Helpless....

I've been looking at the pictures of the devastated towns and thinking of where I would put my command post. I've closely examined the faces and bodies of the injured in the photos and video and found myself thinking of treatment procedures. I've seen the hundreds of bodies floating in the water amid debris and am thinking of cleanup methods.

I've responded to disasters, I've treated the sick, I've distributed food and supplies and I've recovered bloated bodies of the dead from the water. I CAN help. I've done it before. I, and many of my brothers and sisters in the Coast Guard can help. We're really good at it. History has shown that to be true.

If my commanding officer called me right now, "Maddog, be ready to hop at 0800, we're heading East." I'd be turned out and ready to deploy by 0730.

We have the a collection of the best military organizations in the world. We are all volunteers and do this because we feel it's right. Why are we not on the ground in Indonesia, India, Sri Lanka?

Why do Coast Guardsmen get injured and die in Iraq protecting oil platforms when there is the biggest humanitarian need right around the corner? That's what we do, Dammit! Coasties save lives! Set us loose to do our job!!

We are a fat, rich country. We have a force of men and women who are smart, flexible, competent and compassionate. I can think of no shipmate of mine, past or present, who would not drop everything and run to aid if the Commandant just said so.

We're helpless. We don't have to be.

Dammit! Dammit! Dammit!

--maddog

Hindsight, Foresight and why I suck at school...

I'm looking back upon my last academic semester and I am not pleased. I felt that the entire semester was a struggle to keep up. I finished with 4 B's and and A. I passed, yes. Where I feel I did poorly is that I did not finish with the level of understanding I should have had.

Cardiology, for example: I'm still don't have a clear grasp of how the drugs we administer for cardiac emergencies work. That is to say, I don't understand them enough to be able to figure out which one goes for which arrhythmia. I only know them from rote memorization and some great memorization tricks. I ended the semester feeling lucky that I passed rather than feeling that I passed because I learned what I was supposed to.

In a field where knowledge and understanding affect other's lives, I'm shaken to realize that I may care for patients based on rote memorization. Is that fair to the people I treat?

I have felt that I've spent the entire semester trying to keep up with what I have to know to pass the tests and not spending any time learning the material. Miserable, I know. College is supposed to be a time where I'm full of excitement and wonder at all the cool things I'm learning. I've experienced that in the previous semesters. I know how to enjoy the wonder of learning and still have the discipline to get my assignments turned in on time. I'm an adult. That's what I do.

I know, I know. I've had some "acceptable" distractions: Non-stop school since last January, soon-to-be-adopted twins, dead soon-to-be-adopted twins, my uncle dies, my beloved mother-in-law dies and I moved twice.

It's enough to make Socrates stop asking questions! I know!

It is not an excuse. I HATE excuses.

All this self-recrimination aside, what I really need to look at is my attitude towards learning. In the 13 years between the first and second semesters of my Freshman year, I attended a lot of classes. These were classes that were given on a work related basis. Military training, law enforcement academy, technical schools, and much more. They were all driven by learning a bunch of specific, ordered objectives and were easy to map out. I had a clear list of what I was expected to regurgitate or know and I performed within those parameters in order to pass the course. Not a whole lot of actual thinking was required

Often times, the real learning did not occur until I went out to apply those skills in "the world." Working with another officer, another engineer, another crewman (or woman) gave me the necessary experience to apply what I had learned and give me the opportunity to screw up without causing too much harm.

I'm sure there are those of you out there who have met 'Medics who don't think too much and do everything by rote. That is, most emphatically, not my goal. I can be a basic EMT and do everything that way but I want to be a Paramedic. The more I learn about this profession, the more I learn that I must be thinking, diagnosing and analyzing, all the time. I must take nothing for granted and always be ready to change.

Therein lies the fear from my last semester. I fear I haven't learned enough. I've passed the tests but, standing next to my classmates, I feel profoundly stupid.

Well, I'm a "can-do" kind of person. I would not be me if I wasn't thinking of how to fix this problem. Here's my approach: I will take advantage of the next 4 weeks of break to enjoy the "learning" part that I missed last semester. I'll throw myself into the world of cardiology, pharmacology and more with the enthusiasm of a true maven. In the next (Spring) semester, I resolve to enjoy and learn. I will not bog myself down with the worries of trying to meet specific criteria. They'll come easily if I know the material. I'll know the material if I'm enthusiastic about it and, finally, I'll be enthusiastic about it if I take the time to enjoy it.

Lao Tzu talks a lot about the "Art of Non-doing." Now, I'm no ancient sage but it sounds good to me. I'll just do my best to emulate my "Study Monkey":




I love that smile!!

--maddog

Santa Was Good To Me!

Right after finals, I was hurled into the holidays and have been catching up on all the parties and shopping I had been neglecting in order to study.

Fortunately Santa was very kind to me:




My mother says I was born in the year of the monkey and when she saw this, she shrieked aloud.

I love it.

I'll be posting a ton this week, I promise. I have much to tell and more questions to answer from my querilous reader from Japan.

Thanks for your patience and Happy Holidays.

--maddog

Finals, Haiku, Rockin' Irish music and Guinness...

I'm in the throes of final exams for the semester right now. They end on Monday.

So far I've only killed 3 patients during my practical exams...

A haiku for you:

Finals Loom
Tension-twisted guts
Must Not Fail!

I did take a break last night to go see these guys:

http://www.gaelicstorm.com/

The last time I saw them I was brought on stage to race a few chaps to the bottom of a couple pints of stout.

I won.

--maddog

"Personal Injury after an assault, Police on scene."

I love calls that are dispatched like that. They NEVER are boring.

Romeo and I hop in the bus. Before we've gone 100 yards, we're talking about what we need on the call. Romeo has decided to leave behind his idyllic lifestyle as a twenty-something heartbreaker and become a medic in the Army Rangers. He's got an appointment with "Pre-Ranger indoctrination" and he's excited about both being a medic and being a Ranger.

"O2 bag, Aide Bag (our usual "all around" kit) and the suction unit." says I.

"Suction?" asks Romeo.

"You ever been popped in the mouth?" I ask him.

"Oh yeah!" He says. We understand each other.

What this means to me is that he takes EMS as seriously as I do. We arrive at the restaurant/watering hole to see the usual scene of 2-3 police cars and a crowd of bystanders. I'm ready for a belligerent, bloody drunk who's going to alternately complain of life-threatening injuries and swear he'll kill anyone who comes near him.

A person approaches me as I step down from the ambulance. The cops don't even look my way. ...Odd!

"Hey." Says the approacher

"Who's hurt?" I ask. (Simple questions work best sometimes.)

"Me."

"You called the ambulance?"

"Yeah, I'm hurt."

Mind you, all of this dialogue is delivered clearly and without slurring by a person who has walked up to me with no apparent difficulty. I look around. Nobody else cares that there's an ambulance in front of the bar/restaurant. I guess this is it.

My patient is about 20-30 years old, black and of an indeterminate gender. Complains of head pain 8 on a scale of 1 to 10 after a police officer shoved him/her into a brick wall during a scuffle. A quick examination with my flashlight shows no swelling, bleeding or deformity on the site of pain.

"Let's go into my ambulance where the light's better."

"Ok."

In my ambulance, I discover she's female, oriented and alert and exhibits no signs of being drunk or even drinking. I conduct a physical examination of her head, palpate her cervical spine (feel her neck bones) and assess her eyes for pupil response along with horizontal and vertical nystagmus (shaky eyes that indicate either inebriation or brain damage). She comes up negative on all tests. Physically she's fine.

"Ok. Listen. I'm not a cop and I don't care what happened or why. All I care about is you. You wanna tell me what happened?"

She gives me a detailed, coherently delivered narrative of some silliness of her sister's boyfriend being drunk, the manager, an unpaid bill and a tussle involving drunks, girlfriends and cops. Apparently in the scuffle, she got shoved back and hit her head on a wall. She denies any dizziness or loss of consciousness and only complains of pain.

I tell her that I'll take her to the hospital if she wants. I also tell her that if she was my kid, I wouldn't be worried. She says she doesn't want to go to a hospital but wanted to be seen. I'm seeing that my role is an emotionally supportive one at this point and I'm OK with not transporting her to the local ED. After assuring her that she can call 911 at any time if her condition worsens and getting a signature from her, Romeo and I roll out.

"Dude! So, was he hurt?"

"SHE was fine, man." says the maddog

"Wow! I was feeling kinda weird. I thought she was pretty good looking for a guy."

"Well, Romeo, you are pretty hot, yourself, you know."

"Shut up, man!"

I'm still laughing.

--maddog

Question From a Reader, Part Four (Continued)

In a previous post, our querulous reader asked, "Have you ever answered a call and found someone had begun first-aid that was helpful (or not)?" I put out the request to my other readers for their stories but have received none. Alas. I suppose an anecdote or two of mine would be appropriate.

I ran a call for a personal injury at a local bar. It seemed that the bass player of the band had stepped on broken class from a stage light and it went right through her sandal and into her foot. From the eyewitness reports there was a copious amount of blood involved and it was quite dramatic.

When I arrived, I found an alert, oriented and somewhat attractive woman sitting in a chair sipping orange juice. Her foot was elevated on another chair and had been dressed perfectly with cloth napkins. there was 2 of them folded perfectly as a trauma pad and 2 more rolled into cravats holding them onto the wounded part of her foot.

