P.E.R.L.

"I'm going to shine a light in your eyes now. I need you to look at one spot over my shoulder....."

"Pupils Equal and Reactive to Light." says the nurse with the bloody scalp wound.

She fell from standing on her bed and hit her head on the way down. She denies losing consciousness but I assume nothing.

"Yes." I say apologetically, "You know I have to check you out."

She sighs and smiles. Together, we go through all of the normal neurological tests for someone who may have a possible brain injury. She calls out their official name, what nerve they test and what it means to the examiner while I perform each test. Her neighbors got a really good education in neurology.

She passes every test. She looks me in the eye.

"I'm not riding in your ambulance."

I look at the blood trail down the stairs to the kitchen where we met her. I raise one eyebrow.

"You know scalp wounds are bleeders. Besides, My friend, Cindy, will be taking me to the urgent care center."

I want to talk to "Cindy."

Quick as a flash and without any confusion, She picks up the phone, dials, explains what has happened and then hands me the phone.

"This is Cindy."

Yes, it's Cindy. Yes, she's on her way. Yes, she knows where she's going. Yes, she's a critical care nurse too.

This is a patient refusal that I don't feel too bad about.

Good thing too. All of the hospitals were on Re-route. With a patient who's vitals were within normal ranges, we would have waited for hours, I'm sure.

"I saw you playing drums at open mic night at the Café last time. You're good, man." says a neighbor to me.

I love hometown EMS.

--maddog.

Watch out!!

I've gotten a new watch. It's a Timex and I like it a lot. I've had a digital Timex running watch and it's been my standby timepiece for quite a while. In fact, I've gotten so good at reading pulses and respirations off a digital watch that I don't even notice it anymore.

My new watch? Yes, yes, it has a sweep second hand but my recent watch purchase was really about aesthetics. First of all, I love the look and function of analog watches. Telling time on an analog watch requires the brain to interpret a picture rather than another set of numbers.

Secondly, I really like that Timex has put the Indiglo (TM) feature in all their analog watches. Now I can illuminate the entire face of my watch in a phosphorescent green/blue that I find comforting.

Thirdly, and most importantly, my watch ticks. It's a snappy and sure tick that reminds me of the insistence of time. I can hear it all the way down there (I've got loooong arms) when I'm in a quiet place.

It cost me $25; less than 4 pints of really good draught.

I am pleased.

--maddog

Changes are afoot....

        
One of my classmates from last semester's managment class is a preceptor in XXXXXXXX City. Whaddya know!

The CSC has been somewhat helpful, if busy and dismissive ("Send me an email and I'll get it taken care of!") with my problem.

We shall see.... we shall see...

--maddog

The Death of Compassion?

Rabbit and Rubber Band and I spend the day running calls to people who didn't really need ALS but could have benefitted from it greatly.

The 24 year old male who was retching from food poisoning. Rubber Band didn't want me to put him on the cot because he doesn't like to change the sheets.

The 47 year old male with back spasms, elevated pulse rate and mild chest pain. I asked if I could do a 12 lead and Rubber Band said, "We never do those." I then ask if I can at least do a 3 lead for a rhythm strip. I'm thinking I want to have some kind of look at this guy's heart. He's got a pulse of 94, a blood pressure of 180/98, he's overweight and he's got back pain of 10/10.

"Nope. We'll be at the hospital in 5 minutes."

Which we are and we wait for 10 minutes. I could have had 3-4 sets of serial 12 leads on this guy and seen what kind of response his heart was doing to all this stress but no.

We leave the hospital but don't put ourselves back on serviced for about 30 minutes. Rabbit doesn't like running calls, apparently. Neither does Rubber Band.

Here's the one that really set me off, though.

We get called across town for a 19 year old male with a shoulder injury from playing football. We take a crosstown highway to get there. Apparently, we're not the only unit in the city who's slow to go back in service. This call sends us deep into another Medic's area. On the way, I notice a minivan following very closely behind us. I'm sitting in the back of the ambulance facing out the back so I can see very well. The minivan tailgates us the whole way (about 5-7 minutes of driving) to the reported address and pulls right up to us when we get out.

"What the hell is this lady doing?" says Rabbit

"He's in here! He's in here! We called you a half an hour ago!" says the woman getting out of the minivan.

