The aftermath......

Well, here it is. A week after everything is done.

Here's how it went down after my last post:

Tuesday, 5/16: Study Study Study Study and study some more. I took 3 pre-tests and passed them all. Went to bed early.

Wednesday, 5/17: The written exam. I finished the 180 question exam in an hour and a half. I walked out of there feeling pretty good about how I did. Considering I passed all my practice exams and reviewed the questions I missed, I felt pretty good. Ok.

Thursday, 5/18: Showed up at school around 9am and practiced my stations for the practical over and over. I had a plan, I had to do each one correctly without failing 3 times. If I failed a station, that didn't count towards my total. I had a checklist and I meant business. I worked my butt off. One thing that was giving me fits was a taping method to secure an IV. I don't have a picture nor could I find one online. I had been taught by everyone I know that a good way to be sure an IV is secure is to put a loop of tape over it and make a "chevron" to keep the catheter from getting pulled out.

Well, with gloves, sticky tape and such, it's a difficult endeavor for the beginner. Since it's been taught to me as the way to secure an IV, I practice and practice and practice. I want to get this right. Eventually, I get the hang of it and get it down. I've seen a lot of nurses and paramedics do this and I want to be sure I get the IV skill station perfect.

I spend a lot of time working up my dynamic cardiology, static cardiology, trauma assessment, spinal immobilization (seated and supine), bleeding and shock control, adult intubation, medication administration, pediatric intubation and intraosseous access. When I leave the lab Thursday afternoon, I'm feeling confident that I can get this thing done. Which is a good thing since my volunteer firehouse has a kickball game that evening and I end up pretty smashed on cheap beer. (UGH)

Friday, 5/19: Almost the day from hell. Woke up with a hangover (Damn you, Miller Light in a can!). Spent most of the day getting ready for a party I'm DJing that night for Herself's company on board a dinner cruise boat. The problem with this is I expected to show up with my laptop, iPod and mixer and just plug in to the existing system. The dinner cruise boat tells us at the last minute that it's against company policy for anyone to use the shipboard equipment except the house DJ.

An amazing friend comes to the rescue with amps, subwoofers, speakers and other electronic madness. We lug it all in a minivan to the dock, load it up and the party's rockin! Maddog has got mad tunes!! Fortunately for me, at 10:30pm, the crew shuts us down. I mean 10:30 on the dot! Pull the plug! Normally, I'd be cranked as I like to keep it going all night. Not tonight, though. I have to get up at 5:30 am to be at the community college for my paramedic practical exam.

I actually manage to get home, get about 5 hours of sleep!

Saturday, 5/20: I woke up on time, had a good breakfast, packed a lunch, reviewed my drug dosages and headed out the door! I got to the testing center early and the atmosphere was jovial. My first station was bleeding and shock control for the basic skill. I go through it, pretty well, I think, and walk out of there feeling good.

I keep telling myself to visualize a positive outcome. I don't dwell on my past performance, I keep focused on the next task. The next task is dynamic and static cardiology. I go through and think I did ok. There were a few points where I wasn't sure but I reviewed my protocols and am sure I go it right. Sort of. There's still a lot of doubt. Technically, I did the right thing but did the evaluator see it? Did I miss something critical?? It's nerve-wracking!!! I see all of my classmates doing the same thing. Ugh!

You see, with national registry testing the evaluators are not allowed to give you any feedback on your performance. The logic is that the testing is an evaluation of one's skills and abilities, not an opportunity for learning. As a result, I walk out of each station with only my own assessment as to whether or not I passed. The results are tabulated and given out when everyone has completed all the stations. It really does take a lot of effort to focus on the next evaluation and not repeatedly review one's past performance.

The day goes on.

Trauma assessment. Perfect!

Pediatric airway: Perfect!

Pediatric IO: Perfect!

Adult Airway: Double perfect!

Oral Station (where one has to talk through a call from the time dispatched to patient delivery at the hospital, including all aspects of scene management and patient care): Perfect X 2!!!!

IV start and medication administraion: Perfect!