It seems that there were 2 trauma nurses and an EMT in the audience along with a bar manager willing to give up some linens. The bandage looked very good, wasn't soaking through and her toes were showing that it was not on too tight. She told me that the nurses and the EMT cleaned out the wound with a pitcher of ice water, dressed it with the napkins and gave her some orange juice because she was feeling woozy.

At this point, considering the quality of the foot dressing, the patient's mental status (good), level of pain (low) and proximity to a hospital (almost next door), there wasn't much for me to do but load her up. We did have a large audience and many of them taxpayers in our jurisdiction. Well, I love to do my job so I methodically checked her vital signs, got a good assessment of her foot further down from the injury to check for pulse, motor ability and sensation then we loaded her up and took her to the hospital.

I think the only thing we really provided above what she got from the bystanders was a stretcher! That's a case of good first aid.

The most frequent cases of inappropriate first aid that I see are when bystanders pull people from badly deformed cars in auto accidents. This presents a real danger of aggravating a life-threatening injury that requires immobilization before moving the patient. Many times, the patients remove themselves from the automobile.

Another frequent case of inappropriate first aid that I see comes, unfortunately, from the firefighter first responders that get to the scene before me. None of them are particularly egregious but they seem to indicate either a lack of skill or care. For example:

-A 35 year old female assault victim being administered oxygen via an infant rebreather mask. I changed that one out for an adult mask from my bag to the surprised and somewhat shamefaced looks from the firefighters.

-A firefighter attempting to move a patient with abdominal evisceration by pulling on his arms over his head. A clear and authoritative, "STOP!" put an end to that attempt.

-A patient having trouble breathing being administered 6 liters per minute of Oxygen via a Nasal Cannula and the nasal ports are not even pointing into the patient's nose. A nasal cannula is a tube with 2 holes in it that sits under the nostrils to supply oxygen. Useless for a patient that's breathing through their mouth and completely useless for a patient that's having trouble breathing.

-A hypothermic patient being treated with blankets and hot packs. What's wrong with that, you ask? They were being placed on TOP of the patient's wet, cold, cotton clothing. ("Hypothermia = Naked, no exceptions!" says I to the firefighters as I'm pulling off the patient's wet socks and shoes)

I don't have any particularly funny stories of inappropriate first aid. Voodoo and Santoria are not common in my area. I can imagine all kinds of stories of strange home remedies and odd poultices but, alas, I have none to tell myself.

How about my readers? Got any to share? Email me or drop it in the comments below.

--maddog

Where has maddog been?

My dog needed a vacation so I took her to the beach.



She's feeling much better.

--maddog

Better Living Through Chemistry.

I arrived at the station to find "Tuffy" is there. Tuffy is a volunteer at the station who also works in a nearby city as a firefighter. He and I get along very well as we have similar ideas about EMS and he's going to paramedic school as well. He goes to school at a different university than I but we both are keen on the subject. We are equally delighted to find we'll be running calls together tonight.

As we leave the Mexican fast food place from picking up dinner the radio calls us to action: "Personal injury after assault, domestic, police on scene."

Yippee! We arrive at the same time the backup police unit does. In the apartment is a mom, 3 kids and nobody hurt. The police are talking to mom when I realize that it's her that was "injured."

"Ma'am, are you hurt?"

"My daughter attacked me and tried to hit me on the arm."

"Did she hit you?"

"No."

"Do you hurt anywhere?"

"No, but I want you to take my daughter to the hospital to be evalliated. She got ADHD, ADD, OCC and ODC."

(I'm NOT making this up!!)

One police officer is with a surly looking 12 year old girl and mom's looking worried. I look at the other officer.

"No patient." He says.

We're gone! As we're leaving, I hear one of the police officers, "If I have to come back here again tonight..."

In the ambulance, Tuffy says, "That kid was on more medications than I've ever seen!"

"Hm, Pharmaceutical parenting?"

"You got that right!"

*sigh*

--maddog

Questions from a reader, Part Four

Good day, all! This next question from our reader is one that just begs to be put out there. We all love to tell war stories and I think this question will invite the best from the EMS providers who read this blog.

"Have you ever answered a call and found someone had begun first-aid that
was helpful (or not)?"

Hoo boy! That's just begging for some war stories from the street, no? Ok, Here's my challenge to my readers. Email me your story or post it in your blog and I'll either post the email content here or link to your blog entry. I think the comments section would be overwhelmed by this but you can leave one there too.

This should be great!

As to me, I'm covering at the Firehouse tonight and Friday night. I'll also be providing bicycle-based EMS for an ultra-marathon this Saturday. If you don't see some good postings from me soon, I've been living a life TOO ordinary.

--maddog

Veteran's day.

To all my brothers and sisters who have served and serve still, I salute you all.

I hope those who decide to send them into harm's way remember the irreplaceable loss of life that comes with each decision to use our military might. Don't spend that currency freely for it is very dear.

Today is a day for veterans and for armistices.

--maddog

Questions From a Reader Part Three.

This one comes via the comments on a previous entry:

"Is the decision to send ALS or BLS always made at the scene, or sometimes according to the information received from the call? Also, seems as if sheer availability might be the factor."

Once again our intrepid reader had provided an excellent question for us!

Decision made by the Government:
The decision on whether to send ALS or BLS are made on several levels. Some jurisdictions have all ALS response so, that decision is made on the governmental level or whoever had decided how their Pre-hospital EMS system is structured. (some areas have quasi-governmental "ambulance trusts")

Other jurisdictions have what is called a "tiered" system where BLS units, ALS units or both are sent to a call based on criteria. These criteria, if you remember from the last entry, are detailed in the medical protocols and set forth by the medical director of that jurisdiction.

Ok, as I keep repeating, each jurisdiction is different. I'll describe my understanding of how my jurisdiction works.

First off, let's get in our heads the concept of the process of an EMS event: First, someone gets sick or injured. They, a bystander or a family member calls 911. This is the first point where someone makes contact with the emergency medical system. This person speaks with an Emergency Medical Dispatcher (EMD), a person who is specially trained in telephone triage or interrogation techniques.

Decision made by the EMD:
Based on the questions they ask and what the patient or reporting person tells them, they make a decision to dispatch a BLS unit, an ALS unit or both. Of course, they have algorithms to help them make these decisions, just as EMT-Bs and paramedics do to help with theirs. Some calls have a requirement to dispatch ALS. Chest pain, trouble breathing and falls of greater than 25 feet are a few examples of calls that would get a Medic unit along with the ambulance.

Now, the Emergency Medical Dispatcher has made a decision as to whether the patient receives the services of ALS or BLS. Let's assume they send only BLS. That means somebody like me goes to this call.

Decision made by the EMT-B:
Now, let's assume the call is "Injured leg after a fall" and once I get there, I discover the 65 year old patient is having chest pain and shortness of breath consistent with heart attack as a result of all the excitement.

What do I do? Yep! You guessed it! I grab the radio:

"Ambulance XXX to Communications, Request ALS our scene or meet en-route"

Here are examples of how the decisions are made to send ALS. Sometimes the dispatcher makes decisions to send BLS only. Sometimes, BLS units will determine that the ALS, or Medic, unit are not needed and the call them off. I've seen other EMT-Bs do this when they get to a call and decide that the patient is not in need of a paramedic.

Me? Here's what I think (and do): If a Medic unit has been dispatched to my scene, I'm not going to call them off until they see the patient and make that decision themselves. I figure, if a patient has chest pain, they're MUCH more qualified to decide it's only muscle pain than I am. I figure, they're already on the road, it makes little or no difference if they turn around on the highway and I'd much rather they come to the scene and look at the patient.

Decision made by the Paramedic:
In a tiered system, the Paramedic has the opportunity to "downgrade" the patient to BLS. They can decide the patient doesn't need ALS care and leave it to clowns like me to transport to the hospital. In a tiered system, there are less ALS units per capital than one that is all ALS. This decision allows the Medic unit to be available for the next call. Of course, in an all-ALS system, everyone rides with a Medic.

Ok! I hope that answers the first part of your question. As to the second part, whether dispatch decisions are made based on availability. Well, I'm not privy to the decisions made by the EMS supervisors in my jurisdiction but I have experienced situations when dispatch tells me that "no medic available" or "ETA (estimated time of arrival) is 30 minutes" on a busy night. I've also heard from friends and associates that work in less populated areas that citizens are lucky to get a BLS unit let alone a paramedic.

Any of you other readers have opinions or stories? Hit the comments link below or send me an email.

I hope this answers your question. Thanks for reading!

--maddog

Dogs and happiness....

I've written before about my dog. Today, I was discussing bad stuff with a friend. She said, "Please call me if you're feeling depressed!"

"No depression can withstand the sight of my dog frolicking in the woods." said I.

"True, True!"

Ah dogs!

--maddog

Questions From a Reader, Part Three

Howdy, all. I'm sorry that I've been gone so long. Here's another great question from our querulous reader. This one in particular, I invite everyone to chime in.

"3. When you describe deciding to administer certain procedures or even
medications, it seems you are able to decide these on your own. Are there
some procedures which require "authorization" from an M.D. over the radio?"

What an excellent question! The answer is "Yes." If you remember back to my previous entry about the different "levels" that EMS providers achieve, there are associated levels of care that each one can provide. In short, all EMS providers in the pre-hospital environment operate under the license of a physician. We are extensions of his legal and medical authority. Each jurisdiction has a medical director who is responsible for all that is done in the pre-hospital setting and, ultimately, is the one responsible for the care provided by EMS personnel. We call this Medical Control.