It seems she chose to follow us for 5 minutes instead of driving 5 minutes to the nearest hospital. Brilliant!

I go to the back of the minivan and am met with a young man who's covered in mud, in obvious pain and presents with one shoulder about 4 inches lower than the other. I help him walk to our ambulance and get a firm shake of the head from Rubber band when I go to put him on the stretcher. I situate him on the bench seat but once we start moving, his shoulder keeps bumping the backrest and he screams each time. I dislocated my shoulder when I was 18 and again at 32. It's no fun.

I finally override Rubber Band's disapproval and move the kid to the cot and strap him in.

Start an IV?

No

Push some Morphine for the pain?

No, we'd have to get medical direction and we're almost to the hospital, according to Rubber Band.

Well "almost to the hospital" is a 5 minute drive at high speed over the worst potholes in the city. Each scream of pain from this kid elicits a more annoyed look from Rubber Band. Rabbit's driving so, I can't see what her reaction is.

At the hospital, we're 4th in line and the kid is screaming and hollering the entire time. Rabbit tells him he needs to be quiet.

We finally get him a room and Rabbit closes the door on his screams and rolls her eyes as she walks away.

I'm ready to kill someone.

Before we leave the hospital, I walk up to the cab, where Rabbit and Rubber Band are sitting.

"Why didn't we push Morphine?" I ask.

"We'd had to call Medical Direction. Besides it's only indicated for fractures of the extremities." Says Rabbit.

"He had an obviously dislocated shoulder." I reply.

"You can't know that without an Xray." Rabbit shoots back.

"Then how do you determine a fracture in the field?" I ask.

"Look, we were almost to the hospital." She says with exasperation in her voice.

Fine. I get into the back and look up our protocols on Morphine Sulfate while we drive back to our station.

"Isolated injuries requiring pain relief " is what I find in the list of indications from our protocols. That means we can administer it without medical direction.

I've got a healthy kid with no contraindications for Morphine, who's also got an isolated injury and pain that's a 10/10. Why didn't we push the morphine?

Is it because I wasn't aggressive enough with my preceptors? Should I have insisted and told them to go to hell? How would that have looked at grading time? My preceptor holds my grade in the palm of her hand.

Is it because Rabbit and Rubber Band didn't want to deal with the hassle and paperwork of dealing with Morphine administration?

Is it because Rabbit and Rubber Band been on this job long enough that they've lost compassion?

Is it because I need a new preceptor?

--maddog

Is the honeymoon over?

Well, this post is about my preceptor and her partner. I have to come up with names for them so, here we go:

My preceptor has many qualities that I just can't seem to put into words. There are times when I wonder why she's decided to be a preceptor. I often feel like I'm a pain in the butt to her. Other times, she can be very accommodating. She always tells me I'm in charge of the call but she'll frequently take control to hurry up a junkie who's not going fast enough. I don't know. Because of her physical characteristics and the fact that I see Bugs Bunny smoking a cigar and wearing a bowler hat every time I look at her, I shall call her "Rabbit."

Her partner is a 42 year old father of 4 who looks, acts and speaks as if he just turned 21. He alternately scares and amazes me. I shall call him Rubber Band.

Rabbit and Rubber Band show up to shift this morning only slightly less hung over than they warned me they would be. I knew they were going to a big dinner function the night before and when, at 0530, they stumbled in, signed themselves to the roster and shuffled off to bed, I smiled and turned to my homework.

We only ran a few calls but they, combined with the calls I ran last shift, served to give me a clear picture on their attitude towards patients, transport and what the think a 'medic should do.

I'm far too exhausted to accurately describe my feelings. There are also some technical aspects and drug questions I'd like to ask my more experienced readers. Stay tuned. I will post again tomorrow.

Coming up....

Apathy, Compassion, Tailgating and Morphine Sulfate!

Will the fun never stop?

--maddog

More to come....I hope.

On my last duty night had no calls. Blah!

School is demanding but not exciting enough to warrant a post. Blah!

Today? I ran 18 miles. Oof!

Tomorrow? Another shift with Medic XX. There's a good post waiting for me, I know it! Whee!