I'm feeling pretty good. I'm thinking I've probably failed my dynamic and static cardiology. I'm delighted about my performance everywhere else but I won't know for sure until a National Registry official walks into the room, calls my name and takes me out in the hall to tell me my results.

The waiting? It kills me!

Finally, my name is called. The official tells me that I passed everything except IV.

WHAT!!! IV!!!! Wow! I must have made some dumb mistake! That means I passed EVERYTHING ELSE!!!! Woohooooooo!!!!

I'm delighted! I have this vision of leaving the testing center completely finished. Completely done!!! Wow! I just have to go back in and re-take the IV station (they're letting us take one of our two re-tests on the same day).

Ok! One more to go. No sweat. I review over and over again while I'm waiting for my name to be called. I'm going to nail this one and do it perfect!

My name is called.

I go into the station. I do it exactly as I was taught and perfectly!

I walk out of there feeling like a million bucks. Once again, I have to wait in the holding room for the official to call my name and tell me my results. This time, I'm not too worried. I pretty sure he's going to shake my hand and congratulate me.

He calls my name. I go out to the hall with him.

He's not smiling. He does not shake my hand.

I failed it again!!!!!

I'm outraged!! I cannot believe it!! What the hell! I did the station perfect! It's the most simple one of all!! I've started a bajillion IVs in the field and in the lab. What the hell did I do wrong???

Nope. Can't tell you. Thats now how national registry works. You're here to be evaluated, not trained.

I make noise.

I stomp my feet.

I almost make a scene.

Chief, the director of my program, comes to me to ask me how I'm doing. I tell him I failed when I should not have. He starts with the "well, that's how it goes..." speech but I stop him.

"No! I did everything perfect! I did it fucking perfect!" Yes, I drop the "f" bomb. Chief has never heard me cuss. He knows I mean business.

"I'll see what I can do." He says and hurries off.

The medical director for my program, my teachers and the head of the department are all present this day. Chief gets them to lean on the evaluators under the pretense that I may challenge the evaluator's ruling. A bit later, I'm asked to step out into the hall. I meet with Chief and my medical director, Dr. S.

"You violated the sterile field."

"What?"

"You put a piece of tape around the IV tubing underneath the Tegaderm, or bio-occlusive dressing at the IV site."

"Of course I did! That's how everyone's taught me to do an IV. It's supposed to keep it from coming out. In fact, I practiced my ass off to be sure I could do it right!"

"Well, apparently, that's not the proper way to do an IV." Dr. S. tells me.

I turn to chief.

"Why didn't you teach me that two years ago?"

He just shrugs.

Fuck!

As you can imagine, I'm a bit pissed. I go outside, I call a friend and vent for a bit. Ok, I missed one station, I'll have to test it again (Not until june 13th at the earliest, goddamit!), but the upshot of all this is this:

I passed all the stations I was worried about! In fact, I passed them on my first try!!!

AWESOME!

Ok, so I've got a slight delay in my process to certify for paramedic but, it's in the bag! I head downtown to meet with herself and a bunch of other people who have nothing to do with EMS.

Sunday, 5/21 to Wednesday 5/24: Played video games. Read crappy spy novels and murder mysteries. Stayed up all night goofing off. Went running and did a spot of beer-drinking.

Thursday, 5/25: I graduated from college!!!

Friday 5/26: I checked the National Registry website. Under "written exam" it says "Passed."

One more IV start and I'll be a paramedic instead of a pair-of-hands.

Yay!

--maddog

Home stretch....

Oral exam and review with my medical director today...

Written exam for NREMT-P on Wednesday...

Practical Exam for NREMT-P on Saturday.

I'll post when I can.

(waving hands in the air and running around) AAAHHHHHH!!!!!!!

--maddog

...and that's a BAD day!

If I'm doing this to you:




You're probably having a really bad day!

Speaking of bad days, one of my patients was shot in her own home. She deteriorated pretty bad during transport and developed a nasty hemothorax (blood in the chest cavity). I'll try to post more detail later. I'm hella-busy this week (and the next 2 until my registry test!!!! EEEEK!).


--maddog

monday, Monday, MONDAY!!!

In my last entry, I wrote a list of "coming soon!" items. Doc Shazam commented on them as such:

"Just some guesses:
#2 - Normal saline?