There are two types of Medical Control. On-line medical control is when the EMS provider is speaking directly to the medical director or, more commonly, an authorized doctor at the hospital that will receive the patient or a specialty hospital depending on the needs of the patient. We do this consultation in order to get permission and guidance in the treatment of our patients. More on that in a bit...

Off-line medical control usually appears in the form of written standing orders or medical protocols. These protocols differ from state to state in the U.S. and even from jurisdiction to jurisdiction. These written instructions are how the medical director gives instruction to us EMS providers without having to talk to us all the time on the radio.

These instructions detail how and what we can do with patients as their conditions present. They also tell what interventions each level of EMS provider can give under our own judgment and what we need to consult with medical direction to do. For example: I can, as an EMT-Basic, administer an epinephrine auto-injector to someone who is in anaphylaxis, or severe allergic reaction. If I am presented with a patient who is having a severe asthma attack, using the Epinephrine injector may help them very much but I am required to consult with medical direction before administering it.

This is all written out in a book that is readily available. The protocols also direct me as to what drugs, their dosages I can administer and goes into what equipment to use with patients and when. The protocols contain a lot of algorithms that are basically patient care flow charts. There is no shame in consulting with one's pocket version of the protocols when treating a patient.

Any procedure that is outside the scope of what I am authorized to do in the protocols requires me to consult with medical direction. As mentioned before, this consultation is usually in the form of me speaking with a doctor at the receiving hospital via radio. This is also done to notify the hospital of what we have and our expected arrival time so they can be ready for us. This helps to provide continuity of patient care and reduce the wait time at the hospital for the patient.

When an EMT does call for consultation, we give the consulting doctor a ton of information but in a well organized format. According to Essentials of Paramedic Care, Bledsoe, et. al., Pearson Education (2003), a good format for the consultation report is SOAPIE: Subjective information, Objective information, Assessment, Plan of treatment, Interventions taken, Effect of interventions.

Subjective information: This is what the patient tells the medic. "My chest hurts. it feels like an 800lb gorilla is sitting on my chest!" That sort of thing. Often what the patient is complaining of is not the actual problem. These are also called symptoms.

Objective information: This is what the paramedic observes about the patient, the vital signs, patient condition, evidence of trauma, etc.. These are also called signs.

Assessment: The paramedic puts the above all together and, by process of ruling out other possible causes of the patient's condition, comes up with a diagnosis.

Plan: Here the paramedic details what he plans on doing to treat the patient all the way to the hospital. If the paramedic is asking to perform a procedure or intervention that requires approval from the consulting doctor, here's where it is detailed.

Interventions: The paramedic tells the consulting doctor what he/she's done already to treat the patient's condition.

Effect: This is a description of how the patient responds to the treatments and interventions given.

All of this information helps to give the consulting doctor a clear picture of the patient's condition so he or she can give a good consultation to the paramedic and so that the receiving hospital can be ready for them. As with any communication system, there are breakdowns and miscommunications. I have heard tons of stories about bad consultation, poor communications and frustrating doctors.

Do any of you more experienced readers out there have any "war stories?" If they're too big for a comment, post it in your blog and I'll link to it.

I hope that answers your question, Dear Reader. I'll continue to answer more!

Thanks for reading

--maddog

Herself and Herself's Mom.

        
Tonight was the memorial service for Herself's mom. Herself asked me to speak. I did. I cried. I promised myself I wouldn't. I did anyway.

Here's what I said:

" My life is a good one and [Herself's Mom] had a lot to do with that. I am lucky to be in her family and I am proud to be her son-in-law.

Her kindness, consideration and obvious affection for her family are key elements of her personality. Her company was always a delight. I have always admired her perseverance, grace and poise.

She has provided me an excellent example of how to live well. She enjoyed the company of friends, the love of family and was always pleased by their presence. I know of no person who did not think highly of her.  All of these things come as no surprise to anyone who knew her.

As I wrote this, I imagined everyone nodding their heads in agreement. There is not enough ways to express how wonderful my mother-in-law is. I will treasure her memory, the example she has set and the lessons she has taught me. "

If you want to share the moment with me, proceed to cry like a baby right now. That's what I did.

...

I had walked to the podium crying.

"I promised myself I would be poised." I said.

"You are!" Said someone in the audience.

...

After the ceremony, we are inundated by well-wishers and I cry again and again to meet people for the first time who were touched by Herself's mom.

Later, we're at home. Multiple families and many generations are gathered as one. We all are hurting.

At one point, Herself is talking on about something to someone. My hand falls on her heel. We're on the couch, side by side. Her heel fits perfectly in the curve of my hand. I mean: Perfect!

At that moment, she's mine. I'm holding her heel. I don't think I've held anyone by their heel.

She knows I'm there. She smiles at me over her shoulder. She knows. She's mine. I'm hers. That's how it's supposed to work.

Good?

Good.

Somehow, together, we'll get through this.

--maddog

I have not abandoned you....

        
I apologize. My house is teeming with visiting relatives, school is sucking my time like a leech and sleep is just a memory.

I have more questions to answer and a few stories to tell. I'll do more soon, I promise!!

--maddog

Election day!

        
Boo!

--maddog

(That's the most political statement you'll get from me!)

Happy Halloween!

Boo!

--maddog

Happy Halloween!

Boo!

--maddog

Questions From a Reader, Part Two

Here's the next set of questions from our intrepid reader:

1. What are the indications of "Medic 1" "Medic 2", etc.? Seem to be a unit
of a vehicle with one or more people of varying qualifications.

Well, that's exactly it. Some jurisdictions have what is called a "tiered" system where some ambulances go out as Basic Life Support (BLS) that can do interventions and care to a certain point and others go out as Advanced Life Support (ALS) which are usually staffed by at least one EMT-Paramedic. The term "Medic" is usually a shortened version of "Paramedic" which indicates an ALS unit.

To get even more confusing, some areas will staff all their ambulances as a BLS unit, staffed with EMT-Bs and have paramedics in a "Chase Car" or a vehicle that is not capable of transporting a patient. Typically, the BLS ambulance will arrive along with the Medic in the chase car. If ALS is needed or indicated (indicated is a fancy medical term for "needed"), then the 'medic will ride in the back of the ambulance with his (or her) specialized equipment to provide advanced care. The MacMedic works this way, I think, and you can find much more information about it from him.

My jurisdiction has BLS ambulances, which are called "Ambulance" on the radio and ALS ambulances, which are called "Medic" units. They're basically the same except for staffing and some equipment. Further discussion of this answers the next question:

2. What kind of vehicles are these, though? At first, I thought they are
what we know as ambulances. But, then you often refer in descriptions to
"ambulance arrived". (See how much is assumed!?) It seems you sometimes
leave the vehicle you came in to ride in "the ambulance" or "the unit".

My "unit" is an ambulance (dispatchers in my area use the local accent which drops the "u" from the word and it frequently is spoken as "Ambuhlance"). In this jurisdiction being and "ambulance" means it is staffed with EMT-Basics, has equipment for Basic Life Support (BLS) only and is capable of transporting a patient (up to 3 in extreme circumstances). We do not have "chase cars" or anything like that. Every medically oriented vehicle that is dispatched, with the exception of EMS (Emergency Medical Services) supervisors are capable of patient transport.

The only other medical "unit" that is dispatched in my jurisdiction is a "Medic" unit. As my ambulance is called by it's number ("Ambulance 123," for example), medic units are the same ("Medic 45"), As mentioned above, a "Medic" unit is staffed by personnel trained and certified to provide ALS and the vehicle is equipped with the gear and drugs to enable them to do their jobs.

The term "Medic" can refer to both the "unit" (a specially equipped ambulance) and the people that staff it (paramedics). So, yes, these "units" are exactly what you know as "ambulances." The differences between a "Medic" unit and an "Ambulance" are not outwardly obvious. In fact, we use the same vehicle make and model for most of them. In my writing, unless I say otherwise, one can safely assume I mean a regular BLS ambulance when I refer to my "unit" or "ambulance" since I'm only licensed to work as an EMT-B in my area. This may change in the future as I become more personally qualified.

Now, know this: as many jurisdictions exist in the United States, there exist variations on these themes. As our federal government has assigned the regulation and operation of medical services to the states and these states to the local level, each state and local jurisdiction has determined how they want business done. The discussion on how each state has evolved their EMS system and what forces have affected their outcome is a discussion too long for this entry. Suffice it to say that one can encounter many different systems, configurations and organizational models for EMS throughout the country.

I hope my explanation hasn't been too confusing. To the reader who is not in the EMS industry my advice is this: allow your understanding and definitions of terms to be flexible but allow that an EMT is generally a short term for EMT-B and a 'medic is a short term for Paramedic. An ambulance is an ambulance is an ambulance. They mostly look the same but the difference between a BLS unit and an ALS "medic" unit has to do with the level of care and interventions each unit can provide.

Ah, maddog, you always take the easy questions, eh?

Hit the comments link or email me with more questions if you need clarification or with clarification if you think I'm way off track. The comments link will allow others to chime in with their 2 cents.

--maddog

Maddog Barks!

We're out on the road in the ambulance when we get called to a fire. Helga is driving and Tinkerbell is in the front seat. I'm precepting Tinkerbell so she gets to ride up front and do everything. I just observe and intervene when she goes awry. She's pretty competent and, during our post-incident critiques, shows that she's thinking more about the patients and medical stuff than most firefighers.