Soon, I'll be doing rotations at an ED in the same area as my Medic unit. I'm SURE I'll get some blogworthy stuff out of that. I found out that next semester (fall 2005) I'll be in the same ED but I'll be shadowing an ED doc instead of cleaning vomit and hoping for a chance to do an IV stick. It made me think of Doc Shazam and her post about Teachable Moments.

More later, I hope.

--maddog

Cadavers

We went to the "Cadaver Lab" the other day. It's a place in the basement of a nearby University/teaching hospital where we had opportunities to practice some of our more invasive and damaging interventions on the cadavers (dead bodies) of some wonderful people.

Wonderful people? Yes. I found out from one of the doctors that many of the cadavers in the lab came from the Anatomical Gift Foundation. I think this is tremendously cool since that's where my mother-in-law made her arrangements when she passed.

Before we go into the lab, I have a qualm: After hearing that the two cadavers we're working with are elderly women who have donated themselves for our study, I fear that I'll see the face of my Mother-in-law. I love her very much and I'm sure I wouldn't be able to take it.

Irrational, I know. She passed in September and here it is, February. It couldn't possibly be. But the possibility leads me to a wonderful realization. Because of my Mother-in-law's generosity, a whole group of 'medics and doctors may have had the opportunity to learn the finer points of life-saving interventions and skills. It's pretty awesome when someone can be so generous after their heart has stopped. I really love her.

We enter the lab and, at first, I'm not fully prepared for the experience. I've seen a few dead people in my day but they were all so badly done in that they were clearly dead. Bloated, floating, full of critters, that kinda stuff. These two women looked sleepy. They had passed a day or two before. I wanted to ask their permission before I did anything. I was not fully prepared to see someone who looked lifelike who I knew was very dead. I was comforted to hear a mumbled, "pardon me" from one of the doctors before he started his demonstration.

Respect.

It was a great experience and I got to do a lot of interventions and see a lot of things I had only read about. Totally worthwhile. I did a couple intubations and some with a bougie (a flexible stylus to help me find the airway by feel), needle and surgical crychothyroidotomy (making a hole in the throat to allow a patient to breathe), Needle chest decompression, intraosseous infusion (putting a needle into someone's bone marrow to get fluid access) and more! All of these things, If done properly, could and will save someone's life.

At the close of the lab, we cleaned up our debris and we all thanked the ladies who made it possible before we zipped them back up. That final bit made it totally complete. They gave their remains to our education and we were grateful to them for their generosity.

What more can I say?

--maddog

"Well!...F**k Me!"

Well, a lot has happened since I got around to making a post. I'm sorry for not posting sooner.

I went out with my preceptor for a day shift. She and her partner are pretty tight. I'm not quite sure what to name them in my blog. They both have very distinct personalities. My preceptor's partner is a 42 year old man with the libido of a 19 year old. Yikes! He's very funny, whip-smart and loves to teach. So far, I haven't seen him do anything I'd frown on other than be a bit too hyper and distracted.

My preceptor herself? Well, I'm not sure how to describe her. She's kind of hard to pin down. She's definitely got mad skills in the ALS department but also seems to have a cavalier attitude about her job. She's young and pretty but could, no doubt, put any firefighter on his ass who crosses her. I've given other characters in my life "blog names" but one doesn't come to me for either her or her partner. For now, I'll just call her my preceptor and her partner will be the "other one," I guess.

We ran about 4 calls. None of them gave me the opportunity to perform any ALS interventions. Worth any mention were the seizure patient who sells his seizure medications to buy heroin and cocaine. He's so used to riding to the hospital, he put himself in the ambulance and the nurses at the hospital called him by name. There was the diabetic cook at the nearby hotel who was munching candy and smiling by the time we arrived. His manager got scared and called it in as a siezure. I checked his vitals and blood sugar and accepted his refusal of transport without a qualm. He thanked us and apologized for the trouble. I assured him he could call us back if needed. He laughed.

I've got 5 more shifts with these characters and 6 at a nearby emergency room (ED, or Emergency Department). More hijinks to come, I'm sure.