#3 - DOA?

#5 - Hyperkalemia?

#6 - Did they survive???"

Well, Doc, and the rest of you reading, here you go:

"#2: Dehydrated Patient Miraculously Restored With a Miracle Drug!"

The call was dispatched as "sick person." This kind of call induces a lot of eye rolling at Lucky McGee's station as it usually means some indigent person who doesn't feel well and doesn't have cab fare.

We arrive at a single family home to find a woman in a postal carrier uniform sitting on the couch. She's drowsy and obviously uncomfortable. She said she's been having diarrhea all day. "It's like I'm peeing out of the wrong hole." Add a little vomiting and she's rather volume depleted. I check her skin turgor and am surprised to find it actually works like in the books.

Pinch a bit of your skin on your elbow, knee or other bony part. Generally, if you're not dehydrated it plops back into the shape it was before you pinched it. This is called your skin turgor. Patients who are dehydrated have poor skin turgor, that is their skin stays a bit in the shape it was pinched. It makes a little "tent." Sure enough, this woman had a little tent on her elbow after I pinched it.

We load her onto the cot and then into the ambulance. She's fading in and out of consciousness. She's so dehydrated that I can't get a line. her veins just fall flat when I try to start an IV. Lucky comes over at my request and starts a good one in the arm. Once the IV is started we hang a bag of fluid. Some jurisdictions use Normal Saline which is just water with the same salinity as blood (0.9%) but in this place they use what's called Lactated Ringers solution. It's got a bunch of stuff in it but is basically the same. Most importantly, It's got water!

By the time we arrive at the hospital, I have squeezed about 400 ml of fluid into my patient. She's woken up fully, is feeling much better and looking about 10 years younger.

Water, the miracle drug!

"3. How a nursing home killed my patient and I get the 'blame.'"

We get a call for "trouble breathing" at a nursing home.

As it usually goes in this particular city, the Fire department arrives before us and are already preparing the patient to be transported. I walk in and see an elderly man with a gastric tube (a tube going directly into the stomach through the abdominal wall) hunched over to his left side. He's pale, sweaty and trying desperately to breathe. The nursing home has him on 2 liters per minute (lpm) of oxygen by a nasal cannula. The first thing I do is haul out a non-rebreather mask and hand it to a firefighter.

"Hook him up to about 12lpm, willya?" I ask and it's done. I listen to the patient's lungs. He sounds really "gunky." This means I hear coarse crunchy noises in his lungs when he breathes. It's a sign that he's got some fluid or something in there. He's also using his accessory muscles to breathe and this is causing a lot of retractions. This means that his diaphragm and muscles in his ribs aren't enough and he's using his shoulders, neck muscles and more to try and open his lungs up. Right away, I see this guy is in trouble and we need to PUHA.

Pick Up, Haul Ass.

A nurse or attendant hands Lucky a sheaf of papers that contains the patient's conditions, medications list and some doctors orders. After delivering her payload, she promptly disappears.

*sigh!*

In the ambulance, Lucky and I get a line started and begin to debate whether or not we are allowed to intubate. The patient has what's known as a "Do Not Resuscitate - Arrest" or DNR-A. This means if he goes into cardiac arrest, we're not allowed to re-start his heart. It's not clear if we can intubate or take heroic measures before he goes into arrest. Either way, his oxygen saturation levels climb from 77% in the nursing home to 95% in the ambulance. I've accomplished this by sitting him up higher and straighter and increasing the flow of oxygen.

The ride to the hospital is very short and we deliver the patient to the emergency room and a waiting team. I read the patient's paperwork and find that he's on a gastric tube because he has no gag reflex and there is an order not to lower him any more that 30 degrees from. Dammit! When we had arrived at the nursing home, he was completely slumped over on his left side.

When we returned to the hospital later, the doctor who treated him came over to talk to me. He said that the resuscitation team did intubate him and suctioned about 500 ml of the "food" that's pumped into his stomach from his left lung. It appears that while he had been slumped on his side, the pudding-like nutrient stuff flowed up his esophagus and into his lungs. The patient did not recover from the insult to his system and later died. If someone would have checked on him and then simply sat him up, it might not have happened.

