...Junkies make the best teachers for IVs....

"Hello, Sir. My name is Maddog and I'm going to start an IV line and get some blood samples." says I as I come into the room.

I'm on my first shift as an intern at the Emergency Room and the nurses are giving me all the IV line and blood draw orders.

"Yeah, ok. Ain't gonna be no worse than I done to myself." says the patient in Room 5. He's a well dressed, bathed male in his 40's. While I prepare my equipment, he tells me that he kicked his heroin habit 7 years ago and has since gotten involved in his nephew's life. He's become the assistant coach of his nephew's football team, helps him with his homework and spends a lot of time with him.

A few days earlier, he went out and got high. He thought it would be a one-time thing but it turned into a 5 day binge. Chest pains led him to call an ambulance and he has expressed his desire to clean up and "get back on track" once he's in the hosptial.

I've learned to not be judgemental in any way. I hate it when I see that in nurses and 'medics. My job is not to prostelyze, it's to provide the treatment. My patient in room 5 is in a confessional mood and his story pours forth as I get ready. His self-recrimination is occasionally punctuated by assertions that he's gotta get "back on track." We chat and get to know each other. He likes the ideas of new beginnings and my story of quitting my job and going back to school appeals to him. We get along pretty well.

He's got great veins and not all of them are scarred up. Nonetheless, I try and fail twice to start an IV.

"Well, my man." Says I, "I've tried twice and I don't want to hurt you any more than I have to. Time to call in an expert."

"No, man. You're a student. You need to learn. Go ahead as many times as you need. I've done worse to myself so go right ahead.

I try three more times and finally get it. Each time, he's giving me pointers on angle of the needle, how to keep a vein from rolling away and more. All told, we spend about 30 minutes together. At the end I've got a better understanding of veinipuncture and he's got a 20 gauge catheter in his left forearm.

Two hours later, when he gets transferred to another floor, I make sure to stop by and chat with him a bit more and thank him again for the "lesson."

"No. Thank you, man. You've done a lot for me. Good luck." He says.

"Good luck to you, too." Says I, and off he goes.

--maddog

Motivation

I ran a marathon yesterday.

About 10 of the 26.2 miles were head-on into 30mph winds.

Ugh!

The first 24.2 miles, I did fine.

The last 2, I needed some motivation. I rolled up my sleeve and, every time I felt like quitting, I read my motivation.




Thank you, Damage Controlman Third Class Nathan Brukenthal.

--maddog

The goodies are piling up.

I've got a TON of blogworthy goodies. Unfortunately, I probably don't have time to write them all up. I'll take a tip from Tom Reynolds and offer tidbits and let you all vote. You can do so by using the comments link at the bottom of this post or by sending me an email.

Here's the goodies:

-an ED rotation with Icky bedsores and cool nurses!
-a guest volunteer shift in another station with an SUV rollover!
-IV Drug Users teach me how to start IVs!
-Stabbed in the neck! Nervous paramedics! Maddog gets a blister!
-Another rotation in the ED, Maddog Tries to be an IV Jedi!
-Maddog's bedside manner, "You Funny! Go ahead. You can stick me again!"
-75lb (32Kilo) mastiff vs. Maddog. Can you guess who lost?

Ok! let me know which one you want to hear the most. I'll write up the ones that get the most votes first.

Thanks for reading!

--maddog.

My Angel has saved me!

My new preceptor is a wonderful person. She's a runner. She is a bottomless font of compassion. She's sharp. She LOVES working in EMS. She's a goofball.

Clearly, it's a match made in heaven.

I shall call her Angel. I'm sure that's what many of her patients think of her. She calls them all "sweetie," even the junkies.

We run an auto accident. Driver of car A is hit by a taxi that runs a red light. Driver A is pissed because she's been a bus driver for 14 years and has never had an accident on the job. She gets hit by a cab while driving her kids to school.

Low speed impact. All minor injuries.

At the emergency room Driver A glares at Taxi Driver while waiting for the solitary triage nurse to get around to them.

We're outta there!

Another car accident.

Only the passenger has complaints. We do a full spinal immobilization and transport. Nothing much worth mentioning here other than the fact that Angel applauds me for remembering to pad the voids of the backboard to make it more comfortable for our patient.

Wow! Compassion, skill and attention to detail! I'm home.

The next patient is "2 year old. Not breathing."

Shitohshitohshitohshitohshit.......

We arrive to find a little girl in the middle of the floor twitching rhythmically. Mom says she's got an implanted pacer/defribrillator. I see it under her skin. it's almost as big as she is.

I position the kid to open her airway and I see her stomach rising and falling in rhythm. I find a pulse. She's out like a light.

"You carry her. We're going." says Angel.

I scoop up the little girl and take her out to my ambulance.

"Hey, Little one! You there, Little One?" I say.

She seems to be rousing from all the activity. In the ambulance we get her on the cot. I remember from the pediatric seminar I attended (the morning after drinking beer and having dinner with the MacMedic), how to position a toddler to maintain the best airway. She's perfusing at 84% at first. A couple blankets under her shoulders elevate her body enough to allow her head to fall back and her airway to open.

One minute later, on 100% Oxygen, her hemoglobin saturation is up to 98%. Right!