At school, there's been drama. One of the central instructors to the program has left suddenly under circumstances that nobody will discuss. We've had different instructors for our classes and I, for one, am pleased. In general, the quality of the lectures have been excellent and the academic demands a bit higher. I like a challenge. The drama lies in the person who is supposed to arrange all of our clinical rotations. Suffice it to say, she manages by crisis only. This means that everything is left to the last minute and I get frantic emails telling me I have to be at such-and-such at 2:00pm tomorrow or I will fail all of my classes, the sky will fall and I'll be excommunicated.

Well!...F**k me!

I'm a meticulous planner and I try to organize my life as much as possible to enable me to do all the bajillion things I have to do. I am now finding myself dealing with emergencies created by someone's lack of proper planning. It's really pissing me off since the people who can't plan how to take a crap are threatening me with academic failure when I don't meet their insane demands.

This person, as I've been told, is very sweet and you can ask her anything. I made the mistake of asking her what to do since I had a clinical rotation (that she knew about a week before) scheduled on the day she scheduled me to go do something else. Here's the response I get,

"This is a career choice, not a game. Only the committed ones will stay to the end & excel."

Well! Again, F***k me! I didn't know I wasn't committed! ....Let's see....I quit my high-paying job....I sold my big, lovely house.....I gave up all my free time.... I've gotten outstanding grades.... Yep! You're right! I'm NOT COMMITTED! Wow! I guess I'll go get a job as a clerk or something! I merely asked some questions (very basic ones about what was expected for my clinical rotations that should have been made clear in the handouts).

"F**k me!"

Oh, did I mention she sent this email that contained other insulting things to a mailing list that's read by the entire department? I suppose I should be used to being publicly insulted from my years in the military. After reading it, I was ready to chop somebody in the throat and taunt them with an ET tube while they died of asphyxiation.

Fortunately, the jedi in me took over and I calmed down.

I have not responded to any of this, nor have I spoken with the Cranky Spastic Cow or, CSC, as she shall be called from here on. I've still not had my questions answered. I will probably have to figure out what I need to do on my own (spend time I don't have) and also work this situation out with the department head (more time I don't have) who I suspect is not going to help because he doesn't like conflict or other silly things that take up his time.

I keep saying it because it feels like everyone's doing it: "F***k Me!"

When is it my turn?

--maddog

School again.

No, I haven't been eaten by a bear. I've started school again and it's pretty intense. I've decided that I'm going to be getting all As this semester and the fulfillment of that goal is consuming huge quantities of my time.

Calls: Not many. In fact, none. I'll start working with my paramedic preceptor in a week or so. Perhaps I'll get more then. We'll certainly see a new cast of characters!

School: The person who was my advisor and instructor for most of my classes last semester has left under hushed circumstances this semester. There has been a lot of last minute scrambling to fill in the teaching spots but, I must say, the quality of the instruction has gone up considerably. I am pleased. Unfortunately, with the increased quality of instruction, the expectation of performance has increased too. We are graded on our class performance, papers, group projects and research and clinical performance. And THEN we take our registry exams for EMT-I and EMT-P

WHEW!

I'll try better to write more. Does anyone have any good "tricks" to memorizing the ACLS drugs, sequences and dosages? I'm in a rut! Hit the comments section or email me.

--maddog

"One and Two and Three and Four and Five and Six and Seven...and Fifteen. Breathe!"

The call goes out as "trouble breathing" and I see on the printout that the patient has a stoma. That's a hole in their neck to breathe through. It's, basically, a permanent tracheotomy.

We hurtle around corners to the house. Run to the door. The wife is walking circles around the kitchen table.

"In there. Oh my god! Oh my God!" Her helplessness is expressed in her flapping arms and manic look.

Through the hall to the den. I see a man, 60-ish, in a chair. His chin is on his chest. I can't see his breathing hole in his neck. Also: He "looks like Sh*t," which, most people in EMS will tell you, means he's in trouble. Sometimes you can tell right away.

I'm at his side. I tilt his head back. Flaccid muscles. I check his pulse. Flat.

"No pulse. Let's go!"

Furniture is flying! We make room to work. (Have you ever THROWN a recliner? Wow!) We slide him from his chair to the floor and start right away.

"Um, Mask?"

He's got a hole in his neck. There's no use in ventilating him with a mask that covers his mouth!