All day long, Lucky tells everyone how great I am, "He's already killed one today!"

*sigh!*

"5. Missed dialysis becomes nausea and vomiting becomes abdominal pain becomes premature ventricular contractions."

The call went out as stomach pains. In the nursing home we find the patient in a daybed clutching his stomach and in a lot of pain. He's sweaty and warm too. It's a riot in there. There are 2 nurses, a cop and about 3 other residents of the nursing home. Each one hollers a different fact at me.

Okeydoke. Load 'im up! He's got a shunt in his arm where he hooks up his dialysis machine. It appears he missed his last dialysis session and has been suffering diarrhea, vomiting and stomach cramps all day.

Neither Lucky or I can get an IV on this guy. His veins, what are left, are horribly scarred. Between the dialysis and history of IV drug use, he's a mess. Oxygen and monitor. The 3 lead shows some S-T elevation but it looks old. I set up for a 12-lead and get a good analysis when we stop at the hospital.

In the ER, I hand the 12-lead to the nurse. Peaked T-waves and PVCs popping out all over the place.

"Missed dialysis?" She asks me.

"Yep!" says I.

Your kidneys are responsible for regulating the amount of potassium in your blood. If you need dialysis, it's because your kidneys aren't doing a very good job at all. Miss a dialysis session and the potassium levels in your blood get too high. This messes with the operation of your heart's ability to work right.

Good call, Doc Shazam!

"6. Pulmonary Embolism (blood clot in the lungs) + thrombolytics + stopped heart = the ENTIRE ER staff is exhausted!"

While Lucky McGee and I were dropping off another patient in the ER, our driver came over to me.

"Hey, man go to the resuscitation room, you'll find that interesting."

Ok! I like interesting things. In the resuscitation there's a doctor doing chest compressions while a nurse ventilates an elderly woman. The woman has a cast on her right leg. Everyone else is kind of standing around watching.

In a "code" situation, everyone is usually doing something. It looks like chaos but often is very orderly. in this case I'm puzzled that nobody's doing anything. After a minute or two, a nurse relieves the doctor doing chest compressions. I'm watching the heart monitor while compressions are being done and there's a good, regular waveform. Nice job!

"What's going on?" I ask another doctor standing next to me.

Turns out this woman was riding in a car with her son driving. He was driving her from New England to Florida. She couldn't drive because she had broken her leg a week or so before. Half way to Florida, she just slumped over and stopped breathing. The son drove directly to the emergency room of this hospital.

The doctor thinks it was a pulmonary embolism. Her heart was in asystole (flatline) so they decided to try to break up the clot. They pumped her full of Alteplase, a clot-busting drug, and were moving it around her bloodstream (and her lungs) by doing CPR.

"The problem is," says the doctor to me, "Alteplase takes anywhere from 10 to 30 minutes to take effect. We've committed ourselves to this course of action for now."

I see other ER staff lining up to take their turn doing chest compressions. They start to eye me and my student badge. Uh Oh! I'm outta there! I've done enough CPR to last me a while.

We left before I heard the ultimate outcome of the patient but it wasn't looking good. She had apparently been "down" (not breathing) for a good 5-10 minutes before the son even got to the hospital.

DANG! That's a long post! Thanks to Doc Shazam for the comment and feedback. I'm riding with Lucky McGee again tomorrow. My certification tests and finals are coming up in the next 3 weeks. I'll try to post as much as I can.

--maddog

The trailer: "Coming soon!!"

Crazy day with Lucky McGee. We left on our first call at 0600 and didn't return to the station until 1545.

The highlights:

1. Everybody poops. Some more than others!
2. Dehydrated patient miraculously restored with a miracle drug!
3. How a nursing home killed my patient but I got the "blame"
4. "Seeya later, handsome!" from a 79 year old lady.
5. Missed dialysis becomes nausea and vomiting becomes abdominal pain becomes premature ventricular contractions.
6. Pulmonary Embolism (blood clot in the lungs) + thrombolytics + stopped heart = the ENTIRE ER staff is exhausted!
7. Cranky Firefighters and justice served.