Tinkerbell is a firefighter who's transferred from another station. She's an EMT-B but our station is requiring all Firefighters to become qualified on the ambulance before being allowed to ride the fire engines. Good policy I say.

Helga is a real character. She's an EMT-B and a driver for the ambulance. She's overweight, has bad skin and is terminally socially awkward. She laughs nervously and snorts after every sentence and is extremely uncomfortable with silence. This means that she's always talking. She is very sweet, though and does not have a single malicious bone in her body. She's also infinitely selfless. I don't mind her quirks at all.

We get a call to report to a house fire as a back up BLS (Basic Life Support) unit. Since we're nearby when the call comes, we actually get there first. We pull in the street where the fire is to see a scene of apparent chaos: Fire trucks, hoses, personnel and equipment are scattered all over the area and flames are shooting out of the second story windows. Awesome! Helga pulls the ambulance into a position thats out of the way but enables us to depart quickly if we get a patient. I hop out, put on my gear and my helmet that identifies me as EMS-only. That way, nobody will expect me to grab a hose and they can find me quickly if needed.

As we're heading down towards the scene to report in with our stretcher and gear, a minivan pulls into the street and starts to pass us.

"Sir, you can't go down there." says Helga to the young driver. The minivan is full of teenagers. And it keeps going.

It starts from my belly and leaps from my mouth like a tiger:

"STOP!"

He does. The driver looks like he's been slapped. He's pointing down towards the fire and saying he needs to get to his house. It's obvious that nothing's getting through and obvious that there's a bit of something going on (DUH!)

"TURN AROUND!"

"..but I..."

"TURN THE CAR AROUND!"

"...I need to get..."

"TURN THE CAR AROUND NOW!"

At this point I'm barking at him. This is a verbal technique used by drill instructors and I used it a lot when I was in the service. Just beat them with your voice. Never waver, do not have a conversation. Beat them.

It was imperative that the van turn around. I was not going to endanger the driver, his passengers or any of the firefighters on scene by letting him drive right into the middle of a working fire. My face is a scowl comparable to a samurai war mask and I keep barking at him.

"TURN AROUND NOW! TURN THE CAR AROUND! TURN AROUND NOW!"

He leaves in a hurry.

"Sheesh, Maddog!" Says Tinkerbell.

"Good job!" Says Helga.

I give them my sweetest smile.

--maddog

Questions From a Reader, Part One:

This is from the reader in Japan who has a lot of very good questions. As promised, I'm endeavoring to answer one (or more) a day. Any and all of you readers are welcome to add your two cents via the comments log. I imagine we'll develop a treasure trove of information here.

"You use a lot of terminology about EMT-A, B, etc. Maybe a FAQ or background piece for civilians?

Right! Forgive me for my past entries since I seem to assume my readers know what my abbreviations mean. In the future, I'll try to be clearer or more explanatory when I use an industry-specific term. In the meantime, here's a short list.

EMT: Emergency Medical Technician. There are several levels of EMT and they differ from jurisdiction to jurisdiction. The national curriculum and testing standards for EMT are set by the National Registry of Emergency Medical Technicians (NREMT). They have assigned 3 levels of competency and skills known as EMT-Basic (EMT-B), EMT-Intermediate (EMT-I) and EMT-Paramedic (EMT-P). To be certified as a nationally registered EMT-Paramedic allows on to append their name with "NREMT-P." Pretty fancy, no?

Each level indicates a level of competency and to attain each one requires a certain number of training hours and a certain number of "patient encounters" or actual practice in the field. The differences can be significant. For example, as an EMT-B, I cannot start intravenous lines (IVs), perform advanced airway management (intubation or "sticking a tube down someone's throat") or administer narcotic drugs such as morphine. All of these things can be done by an EMT-P or Paramedic and these interventions may be necessary to save a life.

Most jurisdictions either follow the National registry guidelines or have their own versions that, for the most part, similar. Here is a good resource for people who want to learn more about EMTs.

Wow! That's a lot just to cover "EMT!" I'm heading out to school in about 10 minutes. My next post will continue to expand on this with descriptions of BLS, ALS and will segue to my dear reader's questions about the terms "Medic" and "Ambulance."

Stay tuned....

--maddog

Questions From a Reader (Wow! People read this stuff!!)

I've received an extremely interesting email from an American living in Tokyo who stumbled upon my blog. I apologize for his suffering (for having read my blog, not for living in Tokyo). He has asked me a bunch of questions about EMS, my experiences and for clarification on a few terms and methods. He has agreed to let me answer them here in the blog.

As I am madly pressed for time in my day to day business, I'll endeavor to post a question a day from him, my answer and to invite the rest of my readers to give their feedback via the comments link. Some of his questions are beyond my scope of knowledge or practice so, I'll call upon some of you more experienced readers to contribute your wisdom. Some of the questions have answers that vary from jurisdiction to jurisdiction. Again, I'll call upon you readers spread far and wide to contribute your experiences as well.

As it is 10pm and I have 8 miles to run before my 9am class tomorrow, I shall now retire. I'll post the first question and my answer tomorrow.

Thanks for hanging in there.

--maddog

Maddog on the fritz...

Sorry, all, for being so absent. I've been inundated with schoolwork and have been trying to get caught up. You see, I've been neglecting my schoolwork in favor of devoting my time to Herself and the aftermath of her mother's death. Since I've done no schoolwork or review for the first couple weeks of class, i've been a bit behind the curve and the past two weeks have seen me scrambling to catch up.

Fortunately, i've been successful and am feeling much better about where I am scholastically. I'm dying to write and share with you all.

Don't worry! Good stuff on the way. Thanks for your patience.

--maddog

Google Search Fun

If you enter "shit etiology" into a Google search, my blog comes up on the first page of results!

I feel so special!

--maddog

The Final Chapter:

We're plowing our way through heavy traffic to get to the accident site. Plowing is about right. We have to get right up behind each car with blaring horn, siren and flashing lights before anyone notices us and then gets out of the way. People can be so stupid sometimes.

As we pass one car in particular, the driver pulls the cellphone from her head to holler an obscenity at us and give us the finger with the other hand that's holding a cigarette. No hands for driving and she's in heavy traffic. Yep, I'll see her again. In the back of my ambulance, I'm sure.

*Sigh!*

This particular road is a highway with only 2 lanes in each direction and a huge, impassible median. On the scene, there's a line of crunched cars, a closed lane around them and a line of people sitting on the grassy shoulder holding various parts of the bodies while wincing. I count four. I request another unit, make that two.

I get one. Oh well!

I hop out as we stop and go up to each person on the shoulder. I find out which car they were in and briefly ask them their complaints. All the while I'm assessing mental states, airway and range of movement. The police are already there interviewing everyone and their states of mind and physical conditions are not getting me too worried. Good, I have time to look at cars.

As I mentioned in the previous entry this is "...U-haul truck into Saturn Sedan, into Chrysler Sedan into Acura hatchback..." and none of the cars' passenger areas are displaying any deformity with the exception of the Chrysler. The drivers seat in that one has been knocked off it's track. That's the car with the patient who's complaining of back pain.

By the time I get back to the patients, the other unit has arrived and are with Mr. ChryslerBackPain. I give them a quick report on the state of his car. The driver of the Acura has wandered in to the scene complaining of neck pain and looking stiff. One of the EMTs from the other unit manually immobilizes her C-spine by holding her head & neck in a neutral position.

He and I, with some help from another firefighter, perform a textbook-perfect standing takedown and get her into my ambulance. A standing takedown is where we put a backboard behind a person who's standing and immobilize her to the board in such a way as to protect her spine while we tilt the board back and get the whole assembly on a cot. In school, the test for a good standing takedown is to pickup the boarded patient (another student) by the side and there should be only a minimal amount of shifting on the board. Of course, we did not try this with our patient but as we lowered the board to the horizontal position, I was pleased to see that she did not shift at all.

The driver of the Uhaul truck claims to be uninjured and (this sucks for him) is married to the driver of the Saturn Sedan. Hoo boy!

With Ms. Acura on the cot talking to the police, I do a quick assessment of Ms. Saturn. She's complaining of shoulder pain. She says she put her hand out when her husband rear-ended her car and her shoulder got jammed when her car hit the Chrysler. She denies neck and back pain and her range of motion is good with no pain reported. I decide not to collar her and she goes into the rear-facing captain's chair in the ambulance.

This position allows me to treat and assess both patients in turn as I sit on the side bench and I can still reach all my tools and materials in the ambulance. Being over 2 meters tall (6ft4in) I usually can reach anything in the ambulance from anywhere I sit.

So, Ms. Acura-on-the-backboard is complaining of a headache, 7 on a scale of 1-10, but an appreciable lessening in neck and back pain once we have her immobilized. I get her on 15Lpm of O2 via Non-rebreather Mask (NRB) and turn to Ms. Saturn. She's guarding her shoulder pretty well and complains of pain of a 7 on a scale of 1-10.

Junior pops his head in the side door at this point.

"How you doin'?"

"I'm good but let me get a good assessment and stabilize this shoulder before we roll."

"That's cool, Let me know when you're ready."