Like Obi-Wan Kenobi's voice to Luke, during the trench run, a voice comes to me, "In the event you encounter a patient with a stoma, Use a pediatric mask over the stoma hole and invert the longitudinal orientation..." (Can you tell I was trained in the military?).

Pediatric mask is attached but we can't get a seal! Crap!

"Tick, tick, tick, tick, tick!" That's already going through my head. How long has he been down? How long has he been without oxygen? Why didn't his wife tilt his fu**ing head back?!

We can't get a seal with the mask and I improvise by putting the bag-valve mask (BVM) connector, directly into his stoma.

We get a little bit of air into his lungs. (I'm listening with a stethoscope), but most of it goes into his stomach. His belly's getting more and more distended and he's becoming a bright shade of purple.

"Crichoid pressure!" Says I!

"What?"

"Push here!" I show where to push on the windpipe to close off the esophagus (on the Crichoid cartilage) and allow the air into the lungs.

A little better but the pressure in his stomach is restricting lung movement.

Dammit! Dammit! Dammit!

We're pumping and blowing (CPR) as best we can as we transfer him to our ambulance. The 'Medics arrive and pile into the back of "the Bus."

Intubation! A tube down the throat and he's suddenly pink again. It's amazing what you can do when you can get an air "pipe" directly to the lungs.

IV! A direct line into a vein to carry drugs to he heart will work wonders when you need to "restart a ticker."

Than we go into Transcutaneous Pacing. This is where an electrical shock is delivered via electrodes attached to the skin (transcutaneous) on a regular basis to coincide with a desirable heart rhythm(pacing).

Meanwhile, we're still bagging the patient (using a breathing bag to push air into his lungs).

"Check for a pulse." says the 'Medic.

"No pulse. Radial or carotid." Says I.

"Ok! Let's see what he does now!" The 'Medic increases the energy output of the pacer.

"Check for pulse." A bit later

"I have a pulse!" says I.

"No Sh*t?" says the 'Medic.

Not only that but his blood pressure has returned to 122/82. Without chest compressions!

"Right on!" says the 'Medic.

We continue ventilations until the patient begins to breathe on his own.

We transfer a patient, to the hospital, who has a spontaneous pulse and is breathing without assistance.

For weeks afterwards, the name "Lazarus" keeps coming into my head.

I did my job as a BLS provider. I fed oxygenated blood to the brain. Did that help the patient? Is he alive because of me? Did I see this patient for what he was and act in enough time to save his life?

I don't know. So much of what we did seemed to be ineffective. The more dramatic results did not manifest until the paramedics arrived. But still. Did I, somehow, make that possible?

Since then, I have found myself checking everyone's pulse who's close to me. On the subway, I'm watching everyone breathe. Those are the important things. ABC's, Airway, Breathing and Circulation.

It's reassuring to see it.

Lazarus.


--maddog

Desk as a drum....as inspired by Martin O'Donnell.

Have you ever banged on something with a rhythm and realized that it sounds good? I play a drum. Not drums. Just one.

I was just listening to Peril by Martin O'Donnell from the Halo 2 soundtrack (yeah, I got the mp3). It's full of rhythm and strings and generally sounds great! I suddenly found myself bangin' away on my desk. I have this hollow-core desk from Ikea with great acoustics and it sounded pretty dang good!

Who knew?

--maddog

Maddog rides the fire engine! Unresponsive patients respond!

Well, the ambulance developed a pretty major fuel leak. I found out later that it blew a fuel hose and my chief could tell everywhere we drove that night by the trail of diesel fuel we left all over town. I wince at the thought of the sheen that is heading to the Atlantic Ocean as I write this.

Well, I go to bed with the thought that the ambulance is out of service and I'll sleep all night.

WRONG! HA!

At 4am the bell rings and I'm up, dressed and in the vehicle bay before I realize we have no ambulance in service. I do hear:

"...Medic local: 402 _____ Road, Apartment 103, Unresponsive person, Engine XXX (our engine), Ambulance XXX (the ambulance from my old station), Medic XX (from earlier that night), respond on channel 2."

"There's no ambulance!" Complains I.

"C'mon, Maddog! Get on the engine, It's a medic call! We'll get there first!" says LT.

I'm on the engine!