I'm off to bed. I'll fill in details tomorrow.

Good night!

--maddog

Volunteer Firehouse, overnight shift.

A rainy night at the volunteer Firehouse. We had a full crew, that is, enough to staff both the ambulance and the engine. Which was fortunate later in the night as we had thunderstorms and drunk drivers galore.

I had arrived early and picked up a call nearby for a 21 year old with trouble breathing and a headache. The calls sheet also listed him as an asthmatic. Out here in the Eastern US, the pollen count has been ridiculously high so, I wasn't surprised.

We arrive at the apartment and a young woman leads us back to a bedroom. I stop her while I'm still in the doorway, hand on the handle. My crew-mates are behind me. The fresh-faced new kid doesn't understand what I'm doing but my driver knows how I work and pulls him back out of the doorway.

"Do you have any pets in the apartment?" I ask the young woman.

"No."

"Is there anyone else in the apartment?" I ask.

"Just me and him." She replies, indicating our patient aaaalllll the way in the very back of the apartment.

After a look around, I enter. I indicate for her to lead the way and I close the doors to the other rooms in the hallway as I go. I hate surprises.

In the back bedroom I find a young man lying on the bed. I ask him what's going on and he tells me he's got a really bad headache. He gives me a lot of detail and speaks in complete sentences without needing to pause for breath. My initial impression is very good. He's giving no signs of being short of breath.

I have him sit up and take off his outer shirt. He does all this with no difficulty. I listen to his lungs and hear some wheezing in the lower part of his right lung. I ask him if he has his inhaler.

"Yeah, I just got it yesterday."

"Have you used it before?" I ask him.

"I used it for the first time this morning at around 9am."

"When did your headache start?"

"About 9:15."

One shot of the inhaler and his wheezes clear up and I've got him breathing 100% oxygen from our bottle via a non-rebreather mask. He's not complaining of any shortness of breath and his vitals all look good. He had been diagnoses with asthma the day before and, it seems, hadn't gotten used to the side-effects of his albuterol inhaler.

He doesn't want to go to the hospital. In fact, his roommate had only called because his father, who's on the way from 60 miles away, had insisted. I assure him we can take him if he wants but he says no. I'm sure he's going to have quite a discussion with his dad later on.

The other call before bed was for a nursing home patient. Her doctor had done a blood test that morning and the results indicated that she might be in kidney failure. She's got a medicine and illness list that goes forever. I ask her attending nurse/technician/whatever for some background, i.e. When was the last time she took insulin? Is she normally like this? When was the last time her blood sugar was checked?

He hands me a sheaf of papers and looks at me like I have 4 head and am speaking Aramaic. It always amazes me how much better care nursing home patients get when the ambulance crew arrives. Her blood oxygen level was about 82% when we arrived and she was getting 2 liters per minute of O2 via a nasal cannula (a little pronged tube that shoots oxygen into your nose).

Well, she's breathing through her mouth so the O2 is not going anywhere. We put a non-rebreather mask on her, crank up the flow rate to 15 liters per minute and her O2 saturation goes right up to 100% and she becomes almost instantly responsive and almost alert.

Basic patient care! WOW!

Off to the hospital where I write up a very thorough patient report.

The remainder of the calls that night all happened between 2 and 6 am. They were all traffic-related (car accidents) phoned in by people who were speeding by the accident at 70mph and not stopping. As a result, half of them were not there when we got there and the other half were either non-injury, broken down cars and one person who just pulled over to sleep off all the "cerveza" he drank at the strip club. (He got a ride with the police).

Nothing too exciting, I'm afraid. I'm riding the day shift with Lucky McGee tomorrow as a paramedic student. I'll be riding in a city that is one of the top 5 heroin cities in the US. I'm sure I'll have something interesting, exciting or, at least, funny for you after that.

Whee!

--maddog

Is it appropriate to wear black on Easter Sunday?

Today has got to be one of the most painful days of my life. I awoke to the sound of my best friend dying. I carried her downstairs as she vomited and her bladder let go.

My wife and I raced her to the emergency animal clinic. There was nothing to be done.