I assess the shoulder and find tenderness at the top and side of the shoulder but the clavicle (collarbone) is unremarkable and painless as is the scapula (shoulder blade) ribs and humerus (upper arm bone). I put her arm in a sling, stabilize it with a body-wrapped cravat and apply a cold pack on the painful part of her shoulder.

We roll.

Ms. Acura, as a result of the O2, is now rating her head pain as a 2 on a scale of 1-10 and Ms. Saturn's shoulder pain dropped to a 3 as soon as I slung and stabilized the shoulder. Yay! Both had unremarkable vital signs on scene that remained stable during transport.

We go to a hospital I haven't been to before as an EMT since traffic would make transport to the geographically nearest hospital a 2 hour endeavor. At the new place, everyone is organized, pleasant and professional. Nice! No waiting and the admitting nurse was very interested in my notes on the vehicles' deformities and the patients states during transport. That made me feel much better that I took the time to note it. Often times, on a busy night, our local hospitals don't even seem to care or listen to my prehospital notes. I suppose that's common enough.

When we get back to the station, we discover one of our members has come in with a real "hotrod." He's taken a bright yellow 80cc scooter and done it up with flame decals, a logo from Orange County Chopper. This thing's also equipped with a remote alarm and remote start.

We all take turns starting it up and zipping around the station trying to look like a badass while riding a tiny yellow scooter.

Hoo hoo!

I've got ANOTHER duty night tonight. I'm sure there's more on the way.

--maddog

Liver Lacerations??

This is continued from the previous entry.

We roll past the car on the shoulder and I see a woman in the driver seat (pregnant? Oh shit!) sitting with her legs out the open door, talking to a Firefighter and 3 kids in the back. (Shit, shit, and Shit!). The rear of the car is pretty deformed. It's basically been transformed from a sedan to a quasi-hatchback but the passenger shell (from the "C" pillar forward) looks good.

I grab the aide bag, portable O2 kit and the pediatric bag and head to the car. I see 3 kids who are not crying but are alert and orienting to the Firefighters that are collecting around the car. The woman in the front of the car seems pretty oriented but it's hard to tell as she'd on a cellphone, her husband is trying to reassure her and 2 Firefighters are talking to her. She looks pregnant to me and a quick eye shows me the kids in the back still wearing their seat belts and they're looking back & forth with free head and neck movement. The seating area shows no deformity and the seat back has not shifted. This is the car that got hit by the missing drunks in the pickup.

Time to get the woman out of there.

She's fine enough to walk to the ambulance. No complaint of neck pain, just a pain in her lower back, 3 on a scale of 1 to 10. (I'm still thinking she's pregnant and starting to get worried). She turns out to just be fat. Minor back pain, mostly anxious. This was much easier to determine and to give her a full trauma exam in the back of the ambulance.

All the while, Firefighters are giving me anxious glances. There's no fire and they want to leave. Too bad. Patient first.

Actually Patients first. Next is the 3 kids. One of the Firefighter/EMTs has checked out the kids and found them to be OK but one of them is complaining of abdominal pain.

"Can you point to where the pain is?" I ask her.

"Here." She points to the right side of her belly, just above the line of her navel and below her ribs. Where the seatbelt was resting.

At that precise moment, I recalled an entry by Doc Shazam where she specifically spoke about the insidious nature of liver lacerations in children who had abdominal trauma. I mean, this this jumped into my head almost word for word. Thanks, Doc Shazam! You're the best!

The 9 year old girl has her shoes off so, I carry her to my ambulance and I start checking her out. I don't have a CT scanner on my bus and I'm racking my brain to remember the etiology and symptoms of liver lacerations. All I can do is get a set of vitals (good and strong), determine her mental status (alert, oriented and laughing at my bad jokes), ask about pain (none) and check for tenderness in the entire abdomen (none). I even listened for normal gastric noises and heard some.

At this point, I'm torn. The kid seems fine to me. Do I recommend rolling or do I let 'em go? Am I even vaguely qualified to make that kind of decision? The woman and her husband (they're aunt and uncle from several states away) are already talking about getting back on the road. They are 1 hour away from the kids' house after about 9 hours of driving.

After examining the other two kids, I give both of the adults an honest assessment of what I found and explained to them that they can call 911 at any time after they leave us. I also tell them that i'd be more than glad to take the whole bunch to the hospital.

"But we won't all fit!" Says the little girl.

"I'll call every ambulance in the state if I have to." I say to the father. He can see that I mean it. So does a nearby firefighter and a brief look of panic crosses his eyes.

hee hee

Other than a crying 5 year old boy who's too tired for all this drama, everyone else is fine. I get a mountain of signatures and we roll on to the next bit of fun.

hee hee

The next bit of fun:

U-haul truck into Saturn Sedan, into Chrysler Sedan into Acura hatchback! Bang! + Bang! + Bang! = Maddog juggling patients in heavy traffic!!

(All in one night!!!)

Stay tuned...

--maddog

Motor vehicle accident on suchandsuch interstate at the intersection of somethingoranother parkway.

We had just been stood down to assist police at a nearby restaurant and we were at the exit for suchandsuch interstate. Junior's driving. (I call him Junior because his father volunteers at the station on the same night and was a former chief). Traffic is heavy and we blare and honk our way through.

We get on scene to find a tractor-trailer (articulating lorry for you readers in NZ and the UK) diagonally across 2 lanes blocking traffic. I fear the worst. Once we pass the rig we see a white pickup truck, perpendicular to the lanes of traffic, sitting empty. A few other cars on the shoulder. Great! I LOVE it when my patients are walking around complaining of back and neck pain! We cruise past the pickup and pull over down the way.

As I get out and head towards the pickup, I see that it's pretty deformed in the front. I'm immediately approached by about 4 people who are all babbling at once.

"Who was in the truck?" I ask.

"They split! They're gone. They ran off" say all the bystanders.

Dang! Well, I better look at the truck so I get an idea of what to do if they come back.

It's an early model Ford Ranger Pickup. It's got a half empty case of Corona beer in the back, the other half are empty bottles in the front. The seat and floor are littered with the bottles and a mess of really bad Mexican pop CDs. The kind you hear in the local burrito place when the kids are running the shop. There's also an obviously deformed steering wheel, a broken seatback and two perfect stars on the windshield at head height. I don't see any blood or tissue on the windshield but it looks pretty rough.

About then, a man approaches me and says, "My wife...my wife is down the road in our car. She's in shock, I think."

Uh oh! "Was your car hit?" I ask while looking the guy over.

"Yes." comes the reply, "My wife was driving."

I look about 1/4 mile down the highway and there's a car at the side of the road. I signal to Jr., Put the husband in the back of the ambulance and we roll on down to the next wreck.

Lacerated livers?

Stay tuned...

--maddog

More EMS-related entries on the way, I promise!!!

Here's a preview:

1. White pickup with empty beer bottles, bad Mexican pop CDs and two perfect stars on the windshield...Patients?? Where???

2. Three little kids in the back of a car. Belted. Liver Lacerations?? Uh oh!

3. Truck + Car + Car + Car = maddog transports 2 patient in his ambulance and delivers efficacious care!! w00t!

4. 80cc Scooter with flame decals, alarm system and remote start. or "Manly fun at the firehouse!"

I have my first big cardiology test tomorrow. I'll be reading EKG strips until I'm blind. Today's pharmacology test whomped my butt. I'm still reeling from the blow. I'll write more soon. I swear!!

--maddog

Politics vs. Patriotism.

Yesterday, after I expressed dismay at the lack of leadership in the Democratic party and concern over the behavior of the Republican party, I was accused by a 21 year old student of being unpatriotic.

I made no partisan political comment or statement supporting or endorsing one candidate or party over the other. I have, however, been registered to vote for 15 years, have voted in every state, local and national election since then (absentee ballots when necessary) and have served 13 years in the military.

Somehow, I'm unpatriotic?

Well, F***k me! I never knew!

I guess I'll go turn myself in now.... But before I do:

"To announce that there must be no criticism of the president, or that we are to stand by the president, right or wrong, is not only unpatriotic and servile, but is morally treasonable to the American public."

-Theodore Roosevelt (1918)

Hey! Wasn't he a Republican????

--maddog

More marginalized medics...

This article comes my way via Nancy's Blog. It's covers San Francisco's struggle to figure out where to put their medics. Once again, EMS is being treated as the redheaded stepchild by the fire department.

I have great respect for the fire department and their need in our communities is both dramatic and clear. Unfortunately the need for EMS doesn't seem so clear to everyone. I've ranted about this in a previous entry and I'll be sure to rant about it again.

San Francisco fire department has been unsuccessful in its attempt to absorb all of EMS into itself. For example:

"Under the merger, paramedics said they endured a heavy workload and hostility from their firefighter colleagues at the firehouses where they both worked 24-hour shifts."

Of corse the firefighters would be hostile! These Medics were bad for their health or something!

"Firefighters, among other things, claimed they could not sleep because of the sound of sirens from the responding ambulances housed at stations"

Can't sleep?? CAN'T SLEEP??!!!!!

Oh my!! Boo-f***ing-Hoo! I'm crying for ya!

Well, at least the medics will be fairly compensated right?

WRONG!!!!

"At the entry level will be 200 lower-paid civilian paramedics and emergency medical technicians to staff the city's ambulances. They will be hired at $65,000 or more a year, $20,000 less than fully trained firefighter paramedics. ... The next rung will be firefighters, followed by the highest paid group, the firefighter paramedics created in the merger, who earn a starting wage of $85,000."