"Get the suction unit and the AED off the Ambulance!" I shout.

"Right!" says another firefighter and, just like that, It's done.

In the engine, the Cap'n hands me the suction unit and the AED. Woodchuck is in the seat next to me. LT is driving and Jr. is riding officer.

"I'll carry the AED and the suction unit. Cap'n, you follow me with the aide bag and, Woodchuck, come up with the O2 kit. Ok?"

They nod. Once again, I'm in charge. I'm thinking, unresponsive at 4am means bad business. If they're truly unresponsive, they're either really dead or recently dead. AED, O2, Suction, I'm ready for the worst.

The address is right next to where my parents lived when they moved to this town in 1966. I'm not the first out of the engine but I'm the first to the door (runner, me). The door is opened by a worried looking woman in her 20's and I see a man of the same age sitting on the couch.

"Do you have any pets or dogs in this apartment?" I ask.

"No, No pets. Just another roommate." Says the woman with an accent. (German? Russian?)

"Where's the..." I start to ask, thinking the roommate is in a back bedroom, dead or barely breathing. The guy on the couch raises his hand.

"....?...."

I see he has a glucose meter on the coffee table in front of him. Things are starting to make sense. I move in to the apartment and situate myself near the "patient." By this time, the other 3 firefighters show up with the rest of my gear.

"I get like this sometimes when my sugar is low. My girlfriend, She got scared. I'm sorry you all came out." says the man on the couch. He knows exactly what's going on. His speech is clear and well-delivered. He too speaks with an accent. Definitely German. He uses articles. I've found that Russians don't often use possessives and articles in their speech.

"Cancel the Medic." I say to LT, who has the radio.

It's done. I take vitals. All normal. I check his lungs, eyes and look for nystagmus or other signs of inebriation which can also indicate a diabetic emergency. All come up negative. The guy smells of laundry detergent and spice deodorant. He does NOT smell like he's drunk or having a diabetic emergency.

His blood sugar is 36.

"Have you eaten?" I ask. I feel my eyebrows are in my hairline.

"Yes, I just had some cereal and milk." he says as the woman brings him an apple, oddly, on a plate. The patient takes a look around his living room. He's sitting on his couch in his pyjamas, surrounded by 4 emergency responders and a worried girlfriend (I know who called 911!).

"Ok. Your girlfriend is worried. That's why she called 911. I'm worried because your blood sugar is so low. If you want to go to the hospital, we will have an ambulance take you."

"No, No. I'm fine. This happens all the time. I eat something and my sugar comes back up. I'm fine, I assure you." He converses the way people do in books. A consequence of not being a native English speaker, I'm sure. I satisfy myself that he's of a good mental state and is doing something to address his hypoglycemic state. The apartment is clean and well ordered. The girlfriend is concerned and attentive. No signs of a dangerous or risky lifestyle. I also note the lack of tracks in his arms and the lack of "smell" in the apartment.

"Cancel the ambulance." Again, It's done.

"I need you to sign this form. It says that you do not wish to go to the hospital right now."

"Ok. No problem."

"Now, I want you to understand that this does not mean you cannot call 911 two minutes after we leave. If you need an ambulance or medical attention, you call 911. I'll come here 20 times tonight if I have to. Ok?"

"Yes, Yes. I'm sorry to put you all through so much trouble."

"It's no trouble. I'm only concerned if you are OK. Are you sure you don't need to go to the hospital?"

"Yes, I am sure. Thank you." All of his dialogue is delivered appropriately and clearly.

I get up to leave. I look around to find all my gear has already been gathered up and put away. Deferential looks from the Firefighters. Walking back to the engine, clearly the domain of the firefighters, I'm struck by the strangeness of it all. I'm surrounded by people I greatly value, respect and look up to yet, here they are, looking at me like I'm in charge.

Back at the station: "G'night, Maddog. Thanks"

Thanks? Me? No, No! Thank YOU! Wow!

I write a loooong report and go to bed.

--maddog

ALS-a-go-go!

"... Medic Local. 125 _____ Road, The Step Club, Chest pain, Trouble breathing. Ambulance XXX, Medic XX, Respond on Channel two."