An overdose of phenobarbital slid her silently away as we held her head and cried.

I miss you, pooch.




She was my pup for 12 years. I took her on vacations. She was the best.

I'm gonna go cry some more now.

--maddog

The difference between pre-hospital medicine and physical therapy...

"All patients lie, you know." Says the physical therapist friend to me.

"Yah. I know." says, I, thinking of the drunk/addict/prisoner who's "faking it."

"What do you do if the unconscious patient doesn't respond?" he asks.

"Well," Says I, "You put a stick down their throat or a tube in their nose; If they object, they're faking it."

(Oropharyngeal or naso-pharyngeal airway.) This is the best way to ensure someone can breathe, regardless of their mental state.

"Shit, man. You have a cool job!" He says.

The therapist is now intrigued by being a (volunteer) EMT.

--maddog

"...You say it's your birthday!" Dah Nee no Nee nee ner..;."Well, Happy day to you!" Dah Nee no nee nee ner....

I turned 35 today!

I received a ton of well wishes.

Herself got me a book. It's Karambolage by Arnold Odermatt.

From the Review:

"With thoroughness and a meticulous attention to detail, Arnold Odermatt photographed automobile accidents on the streets of the Swiss canton of Nidwalden between 1939 and 1993. For 40 years, the Swiss police office recorded the wrecked cars left in the wake of excessive speed, drunk driving, right-of-way errors, and plain foolishness, in poignant, sometimes funny, and always strange atmospheric photographs."

Let me tell you: It's a great book! What fun to look at photos of auto accidents from so long ago and done in such a style! They seem to be artistically arranged!

An example:



And another:



I love it!

Each picture tells a story for those of us who know how to read a deformed car. There is also a history lesson. There are no airbags, crumple zones or side-impact guard bars. Twisted metal and physics rule the day in these pictures. I'm particularly enamored by the prevalence of VW beetles in this book. They were, mostly, ubiquitous in Switzerland during that time and persist in being my personal fantasy car.

As it was my birthday, my family invaded my home. Wine, food, nieces (3 and 4 1/2 years old), and silly stories helped make this the happiest birthday I've had in an entire year!

I'm so lucky!

--maddog

Do you need a seatbelt if you have an airbag (or six)?

At my volunteer house, we get called out for a multi-vehicle accident. Apparently, a brand new (2006) German Import crossed 4 lanes of traffic and hit head-on into the cement barrier in the median.

By virtue of traffic, our arrival vector and the ambulances that got there first, my ambulance was assigned to a barely injured belted driver of one of the cars that was struck by the German Import as it crossed 4 lanes of the interstate.

The passenger of the German Import was uninjured. Both front airbags, Both side airbags and both curtain airbags deployed on the German Import. The passenger wore her seatbelt.

I was about 30 yards away from the German Import. From there, I could see the outwardly bulging impression in the windshield. I could also see the ring on the driver's forehead as the other crew loaded her onto the backboard and began CPR. The ring was clearly visible because it was depressed about an inch into her skull. In fact her eyes, tongue and face were protruding from the pressure of the impact.

She was driving a brand new $25,000 car with all of the latest safety features but she died because she didn't use the most basic one: a seatbelt.

MY patient, on the other hand, was driving a 10 year old, inexpensive, Japanese sedan and was only shaken up. Seatbelt.

Buckle up, kids!

--maddog

"Are you flirting with me?" or "The ladies man! Chapter Two!!"

Lucky McGee and I get a call for a "sick" woman. In the city where I'm doing my clinical rotations, a Medic unit (an ambulance with at least one Paramedic on board) is sent to every call requesting an ambulance.

She's 73, she's got a fever and, clearly, the flu or a cold. Ok, we'll take her to the hospital.

On the way, I'm keeping up my usual chatter. I'm taking her vital signs while Lucky McGee is doing paperwork.

While I'm checking her blood pressure, she asks me, "You got any kids?"

"No, Ma'am."

"When you do, I bet they'll be good lookin' like you, hon!"

"You think I'm good lookin'? Ok, when we get to the hospital, you need to get your (glasses) prescription checked too, eh?"