To those of you who don't live in SF, $65K can sound like a lot but, just ask Nancy how expensive that city can be, especially since the Dot Com boom. I lived there from 91 to 94 and then went back to visit in 2001. Wow!

Sigh!

Not to dump on the firefighters out there but I'd rather have a well equipped, well funded and well trained paramedic come to my mom's house when she falls down the stairs than a hundred well financed, well equipped, well trained firefighters. Hell! She's not on fire!!!

GRRRRR!!!!!!!!

--maddog

Thank you.

To all my readers who have left comments, email and other murmurings of support and condolence, thank you. It has been very comforting to hear from each of you.

--maddog

Gmail invites.

I've got a few Gmail invitations.

Anybody want one? Let me know via email or use the comments link below.

w00t!

--maddog

"I can't breathe!"

The patient looks like crap. Pale, cold sweat and her lips are blue. She looks about 80 but her worried daughter says she's 55. I look up at my partner. She looks just as worried as the daughter. The patient is in the tripod position and working hard to breathe. She's wincing.

"Does your chest hurt?" I ask.

She nods

"Have you had heart trouble before?"

Her eyes are screwed shut and she's nodding.

"Mom had a heart attack last year!" Says the daughter, her voice rising with anxiety.

"I'll...uh, i'll go get the cot." says my partner and she's gone.

Next I'm in the back of the ambulance with the patient. My partner has closed the doors on us with a finality that gives me a chill. Through the window I see the anxious face of the daughter.

I grab and IV bag and a needle but it's huge. Somehow I can't figure out how to put the two together. Isn't there a tube that goes between?

The patient codes. Falls right out. Dead as a doornail.

Shit!

The ambulance is rocking as we head out the winding streets of the suburban enclave.

Shit!

I grab my Lifepack 12 and a set of electrodes. The wires are a mess and the electrodes won't stick. The patient slides off the cot on a hard curve and I fight to get her back on. Where the hell are the straps???

Shit!

Somehow she's got an IV in her arm. A good one too. Thank god.

I ventilate and do chest compressions for 1 minute and then grab the drug box.

I open it and all the vials are black, red and green. No labels. Nothing. Just rows of bottles filled with red, green and black fluid.

Shit!

I don't even know what I'm supposed to give her! Or how!

We take another corner and the side door flies open. The lifepack bounces down the steps, pulls the leads off the patient and I see it skittering across the pavement of the shoulder before it's gone behind us.

Now it's raining and we're sliding all over the place.

Shit!

Drugs!

Shit!

Do I have an AED in this rig?

SHIT!

My patient has the dead stare. She's looking right at the overhead lights and lolling around the cot with each bump and swerve.

Did we just hit something?

Shit!

Is that hail????

Shit!

She's been pulseless for how long?

Shit!

What the hell am I doing?

SHIT!

I wake up with a start. Herself is quietly breathing beside me. My heart is pounding. Despite the over powered air conditioning in the house, I'm soaked with sweat.

I get up to get a glass of water.

What the hell am I doing? Am I going to make it? There's so much to learn, so much to know. Gear to learn, drugs to memorize, signs and symptoms to learn. The sheer volume of information to absorb is staggering.

Is there any way possible I can do this? Logically, I know I can.

Focus and Discipline.

But late at night, I wonder...

--maddog

WARNING! GEEK ALERT!

Today, my 40Gb iPod arrived.

I took it out of it's lovely box, plugged it into my 12" G4 aluminum Powerbook and they immediately began to love each other.

Ahhhhh!

11.1 days of continuous music will now reside in the palm of my hand.

I also got an iTrip.

My commute just got a LOT better!

--maddog

Pharmacology test tomorrow. Here's a sample question:

"Your patient weighs 148lbs. Start an IV of Lactated Ringers solution. Administer 1500ml over 5 and a half hours through a 10 drop set. Give the patient a 3% drug via IV push. The Physician requests that the patient receives 1.5 mg/kg. Hang a medication Drip. Start the patient at 3 micrograms per kg per minute through a 60 drop set. The medication drip is 800mg in 500ml.
Please provide:
1. Patient weight in kg:
2. How many drops per minute do you run the LR IV? round to the nearest whole drop:
3. How many milliliters of the drug do you push?
4. How many milliliters of drug do you infuse per minute? Give the raw number to the 4th decimal place.
5. How many drops per minute do you run the IV medication? Round to the nearest whole drop."

Fun, eh?

Oh yeah, no calculators, Show all your math, I have about 5 minutes per question. My test will be about 6 to 8 of these questions.

Wheee!!

--maddog

Message to my classmates:

"Team,

I'm sorry that I haven't had time to let you know. I've had a pretty crazy weekend.

At about 1:30 on Saturday morning, the mother of my Very Best Friend, (my wife) passed in her sleep.

She wasn't worked (no tubes, no cracked sternum and no ugly corpse). She had been fighting a cancer that made it tough for her to fight infection. She died quietly and as well as she could. She gave a noble death.

My wife, my best friend in the world, is now an orphan (her father died in 1999).

(((Yeah, What the F***k do I do with that?))) You ask?

Well, she's MINE and I grieve with her. (She's a part of ME, isn't she?)

"What the hell do I do?" you ask?

I'll tell ya: The maddog is on point to support Herself (my wife). It's all about her (and, when she's not looking, I cry for me). The answer: Just keep being my classmates. I value you all as you are and don't stop being who you are.

I'm here to be the best paramedic in the world. I'm sure you all are too. Thank you.

Don't be ashamed if I cry for no reason when I'm talking to you. Don't feel weird when my eyes get glassy and filled with water. Put your arms around me and tell me you're my brother or my sister. That's what I need. We're going to have patients and families of patients who are going to feel this pain. I'm a fellow medic. Practice on me.

I'm gonna miss that lady. She gave me my wife. She made me proud to be in her family. She was a great lady.

Thank you all for having the guts to want to be a medic. Compassion is no small part of what we do. I'm glad to be counted amongst your number."

--maddog

"¡Soy el Doctore! ¡Soy el Doctore!"

The best way to keep a kid happy in the ER is to put gloves, mask, gown and cap on him and tell him he's a doctor.

He then proceeds to "treat" his dad who's there for an allergic reaction. I suppose the distraction is welcome. This is an ER that goes to "Yellow" status with 4 empty beds. Yellow status means that they can only take emergency patients and everyone else has to wait until they have space. Including my patient, the father of "El Doctore" who's eyes are so swollen shut, I have to guide him to a seat.

"I'll make you better, Daddy!" says the son (in Spanish). Hugs ensue.

I get a signature from the charge nurse and prep for the next call. Nothing has prepared me for my next call.

Dammit!

--maddog

Day one:

At 2 am, my phone rings. It's the Oncology charge nurse at the hospital where Herself's mom is.

"I'm so sorry...."

My lieutenant is the best:

"Go home, maddog, there's no patient here who needs you more than your wife. Go, man, go!"

I wake her up. There's no other way to say it:

"I'm sorry, honey. You're mom has passed away."

I have not stopped hugging her.

I call her sister and wake her up. She's crying:

"Mommy's died! Mommy's Died!"

I feel like the angel of death.

Herself and I sleep entwined like pretzels. In the morning, I make a huge breakfast and nudge Herself and HerSister to make decisions. To her credit, Herself's mom had already made arrangements with the Anatomical Gift Foundation. Her remains will be sent to us.

My job is to work the phones. Every 5th call or so, I have to stop and cry. Herself's mom has touched many people in her 78 years. She's touched me too (stop to cry).

Now we're planning parties. So many people wish to honor her and we are the crux of her life. We have a lot of parties to plan. My parents come home early from their weekend getaway. My mom (the one who who forces planes to land): "Of course, I had to come home. We have to be with you." Tonight, we gather as a family should, share funny stories and cry a little.

Herself has gone to bed. The day has been busy with grief, business and condolences. Herself's mom was extremely well known and loved. Everywhere I went today I made people sad with the news.

Herself has a lonely road. I'll do my best to be the friend I hope I can be. I can't make her pain go away but I will try my damndest to make her life as good as I can. Is there anything more important in life?

(stop to cry)

--maddog

"I'm having an allergic reaction! My eyes are burning! I'm allergic to pepper spray!"

I look at the police officer who's handcuffs are on my patient. We share a wry smile. I get vitals and my "Patient" goes to lockup, not the ER.

I'm sure he's allergic to pepper spray. Aren't we all?

--maddog

I'm sorry for not posting. I've been busy.

This morning, my mother-in-law passed on. She's a great lady. I will miss her.

Herself is now an orphan. My heart breaks every minute.

--maddog

maddog AWOL

I haven't been arrested or anything. My mother-in-law has been very ill and my time has been mostly spent at the hospital with Herself and Herself's mom.

School has started with a bang.

I have a ton of blogworthy calls.

I was in a parade.

I'll post when I can.

--maddog

Recent call:

The buzzer rings once. That's the signal for a "rescue" call. That means that I'll be going out on the ambulance. I stand by the printer, waiting for it to spit out the paper that will give me more information than the scrolling LED screen above the TV set in the lounge.

"MVA, Injuries after accident" Ok, does that mean they got out of their car and fell down or did they discover they were hurt AFTER the accident? I don't care. We roll and I'm ready for spurting blood, broken necks and flail chest. That's what I do, right?