I know exactly where the address is (I've lived here my whole life) and I know the Step Club is a meeting place and hangout for recovering substance abusers. It's right next to the grocery store and in the basement of the barber shop.

I'm assuming it's a heart attack but I'm also ready to be greeted by someone who's fallen off the wagon and making a scene (it's happened before).

We roll and, this time, my LT is driving. He's also in charge of the EMS side of things at my station so, I'm kinda glad he's along. I'll get to "strut my stuff."

We arrive on scene in 2 minutes and find a man being walked out to our ambulance by a friend. He looks like crap but he's walking, alert, oriented and answers my questions appropriately. I ask him if he can climb into my ambulance and he says yes. I'm prepared to help him up but he has no trouble. Good.

In the ambulance we get him situated and get his complaint:

"My heart's racing and I have a funny feeling in my chest."

"Does your chest hurt at all?"

"No, it just feels funny

I give the guy a full check out. The pulse oximeter(PulseOx) is showing he's got a pule of 114 and saturating at 99% on room air (no oxygen supply) and talking. I check his pulse manually and it feels strong but irregular. I look over at the PulseOx and compare what it's rhythm says to what my fingers tell me. The PulseOx clips onto a finger tip and reads the electrical impulses of a heart rate along with how saturated the blood's hemoglobin is. These are great things to know but they don't mean anything by themselves.

I notice that his wrist doesn't always pulse when the PulseOx is saying he should. He's dropping beats, or, his heart's not beating all the time. That would explain a "funny feeling" in his chest!

Otherwise, this guy is unremarkable. He's 49, healthy-looking, sober and has a good mental status. He says it all started when he was on the treadmill earlier that day. The rest of my exam reveals clear lungs, eyes: PERL (Pupils Equally Reactive to Light), skin: warm, pink and dry, no edema at the lower extremities and his carotid and distal pulses match in all 4 extemities. I take a careful listen to his heart in 4 places and it's giving me an unusual "harrumph" at the apical point that's faintly echoed at S2. Hmmmm.....

I look across the cot at LT. "Medic Status?"

He checks via radio and I hear they're about 3 minutes out.

"Medics? What's wrong with me?" asks the patient. He's worried.

"I don't know." I say honestly. "There's definitely something funny going on with your heart. The paramedics have much better equipment for looking at your heart and more advanced interventions if you need them. I'd be a lot more comfortable with them here."

"Oh, man. This is bad. I don't know what's wrong with me. I work out every day...."

He's worried and it's making him more anxious which is making his heart rate go up again.

"Look, you're about to be in an ambulance with 2 EMTs and 2 paramedics. If anything is going to go wrong, this is the best time for it, okay?"

"Okay." He's calming down again. I watch his pulse go from 105 to 88.

The paramedics arrive and climb in. I give my report to the lead medic. I tell him about the guy's pulse and the pulseOx reading on room air, the patient's family history of heart disease (brother and mother had heart attacks) and exercise intolerance(the symptoms appear when he exerts himself. I also tell him of the "Pertinent negatives:" No unusual lung sounds, No briuts in his carotid, no edema in the extremities, skin condition, etc..

The medic leans his head over to look over my right shoulder. I follow his gaze thinking someone got in the cab of the ambulance.

"Hm, I was looking for a paramedic patch on your shoulder but all you're wearing is a Basic patch. You don't sound like a typical EMT-B."

"Oh! Uh..thanks. I'm going to 'medic school" (I'm actually BLUSHING!!!)

"Really? Where?"

"Up at _______."

"Yeah, I've talked with ______ (My advisor) a couple times. I'm thinking of taking the management program there."

We turn our attention back to the patient.

"You remember your 12-Lead placement?" he asks me.

"Sure!"

"Great! there's the kit. Go to it!"

He directs his partner to start an IV line and, as I'm setting up the leads for the EKG, I notice she must be new at this. She doesn't warn the patient that she's going to stick him, she has a hard time finding the vein (She went for one she could see easily and it kept rolling away.) and once she's got the vein, the guy's bleeding all over the place because she forgot to take off the tourniquet.

Fortunately, she's paired up with a pretty squared away medic. He decides that we're taking the patient to a cardiac specialty center that's a longer drive than 3 other local hospitals. He's clearly more concerned about the patient than getting back to his dinner or TV show (There IS hope!). He also decides to ride in the back of my ambulance with me helping while his partner follows us in the medic unit.