"Aw, cutitout! You're a handsome boy!"

I put on a serious look. "Ma'am, are you flirting with me?"

She pats my knee. "Yes. Yes, I am." *wink*

--maddog

The stink of death.

There is a smell on people who are recently dead (or dying). Perhaps it's all in my head but I smell it. I ran a code today (did a lot of stuff on someone who's heart had stopped to reverse that) and I got the "stink" on me.

I'm riding as a student with one of my preceptors who I'll call "Lucky McGee." I'm calling him that because, 12 years ago, he fell 50 feet to his death while fighting a fire and was resuscitated. He's a GREAT preceptor.

We're wrapping up from another heroin overdose when a call comes out as "not breathing." Lucky McGee knows I need experience with endotracheal intubation (putting a tube in someone's windpipe to be sure they can breathe) so he "squirrels" the call. It's right down the street. I hear him say:

"Dispatch, we'll take that call."

The patient is 89 years old and is at a nursing home and an EMS supervisor had arrived before us and taken over care. What I didn't know was that Lucky McGee called the supervisor and told her not to intubate the patient. He told her that he had a student who needed a tube and if she thought the patient could wait, hold off until I got there.

As it turned out, the patient had been down (not breathing and/or pulseless) for a while before we were even called. That didn't matter to me or any of the other 8 rescue workers in the room when I arrived. We all worked her as if she was our own mother.

McGee and I slide into the room.

"Maddog, Set up for the tube." He tells me and I do so.

I'm set up and I "go in" with the laryngoscope. This is a device that is, basically, a "spade" to move the tongue out of the way and show me where the vocal cords are. It scoops the mouth open and has a light on the end of it that lets me see where to put the tube.

I see the vocal cords perfectly. I pass the tube perfectly. Apparently, when I was removing the stylet (an insert that makes the tube stiff and easy to push), I dislodged the tube from her trachea and it slid into her esophagus. When checked, it showed as being in her stomach.

I pulled the tube and ordered the patient to be ventilated. There was some fumbling but we got some air into her in short order. We did a really good job of putting air into her lungs without an endotracheal tube. This, combined with the regular, rhythmic shocks to her heart, caused my patient's heart to start beating and for her to try to breathe on her own.

I was undeterred. Despite the positive change in my patient, I knew she needed an airway.

"Stop bagging, I'm going in." I tell the firefighter who's helping.

This time, my patient's been knocked around a bit by all the other people there. Her head has shifted and I can't see her vocal cords or any necessary part of her airway. I'm digging around with my 'scope but I can't find her vocal cords in time.

"How do you know how long to look, Maddog?" You might ask.

Well, this is one of those cases where what you are trained to do actually works in the field. When taking the time to pass an endotracheal tube into the trachea (windpipe) of someone who's NOT breathing, one necessarily deprives the patient of oxygen and breathing. Understandably, one must limit the amount of time that one deprives the patient of oxygen. In hospitals, there is a cornucopia of devices such as Pulse Oximetry, Blood Gas Analyses and other deep and dark magic to determine when someone has been long enough without oxygen. In the field (such as in the crappy room of a patient in a nursing home) we may not have such tools.

So, you ask yourself, how do I know if someone is short on oxygen?

"Physiological empathy!" Says, I!

I hold my breath from the moment we stop ventilations on my patient. When I need to take a breath, so does my patient. It seems cosmically fair to me. I'm going to jam this tube down your throat. The least I can do is starve for oxygen with you. More importantly, I know when my patient needs to get more air.

After digging around for a bit, I need to take a breath.

"Bag her!" I command and give the 'I need your help' eye to my preceptor.

Lucky McGee slips into my spot. He takes a second to re-position the patient's head. He tilts her head back a bit more and then performs a perfect intubation. His true coolness is displayed when he asks me to confirm the tube (listen, with my stethoscope, to her stomach and lungs to make sure we don't have air in one and we do have air in the others). The man is dead on. I'm learning from a master, no doubt.

Once we have an airway, we move the patient to our Medic unit. On the way, she loses her lovely heart rhythm an her pulses. CPR starts and I say, "Pacing?" to Lucky McGee.