Cap'n Jack, one of the "Old time" firefighters happens to be driving my ambulance this evening. I've never ridden with him and he's a quiet sort. I call him Cap'n Jack because, as I discovered later, he loves sailing as much as I do and moved about 40 miles away so he'd have a place to dock his boat by his house. I can appreciate that. The Cap'n is a quiet sort who manages to exude the air of competence without saying a thing. He does everything as if he was born to it.

We arrive on scene to Suchandsuch Interstate to find the patient sitting on the guardrail next to her mildly deformed car. She's got a shoulder that is about 3 inches below the other one and she doesn't want to go to the Emergency Room. Mom, Dad, husband and many others are there and they are trying to tell me to take her there NOW before I can even look at her.

Of course, I get her into the ambulance because it's "Safer." (Really, I want to get us away from the family members who are giving me a headache!)

Of course, all 20 family members want to come in too.

I'm so glad the doors have locks.

While I'm assessing what I think is the obvious patient, Cap'n Jack discovers that her 4 year old son was in the back seat (in a fully restrained child seat) during the accident and begins assessment. A quick glance tells me that I only have to worry about one patient myself. I LIKE working with The Cap'n! He's regularly looking to me for affirmation and confirmation of his diagnoses. He's been fighting fires since I was 8 years old but he looks to me on the medical. Wow!

Nobody's going to die, Mom's got pain, Son's got a small bump on his forehead but fully with it and alert. Dad (who showed up later) looks like a complete Gangsta or rap star on a bad hair day rides in the ambulance with us.

I never cease to be pleased and surprised by how people do not live up to the expectations set by their appearance. Here's a big, scary looking man, the visual archetype of inner city thug, who's entire attention is tenderly focused on his wife and his son. He's bigger than me but he's so gentle with them both. I am an ass for thinking what I thought when I first saw him on scene.

The entire time we're transporting, the son is fixated by the gear and mechanisms at the "Action Station" in the ambulance. That's where we keep most of our tools and materials close at hand. I joke with dad that this kid's going to be an EMT some day and dad says, "That would be cool."

Right on!

-maddog

School

I've started classes. This is the point where all of my classes (except about 2 electives) over the next 2 years are focused on me becoming a paramedic.

in Pharmacology today, my teacher handed me a list of 105 drugs to memorize. I have to know their typical dosages, what they're taken for, their brand and generic names, interactions with other drugs, overdose symptoms and OD treatment.

Woo hoo!!

I think we might see a shift in my blogging style. knowing that there's some Paramedics out there that actually read my drivel, I might be asking you some questions through my blog.

--maddog

Today was a cookout to welcome the new students to my program and to re-connect with old classmates and teachers. What better time to call in my bet!

Ah! Sweet victory!

Here's one of Peaches and I:


Don't he look sweet? (The flowers were Herself's idea!)

This is the sign I wrote up for him to wear:

All the students now agree that it's a bad idea to make a bet with maddog.

Hee hee

--maddog

I've won the bet.

Tuesday is the day for the cookout welcoming the new students into the paramedic program.

This will also be the day when Peaches makes his debut!!!

Tonight, Peaches, Trainwreck, Herself and I are going dress shopping.

Hee heee!

Pictures, I promise.

--maddog

I got to stick a ton of people today, help diagnose a urinary tract infection and generally run around like crazy.

I'm off to the firehouse for a night of duty and then back to the University Heath Center tomorrow morning. It'll be Freshman Move-In day so, we'll be hella-busy.

Woo hoo!

I'll write more as I have time to.

--maddog

Today I heard a doctor tell a patient, "If you don't know what you're doing, don't have sex!"

I love campus medicine!

--maddog

I started my job at the University Health Center today. It's really cool. I had to work a bit to get my head around the idea that not all my patients are emergencies. Hee hee.

As I was getting oriented, I was talking to "Charlie," the CNP who's the head resident medical person there, and I asked him, "Where's your code cart?"

He smiled at me like a tolerant parent. "We don't have a code cart. We have a 'critical care' cart but we don't have codes here."

I can see he's right. This place is tiny and nobody comes here for an emergency, they call 911. I think he's also smiling because he knows where I'm coming from. His partner (We'll call him "Chief" since that's what I call him) is a paramedic, one of my professors and the head of the paramedic clinical program at my school. He's also my advisor.

As far as the workplace. It's the coolest. Everyone here is professional, open minded and competent. I'm going to like it very much.

--maddog

Sick....

I cought some nasty intestinal bug.

I've been laid up all day. Bleah!

Today, my parents got on a plane for Ireland for a 10 day vacation. Hmmm.... I wonder where mom will land a plane this time?

--maddog

Blog every day?

I've been trying to keep my promise of an entry a day. Tonight is more difficult than others. I suppose that writing an entry about not having anything to write about is a cheap way out. This will be my only one, I promise.

On a slightly medical note, I bought scrubs and a lab coat for my new job as a medical assistant at the campus health center. I'm looking forward to having some non-emergency, clinical experience to round out my skills. Everyone there is the coolest.

This evening my mom had me put them on and she was tickled to see her "baby" in scrubs. Mind you her "baby is over 6 feet tall and 230lbs! And I'm the smallest!!

There, I wrote about SOMETHING. Blah. Be sure to visit some of the links I have over there to the right ---->. There's some pretty good reads there.

--maddog

My mom is the coolest!

She's on a flight from Minnesota to Cleveland when the flight attendants come onto the loudspeaker system asking if there is a doctor or nurse on the plane to press their call button.

My mother is a Nurse Practitioner (CNP) who's had a ton of experience from neonatal intensive care to transport nursing (helicopters) and now is in private practice at a pediatrician's office. She and I trade stories all the time and she loves hearing about my calls. She presses her call button. Of course.

The flight attendant takes her up to first class where she sees a man, about 60, who's pale, sweating and complaining of chest pain. His hands are very cold and his capillary refill on his fingers is about 5-7 seconds. She gets him on O2 and takes his BP. He's at 190/110 with a fast, powerful pulse.

"Have you had high blood pressure in the past?" Mom asks him

He nods

"Have you taken medicine for it?"

"Yes but I stopped a couple months ago."

"Does anyone in your family have heart problems?"

"Yes, both my parents." He starts shaking.

Right now the plane is a cruising altitude somewhere over the midwest. My mom turns to the flight attendant.

"Land."

20 minutes later they're on the ground in Detroit. One does not argue with mom.

Awesome!

--maddog

Late post

I'm sticking with my blog a day promise but it seems I got to my posting a bit late tonight.

I went out tonight and ran into a friend that was in a horrible accident on his motorcycle. He got treated by a lot of medics and flown to trauma. I was delighted that he was recovering so well. He was delighted that I'm going to be a medic. He thinks they're the best.

Every day I find reassurances that I'm doing what I'm meant to do.

--maddog

Herself and I are walking in to a supermarket this evening. On the way out the door comes a "youth." He's got his hair in cornrows, he's wearing a baseball cap I've seen on some rap artist's head, baggy jeans, and Timberland boots. He's got the mean set to his mouth and a walk like a gangsta'.

He breaks into song.

"...Leeeeaavin' on a jet plane....Don't know when I'll be back again...."

Peter, Paul and Mary?????

Awesome!

--maddog

I'm Done!

Big sigh of relief!: "Whoooosh!"

I STILL don't know if I or Peaches has won. (Yes, we're THAT close!!!)

I'm ahead of him in the lecture but he's KILLING me in the lab.

Who knows? You ALL will know as soon as I do. I have promised Marc pictures of the victory dinner and I intend to deliver!

I celebrated this evening by spending some time with some friends of Herself. We drank a lot of wine, ate a lot of FABULOUS food and had a wonderful time. At one point, the husband, The Sandalmaker, asked me a lot of questions about my school and what I do. He asked me in a tone that led me to believe that he thought I was doing something pretty cool.

Mind you, I think the Sandalmaker is a pure and true Jedi and I admire him beyond the scope of words.

He thinks that knowledge of science and the ability to NOT puke in the presence of sick people is cool.

I am honored.

Is that humility or just a lack of self-esteem?

"The path that can be told is not the true path."
-Lao Tsu (who TOTALLY would have been a Jedi, given the chance)

--maddog

Wagh! I've been cramming all day and my brain is destroyed.

Tomorrow signals the end of my summer session.

2 final exams and a laboratory practical.

I can't wait.

I'm going to trudge out of this library to my car, drive the 28 miles home, curl up with Herself and sleep.

...mmmmmm....Sleep.....

I'll probably dream of the negative feedback cycle of hormonal influence on gametogenesis.

...mmmmmm...Sleep.....

--maddog

The summer is coming to a close and I'm starting to see some of my classmates come back to campus. I'm in a pretty tight program starting in the fall. I'll be one of 13 people out of a total of 50 or so applicants that start this paramedic clinical/degree program in September. Some are new faces. Some are people I've seen (and liked a lot) for the past year and a half. Peaches is in the program too, and we're two peas in a pod. It'll be neat to see how we do. We're already talking about competition for the fall semester.

Peaches (or me) in a dress update: As of the end of the 1st session, Peaches was ahead of me by 0.1 percent (that's one tenth of a percent). The second session ends on Thursday and we'll score from an average of the two.