On the way he takes a good 12 lead and 3 lead strips. He hands them to me for interpretation prior to saying anything and we discuss how it could or could not be a Type 2 Mobitz II AV heart block. He then asks me what drugs I would give this patient and the only one I can think of that was appropriate would be Aspirin. He's not in obvious need of Nitroglycerine (no chest pain), His pain and blood pressure don't indicate Morphine and I'd already started him on 15 liters per minute of O2.

"The aspirin is in the top of the drug box next to you. Go ahead."

He quizzes me some more. We talk some more. At the hospital, we hand off the patient, re-stock our rigs and he wishes me luck.

All in all, a very enjoyable call.

Up next:

Maddog rides the fire engine! Unresponsive patients respond!

Stay tuned!

--maddog

Am I an angel?

The bell rings. One long bell. My eyes go to the scrolling LED display high on the wall and I see it's an ambulance call. I also see that it's a personal injury after an assault and it's 2 jurisdictions away. It's been a busy night and we've been called into this one because the ambulances in the neighboring areas are all occupied.

I grab the printout to be sure of the address and am deep in the map book for that area by the time Helga hoists herself into the driver's seat. It's a long drive but we don't get lost. Once we get close, the lights of the fire trucks and police cars act as beacons, guiding us in.

As I'm grabbing my bags, I ask the nearest cop what happened.

"She and her boyfriend were arguing and he stabbed her. She ran to a neighbor's house, in there."

"You got the boyfriend in custody?"

"Nope."

Great.

One of these days it's going to be me vs. assailant. I'm not looking forward to that but I'm sure it will end badly for the assailant. (Let's see, I'm 6'4" (2 meters) and 245 lbs (110Kilos), yep, bad day)

In the house I find a crying 35 year old woman from El Salvador sitting in a chair and being attended to by 3 firefighters. She is being administered oxygen by an infant non-rebreather mask(NRB) (about the size of her nose) and has a wad of trauma sponges on her neck. Hoo boy!

To the firefighters: "Hey, fellas. What do we got?" as I pull an adult NRB out of my oxygen mask.

"We didn't have any adults in our aide bag on the engine." says one of them apologetically.

"No worries. What happened?"

"We don't know, we don't speak Spanish."

"Hola, Señorita. Me llamo Maddog. Me voy a ayudarte. Digame que pasó."
"Hello, Miss. My Name is Maddog. I'm going to help you. Tell me what happened"

She cries and, through the tears tells me that her boyfriend is not happy that she's renting a room in a house that is populated by men. He stabbed her with a knife.

"¿Un cuchillo de cocina?"
"A kitchen knife?", I ask.

"Sí, sí. Al primero vez, un grande pero yo lo luchó. Él tiró de mi pelo y me lanzó en el suelo."
"Yes, at first a big one but I fought him. He pulled my hair and threw me on the ground."

I see that chunks of her long, black hair are missing.

"¿Con qué tipo de cuchillo él le apuñaló?"
"What kind of knife did he stab you with?"

"Un pequeño, para las frutas."
"A small one, A fruit knife."

I gingerly pull away the dressing from her neck to find a small incision at the angle of her jaw. right to the bone of her mandible. Two inches further back, and I'd be bagging a corpse. Wow!

She's upset. She's crying. She's scared.

"¡Oye! A mí, hay seguridad. Yo, y las policia, vamos a protectarte. ¿Me intenedes? En mí ambulancia, es un espacio seguro. Es importante que usted va al hospital. Voy a tomarle allí. ¿Bien?"
"Listen! With me, you're safe. I and the police are going to protect you. Understand? My ambulance is a safe place. It's important that you go to the hospital, I'll take you there. OK?"

"¡Sí, sí gracias, gracias, gracias!"
"Yes, yes, thank you, thank you, thank you!"

In the ambulance, I take the time to explain everything that is happening. The neighbors have gotten her a change of clothes to replace her blood-soaked dress. I'm gentle with her. She's scared and fragile.

"¿Porqué eres bueno?¿Es usted un ángel?"
"Why are you so good? Are you an angel?"

Wow!

--maddog