we would need assistance getting her out so we requested help and started evaluating her. We had just taken out the blood pressure cuff when we heard gunfire, very clearly thanks to the open door. The police must have been nearby because it wasn’t long before several of them started running past the opening. Two officers briefly stopped in to ask if we had seen anything but continued down the pathway when we said we hadn’t.

Then our patient started seizing. We automatically tried to get an IV line because that was our usual procedure and habits are sometimes hard to break. We heard more gunfire in a different direction but we were completely distracted by our inability to get a line on a flailing armed woman with poor vasculature. It probably would have been safer to finally close the door but we were pre-occupied. Finally one of us remembered our new wonder drug. We have Versed now! We can just give an injection! Problem solved. We took a vial out of the case.

“Do you remember how much to give?” my partner asked.

“No,” I said, embarrassed. “Do you?”

“No.”

This was great. The answer to our problem was here but we had no idea how much to give, rendering it useless. There had recently been somewhat of a scandal about Versed dosing. Someone in the Bronx had given the intramuscular injection dose through an IV. Other details were hazy of course, as is all information that just comes through, passed down from from person to person. The IV dose was smaller, no doubt. But how much smaller? Did anyone remember the milligram amounts? No, of course not.

Thankfully, we lived an age of technological advancement. We could use our brick-like newfangled “cell phones” to get more information. Sadly, there was no internet access. Texting was still being done through telephone numerical keys with digits appearing on a tiny grey screen. The best we could hope for was to call someone that might know. I had lots of paramedic coworkers listed in my directory. My partner had more. Someone would surely have the answer.

We continued with the IV while phone calls were made. Many calls went unanswered and the ones that did had no answer for us. At least 12 state certified paramedics had been reached and none of them knew for certain or had access to a location where they could shuffle through the bulletins on the wall to look it up. Two milligrams was the most popular guess. Some said 5 mg, others said 1 mg. Only one person emphatically told us it was 10 mg, the correct answer, but he was someone neither I nor the person he was working with, who had been my phone contact, trusted to know the actual dosage, given his unorthodox interpretations of other protocols and procedures. “Are you guys at that fire?” they asked us, during our telephone poll. Why would they ask us if we were at a fire? No, silly we are on a status elepticus, obviously.

Thankfully we were finally able to get an IV and called telemetry to get permission to give the other drug. But we now had to figure out how to get out of there. We had no assistance yet. Our patient was really heavy and had the possibility of seizing again making carrying her down all those stairs incredibly dangerous. We asked for assistance again. Then we heard the fire call come over asking for additional units at the same time that we glanced at our open door and saw large flames and smoke coming from another complex nearby. It was like we were in an apocalyptic vortex of 911.

Everyone was obviously being dispatched to all the other ‘exciting’ things going on nearby. After waiting a considerable time for help that wasn’t coming we decided to try this on our own. She was really beyond the weight limit I felt comfortable carrying but I thought I could probably do it. If it was too much we would stop on the next landing and wait there. As we walked over to the stairs we saw some of the cops dealing with the shooting. Normally helpful, they quickly disappeared, fake talking into their radios. We also ran into some firemen who were checking out the complex for a possible second fire, which was really just a bad address for their real fire, given the similarities between the two complexes. But they too disappeared. We were on our own.

We went down the stairs very slowly, hugging the side of one wall for support. Then we went back for our equipment and walked over to the next set of stairs. When we reached those stairs we saw the teen who had opened the door. “What happened to her?” he asked, as by now most of her bobby pins had become undone and her hair was an unruly mop of curls.

He briefly tried to communicate with his aunt. We asked if he would help us out by carrying some of our stuff. He shrugged as if it were no big deal and enlisted the help of a friend who was standing with him. They picked up the drug bag and the monitor. Then they quickly put them down.

“This shit is mad heavy! I ain’t breaking my back down those stairs.” Despite more gunfire in one direction and an active fire in the other, the two boys took off running. Getting overcome by smoke and possibly getting shot were better alternatives to carrying our heavy equipment. It was a sentiment I fully understood and sympathized with.

It took us about a half hour to get to our vehicle, going through the maze of stairwells, rolling our patient over uneven pavement. And at one point we had to stop and give more medicine when the patient started seizing again. Thankfully, we had made our way down most of the steps when it started. When we got to our ambulance we were surrounded by police cars, but no officers. Down the street fire trucks blocked their way out and they had gone to clear the path. It would be another short wait before we could be on our way. Our patient had chosen a very inconvenient time to start seizing.

As long as I live, I will never forgot the dosage of Versed, unless of course, they change the dosing. Memorizing something by associating them to specific events is one of the most effective ways to retain information. Recalling how much Versed to give and everything else associated with sedation and the status ep protocol brings back very vivid memories of feeling all alone during an urban mountain trek, gunfire, smoke, flames and flying bobby pins.

Update: A recent protocol change has been implemented to take place two months after this story was written. It will have the dose changed completely to 5 mg.