I set up a 12 lead EKG on her. This requires me to place 10 electrodes on her body that I'm trained to do on an adult. Fortunately, the landmarks are the same and I find the 4th intracostal space (the space between the 4th and 5th rib) and the mid-clavicular line (the line straight down from the collar bone) with ease.

I crowd the big adult-style electrodes on her little body and press the button marked "12-lead". I get a readout (Sorry, I didn't get a copy) that tells me she's bradycardic (slow heart rate) with no abnormalities except a cardiac pacer spike (the electrical readout of her pacemaker shocking her heart) and a slight left sided hypertophy (the left side of her heart is a bit bigger than normal from working so hard). She's slow and low.

Meanwhile, Angel tries and fails twice to start an IV in the kid's fat little arms. We discuss an Intra-Osseous (that's where you jam a needle through the bone and into the marrow of the lower leg bone in order to administer fluids and medications) but we decide that our ETA of 3 minutes to the pediatric emergency room rules that out.

We can't get a decent blood pressure on her and I'm watching her oxygen saturation closely while trying to decide if I need to start bagging her (providing breathing assistance with a bag and a mask, effectively forcing more air inter her lungs when she inhales). Her activity level is increasing and she's becoming more responsive to pain and stimulus. These are good signs.

So far, we're thinking she's one of the rare kids with cardiac problems. I get three 12-lead EKG readings on her in sequence to give to the doctor when we arrive.

We arrive.

Into the ED. Nurses galore. Lots of consulting. Someone asks me to show them a pacer spike on an EKG readout. Eight people, one medic (Angel), one medic student (me), one nursing student and Mom are in this room.

Chaos.

Or is it?

3 minutes into it, the little girl cries.

"Moooommmmyyyyyyyy"

A collective sigh and everyone relaxes.

"Blood sugar?" asks the doc.

"Too low to read." says the nurse with the glucometer.

Blood Sugar? I look over at Angel.

An exasperated "Dammit!" is written all over her face.

We were so concerned with cardiac that we didn't test her sugar. Dammit!

The nurses couldn't start an IV (intra-venous, or needle-into-your-vein) line either. The doctor ordered an NG (naso-gastric, or a tube that goes into your nose and down to your stomach) tube and they filled her with glucose.

She came around beautifully.

I heard later that she went home the next day.

After the call, Angel was more concerned with figuring out how we could do that better next time than with justifying her actions. She is, truly, a Jedi. She believes in what she does so much that she can set down her pride and learn from her mistakes. I am humble in her presence.

All my worries about not learning or having a bad preceptor have vanished. Angel and I are of the same mind and she doesn't mind giving me the time to do the skills I need to learn.

My next shift with her is on Sunday night.

I can't wait!

More to come!
-an ED rotation with Icky bedsores and cool nurses!
-a guest volunteer shift in another station with an SUV rollover!

I've been sick. I haven't been dead.

--maddog.

10,000 hits

My blog achieved 10K hits today.

Happy birthday to me!

w00t!

I'm working on a rather long-ish post about my first run with my new preceptor ("Angel").

Stay tuned!!

--maddog

Birthday presents.

Today, I'm 34.

I've gotten 2 presents.

1. I've slept without nightmares, sweats and fevers for the first time in 2 1/2 weeks.

2. I succeeded in registering for the 2005 Marine Corps Marathon.

#1 means I feel awesome. #2 means I'll be running one of the most beautiful marathons in the world for the second time in my life.

Oh, yeah. I've gotten 3 presents.

It's 80 degrees Fahrenheit and sunny today.

I'm going running!

Once I'm done playing outside, I'll write up about some of the more interesting patients I've seen lately.

It's good to be alive.

--maddog

Sick....

This sickness has lasted for two weeks now.

Somehow, through it, I've done a rotation at the ED where I've seen a type 4 decubitous ulcer (that's a bedsore with bone showing through), moved my household goods into my home, took a midterm exam and assembled my new grill.

Bloodwork results come on Wednesday.

It's all been a haze.

The worst has been the fevers. I go to bed at night freezing cold and I wake up hours later, bathed in sweat with bizarre and nightmarish dreams.

Here's one:

My left hand grabs a magazine out of my belt as my right index finger releases the empty one from my rifle.

Hold it by the bottom. Feel the mark in the front. Jam it in. Slap the bolt release with the palm of my hand.

Sight in....

"Sproingggg!"

The M-16 makes a distinctive noise. My cheek is jammed against the stock, right over the long spring that returns the bolt to the forward position. Those on the other end of it hear the deep bark as I fire. All I hear is the spring transmitting through my cheekbone.

My right thumb switches my gun to semi-automatic. Three shots at a time.

Sight in...

BUh BUH Sproingggg!

Pick a new target....

Sight in....

BUh BUH Sproinggggg!

Next!

Sight in....

It goes on.

All of my thoughts are on my actions.

I sight in with my right eye. My left one is looking for more targets. My hands do their work. New magazine, Clear the jams. Reload. Change sights.

I focus on what to do on my end of the gun.

The nightmare is on the other end of it.

If I don't get better soon, I'm going to go crazy.

--maddog

I'm not dead......

I've been busy.

I went to an awesome conference and met the MacMedic.

I've been moving into my new house.

I've done an awesome shift with my new preceptor (15 leads and 2 year olds with implanted pacers!!!).

I've got the flu.

Blah!

More to come, I promise.

--maddog

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