For those of you who haven't heard. Peaches and I have been taking Anatomy and Physiology I and II together this summer and we're very competitive. Whoever gets the higher grade at the end of both sessions gets taken to dinner by the loser. To sweeten the deal, the loser has to wear a dress! Wooo Hooo! Peaches is tall and skinny and I think he's look GREAT in a blue floor-length slinky thing with a slit up to his hip. Me? If I lose, I'll wear a tube top and a miniskirt. I'll not shave for a couple days and introduce myself as Peaches's "Hungarian girlfriend." I'll hang all over him like a whore onto a millionare and make sure everyone knows how much he loves me. Even if I lose, I'll win! There will be pictures. I promise.

As to my classmates for the fall. I'm seeing these people again and I'm looking forward to working with them in the next 2 years. The ones I know, I like. Each and every one. I've been introduced to a couple new ones and they strike me as competent, eager and likable. I'm going to have blog names for them as they develop.

The fall semester should give me a lot of blogworthy materials. I'll be taking pharmacology, cardiac patients, respiratory patients, EMS leadership and critically ill patients. All of these classes will be with a group of people whom I find to be as interesting and likable as they are different from each other.

I'll also be working at the University health center as a Medical Assistant. Peaches has worked there for a couple semesters and has told me about it. He says I'll treat a lot of STDs, burn (or freeze) off a lot of warts, and give a lot of flu shots. I'm looking forward to the non-emergent clinical experience. I think it will round out my paramedic training a bit and give me a perspective on medicine when there's not an imminent threat of death. It will also give me a chance to get really good at HIPAA confidentiality since many of my patients will also be classmates. (HIPAA is the Health Insurance Portability and Accountability Act, a US law that basically says you have the right to have access to your medical records, take them with you and your medical information is private. It holds ALL medical workers accountable for maintaining the confidentiality of patient records, conditions and identities.)

Ok, I have 2 finals and a practical exam on Thursday. I need to get some sleep so I can spend all of tomorrow in the lab getting ready. Wish me luck! Thanks for reading.

--maddog

Dang! What the hell do I write?

Herself writes every day. Each morning she gets up, grabs a glass of orange juice and writes 3 pages in her big black journal. I don't read it. It's her thing. The stuff of hers that I have read is fabulous. She's, quite possibly, the best writer I've ever read. She's an editor and has a degree in English and Literature from a fabulous university.

Me? Mornings? They're like this: Out of bed, potty, dog's gotta go out, pour coffee for me, dog's gotta go out, Pour coffee for Herself, dog's gotta go out, Look at dog, She's REALLY gotta go out. Drink a glass of water. "Hey! Does the dog have to go out?" Take the dog out (Let the cat in.). Get the paper. Give the dog her vitamin and her medicine (incontience, she's old) Print my homework. Have another cup of coffee Start the eggs/oatmeal/cream of wheat/cereal/french toast/breakfast burritos or whateverthehell I make for breakfast. Check email. Pack lunches for herself and I. Have another cup of coffee. Have breakfast with Herself. Have another cup of coffee. Spend 2.75 seconds contemplating how awesome Herself is. Head out the door.

As you can see, I write at night.

I'm trying to stick to my "Blog every day!" promise. It's pretty hard when my brain is full of A&P homework, stress about finals and worries about my grade.

What does this have to do with EMS, me becoming a medic or any of that stuff? Nothing.

Bah!

--maddog

God in my ambulance?

Jason has an entry in his blog about God.

Wow, man. That's a heavy topic. In fact, I have made it a habit to NEVER discuss politics, religion or any extremely contentious social issues. It always turns out bad and I've yet to change anyone's mind (or vice-versa).

With that said, here we go:

Jason says,

"Who here prays before they arrive on a scene? It's become second nature to me to say a little prayer on the way to a scene for God to help guide my hands and mind to help my patient, and for Him to be with the patient. I'm sure it helps, and it sure helps give me a better feeling about the events that are about to unfold (which probably gives me a better self-confidence, which in turn allows me to perform my duties better)."

First of all, I don't publicly adhere to a specific religious affiliation and I make no claims as to the evidence or belief in a supreme being/higher intelligence/divine force. I was raised in a Judeo-christian faith and I'm sure it has colored my approach to divinity. I have also extensively studied, practiced and read many Eastern beliefs and doctrines and draw upon them as well.

My relationship with the supernatural/divine/higher power/spiritual force is an extremely personal one. How that fits into my work with life and death and my influence on it can be summed up as this. If there is one, the Man(Woman?) upstairs is in charge of the afterlife. Everything up to that point is my problem. I don't mess around in the afterlife, She (He?) doesn't mess around down here in the dirt. It's that simple.

From the Tao Te Ching By Lao Tzu (about 2,500 years ago): "Heaven and Earth are impartial; they treat all creation as straw dogs."

I'm here to do something. That's to be a Medic. I know I'm going to die. I know I won't be famous or immortalized in my artistic works. I don't have the pride to think I'm going to contribute something bigger than myself. I'm just a foot soldier. I will work to do my best to save every life I can and alleviate as much suffering as I can. I'll fight each battle with the tenacity as if it were my last and with the energy as if it were my first. I'm alone. Nobody's guiding me but me.

The Hokkagare (the "manual" of the Bushido, or Samurai, code) says, "The Samurai embraces death. He breathes each breath as if it were his last and welcomes death into his heart. By doing so he is free of fear." (badly paraphrased, I'm sure)

Each moment is the last. Each patient is the only patient I have. Each call is the most important call ever. I fight each "battle" without focusing on losing, I only focus on winning.

Now, please know this: This entire entry is my own personal approach to the divine in EMS. I, in no way, mean to make a judgment on how anyone else does it. It's important that everyone find their path and I'm not prideful enough to think I have the answers. I can understand where Jason's coming from and I'm pleased he has a path. I merely intend to share a bit of my own.

The "GOD" question? My answer: I don't know. All I know is my patient before me, my tools, my talent and the battle is on.

From the Tao Te Ching again: "Love the whole world as if it were yourself; then you can truly care for all things."

--maddog

Television?

I don't own a TV. Sometimes I get left out of a conversation because I didn't see the finale of "Friends" (in fact, I've never seen an episode of the show). Then again, I'd rather talk about topics more interesting than TV shows. Herself and I inherited a non-functioning television in our old house that only worked with the VCR which was fine. I love movies. We sold that one with the VCR for $30 at our yard sale.

Now, if I were going to put a television in my home, it would have to be beautiful, even when it's off. These are the most beautiful TV's I've ever seen. They work with a VCR or DVD player too!

Hmmm......

--maddog

Blog every day!

I've heard from a couple readers who are griping about my posting schedule. Thank you. I'm still delighted that I'm being read. (I reached 3K hits today! w00t!) I've decided to post an entry every day.

Now, those of you who've read my drivel for a while know that I don't like writing drivel. I strive to post only that which is a good read or, at least vaguely interesting. Here's the challenge: Since I'm going to post every day I've got to find the interesting anecdote, event or thought to post. I suppose some days will be considerably shorter than other but we'll see. I'll do my best to keep my posts related to EMS and Paramedic school. I'll try not to wander too far into "the weeds."

I can't claim inconvenience since I use a really cool program to write my blog on my Powerbook laptop and it posts directly to Blogger. I can't claim lack of connectivity since I have wireless access at home and school and Macjournal enables me to write them when I want and post them when I can.

There you have it. Jason, Psychwolf, Clarke and the rest of my adored readers will at least have some new material on a regular basis. Thank you for your comments. All of you, please feel free to email me or leave a comment with the link below.

Thanks

--maddog

Getting lost seemed to be the theme last night.

4 o'clock this morning the buzzer goes off. MVA (Motor Vehicle Accident) on the southbound side of Suchandsuch Highway just after Somethingorother Interstate. We roll out just after the engine and the radio is all a-chatter with the 5 units responding to our wreck and another just around the corner.

Our engine drives right by the site.

Our ambulance (with me in it) drives right by.

So does a rescue squad and a batallion chief.

We don't see a thing!

Finally somebody notices that the "wreck" is a car in a ditch in the median that's been there for 2 days. The only difference is that it's night time and raining.

Yippee!!!

--maddog

I rode a fire truck for the first time last night. Both Engines were heading out the door to a fire in the next area over and there was no driver for the ambulance left behind. Somebody told me to grab my gear and get on board so, I did.

We got lost

Never made it to the fire.

Turns out there wasn't a fire anyway.

HA!

--maddog

I'm scheduled for Firehouse duty on Friday the 13th.

Sounds like fun! Stay tuned...

--maddog

If you're rich, does that make you stupid?

I commute over 50 miles (round trip) on a major interstate every day to get to school. I keep seeing people in very expensive cars, driving fast and doing stupid things. This week I've seen:

-a man in a 2004 Jaguar S type (about $40,000) reading a magazine at 70mph
-a man in a 2003 Ford Taurus SE ($25,000) typing on a laptop in the passenger seat while changing lanes at 75mph
-a man in a 2002 Ford Expedition (about the size of a house and just as expensive) with a newspaper fully open on the steering wheel driving at 75mph.
-a woman in a 2003 Lexus SUV ($40,000+) eating a bowl of soup (with Both hands!!!!) while tailgating me at 80mph.
-a man in a customized 2000 Ford Econoline van (Price: unknown but it's a big van!) typing text messages on his cellphone while swerving between lanes and cutting people off (Did I mention he frequently used his other hand to "gesticulate" to other cars that were honking at him?).

Did these people have to sell their brains to afford their vehicles?

I work in EMS. These are the people that keep us in business. Unfortunately.

--maddog