He nods and I set the cardiac monitor/pacer/defribrillator to 80 beats per minute. I start the pacing (this is where a regular, rhythmic shock is given to the chest of someone in order to make the heart contract and pump blood the way it's supposed to) low and work my way up. At 45 milliamps, I begin to see electrical waves that tell me her heart is responding to the shocks.

"I've got electrical capture," says I, "check for pulse."

"She's got a pulse!" Says Lucky McGee. Awesome! I'm making her heart beat!

Unfortunately, that quickly goes away. We 'work' her. This means we pump her heart for her, breathe for her, shock her heart and give her drugs that will (hopefully) make her heart go to work on it's own. We don't have the legal authority (nor do we want it) to declare this patient as dead. I've done marathon sessions of CPR before. I get to work and we 'pump and blow' all the way to the hospital.

In the ER, the doctor declares her dead. Nurses take over the necessary parts of the process. As I clean our cot, our monitor and gear, I watch the team perform the legally necessary steps of declaring someone truly dead. They use a sonogram to check for any heart activity, record the EKG of a flat line (asystole) and such.

Okeydoke! Get the medic unit ready and we go back in service for the next call. Like nothing unusual had happened.

But there's the smell.

The smell of death.

I'm sure I'm the only one who notices it. Every dead person I've 'worked' has a smell on them. It's a combination of a lot of elements. There's urine, bad breath, some unidentifiable sour smell, and a bunch more I can't articulate into words. The thing is, it's a sticky smell. An hour later, it's on me. It gets into my clothes. I smell it later. It somehow works its way into my pores. It gets in me.

Is it a condemnation of my inability to 'save' this one? Is it a reminder that sometimes we paramedics are the shepherd of death as well as the giver of life? I don't know. These questions are too philosophical for me. All I know is that I stink.

I turn down the offer of a pint after work from Lucky McGee. Instead, I go home and change into some running clothes. I go out for what should be an easy 4 mile run but turns into a 3 mile march of misery. I'm trying too hard to outrun something. As I sweat, I can smell it. I can smell the death. It's in my pores. It's in me. I try to go faster. My knees hurt. I try to go faster.

Ow.

Ugh.

Crap!

Now, I'm sore, cranky, sweaty and I smell bad. Somehow, I feel I've sweated it out. I go home and get the dog.

The winter sun is setting but I have about 20 minutes of light left. The pooch and I go out and I don't even bother with the leash. She's 13 years old, incontinent and mostly blind but she's still my puppy.

In the open field, she runs for the joy of running. Go, puppy, Go! I run with her. Somewhere in that field, the Stink leaves my pores. A shower at home is all it takes. I'm ready again.

There is no doubt. I'm ready to be a 'medic. I'm ready to be the best medic I can be.

"Try not. Do, or do not! There is no try."
--Master Yoda

--maddog

Didn't I see you on an episode of COPS?

Zach and I are dispatched to the local police department. They had someone in custody who they needed looked at.

"Do you have any medical conditions?"

"Yeah, I have diabetes."

"Do you take anything for it?"

"Yeah, insulin."

"Really? When was the last time you took your insulin?"

"About a month ago."

The cop by the cell door shakes his head. He's an EMT too and he knows that an insulin dependent diabetic can't go more than a day or two without insulin. I give the guy some lemony glucose paste to keep him occupied.

"I can't move my legs!"

I check and he's got pulse, motor and sensation (reflex) in both feet.

"Buddy," Says the cop, "I chased you for six blocks before I had to hit you with the tazer. I can't move MY f***ing legs!"

Zach and I go back to the firehouse. Sometimes we watch COPS reruns. Sometimes we live them!

--maddog

Yes, school has DEFINITELY started!

And that's, pretty much, where I've been for the past month and a half.

I haven't even been keeping up with my regular EMS blog reads. I find I'm missing my regular posting. I write this blog for my own sake, really.

I also write (by hand) in a real paper journal with a real pen. What goes into there are my thoughts on the rest of my life that's not EMS related. Over the past month and a half, my life has been so full with "other" stuff that I haven't had or made the time to post here.

I miss it.

I'm back.

--maddog