Tidying up.

I've been making a few changes to my blog and there are more to come. Sorry for the boring "housekeeping." I've gone through and edited a few posts to make my blog just a tiny bit more anonymous. It might just be paranoia but I'd rather be on the safe side.

In the next week or so, I'll be making some more cosmetic changes and updating some broken links. I'm still using the same Blogger template I started with in January 2004!! Wow! I'll be looking for a newer, more functional layout that still has the same clean style.

Why all this recent activity? Well, I've "unplugged" from the biggest time-waster of all time: Facebook! Man! That thing just drained all the creative energy out of me. I'd sit down to just, "see what my friends are up to" and the next thing I know, 2 hours have passed! I'd look back and see that I had done NOTHING substantive; I hadn't had any meaningful communication with anyone, I hadn't written anything worthwhile and hadn't done a single productive thing!

That thing is like a drug! I had to put that mess down and walk away!

*Yawn!* Yes, I know. That was boring. More exciting posts are on the way. I promise.

--maddog

Life in the Kingdom Part 2 of ?

Well, here's a bit of news that may affect yours truly. It appears that the Ministry of Interior intends to try to regulate all online publishing via "licensing."

Hmmm... You know, I'm squirrelly enough about getting "found out" that this is just the thing to put me into hiding.

Never fear, dear reader, I'll soldier on and post post POST!

This bit of news does open a door into another discussion. There is NO free press here. In fact, it's kind of funny, coming from the United States where, basically, the press can say ANYTHING they want to. Here, it's not so much. A lot of what I read in the local English language press, aside from grammatical and translation errors, is full of unsubstantiated facts, opinion of the author (or editor) presented as fact and a clear sense of "talking around" an issue.

I'm not media-savvy enough to discuss the issue at length but when I read the local press, I'm always left with a sense that there's an actual story looming behind the print and somehow it isn't allowed to come though. I wonder if readers here take the news for fact or if they have developed a refined ability to read between the lines.  There's much that has been said about the Bedouin ability to perceive much more than what is on the surface. Does that apply to reading the news as well? I wonder. I don't have the answers. It's yet another thing to ask my hosts, colleagues and Arab friends.

For my own sake, I'll have to carefully navigate the next few months of my blogging. I know other bloggers here in the Kingdom who do not blog under a nom de plume. I wonder what it'll be like for them.

Strange times in a strange land.


--maddog

Life in the Kingdom Part 1 of ?

I see that I've just kept going on (albeit slowly) blogging about my work and antics as a paramedic as if there was no change in my life at all.


But there has been. For those of you who only occasionally visit here, I've moved to the Middle East and taken a job over here as a paramedic in a small clinic in the middle of the desert (Really!). I've posted a few things about working here and some of the differences but it's mostly been in the context of a particular call. Of course there's entries like this one that make it obvious that I'm not in the USA anymore.


My call volume is considerably less than in the USA and, honestly, I'm not as fresh-faced and filled with wonder as I used to be. These may be reasons I'm not as frequent in posting. I'm still here and I'm still having a blast. There are times when It feels less noteworthy.


I'm going to try to change that. At least I'm going to try to post more about EMS and, specifically, about my particular experiences over here in the desert. I've got a pretty cool thing going on here and, honestly, it's worth sharing.


Over the next few weeks, I'll be posting 2-3 times per week describing the peculiar, different and outright bizarre aspects of my life here in the Kingdom from my perspective as a paramedic. I'll discuss how the EMS system is structured differently, how we practice medicine differently (and the same) and how my attitudes towards, death, suffering and human treatment have shifted to adapt to my life here. It's pretty odd.


Please feel free to hit the comments or email me if you have any questions or if you're curious about my life over here.


More soon (I promise this time)


--maddog

Car Vs. Camel!

Jolly and I are working this warm desert night when we get called for a car accident about 30 km south of our location. I let Jolly take the front seat and I hop in the back of the ambulance. From the dispatch information we receive en route we figure  it's a single-car accident with two victims. Injuries unknown. I know this stretch of desert road pretty well. It's straight as an arrow and completely unlit. I drive it from time to time to work at a remote clinic about 140 km away. On the way to the scene, I find myself wondering what would cause someone to go off the road on such a straight length of highway. Well, I decide, I'll just have to see when I get there.


It's moonless and dark when we arrive. No streetlights and no other light source for a few kilometers in each direction. This is the middle of the desert, you know. We park as close as we can but the car is up a 2 meter embankment, about 20 meters off the roadway. Jolly goes ahead to check it out. Anticipating trauma, I grab two backboards, collars, and the usual. Jolly hollers at me to not bother.


This is going to be good. I scramble up the rocky embankment and join Jolly at the scene. Jolly is a local so he's doing all the talking with the local police and security personnel who have arrived before us. This frees me to check out the car. We have a Toyota Camry resting upright on its chassis. The front and the rear are completely smashed, there's not an intact piece of glass in the whole car and the sheet metal of the roof looks like it was ripped off with a giant can opener. No sign of the roof anywhere nearby.


There are no tracks leading to the car either. Just an impact print about 8 meters behind it, then blank sand then another impact crater a few meters back. End over end roll. Up a 2-meter embankment. Wow.


The driver (I assume he was) is completely wrapped around the center console. Yes, completely, like 270 degrees of twist. His head is so badly deformed that it's clear we're not rescuing him. Even assuming we can cut him out of the car. The nearest rescue squad is at least 45 minutes away. The passenger is lying next to the car and I get that the responding police had pulled him out of the front seat. He, too, has a badly deformed cranial cavity (skull). Even though there's no brains leaking out, both of these guys have what we call "injuries incompatible with life."  No, they weren't wearing seatbelts.


Jolly and I proceed to search the surrounding desert. We surmise that the car bounced end over end and, without a roof, we worry there may be someone lying out in the sand having been thrown from the car. We work our way back along the estimated path of the car. From the bits, pieces and imprints in the sand we figure this car was going pretty fast. About 100 meters back, we find the gouges in the shoulder that shows us where the car went off the road. To have traveled 100 meters, bouncing end over end, that car must have been going pretty dang fast when it left the road.


100 meters further down the road, we see another police car with its lights on. There's a dark mass on the road in front of it. As Jolly and I work our way down the roadway, the smell hits us. I've not smelled anything so nasty and vile in my life. It's the smell of an eviscerated camel. We find the roof of the car. Most of it is still in the camel. A quick look tells us the story: Our two friends were speeding down the road when, out of nowhere, there's a camel in their headlights. They hit the thing full speed. I estimate they were doing at least 200kmh. This is not unusual in this country and specifically in this part of the country.


The front of the car snaps off all four of the camel's legs and the camel's body hits the roofline of the car. It rips the metal off the roof and impacts with both occupants' heads, killing them instantly, I'm sure. Bounce, flip, the camel goes over the car leaving the Camry to swerve a bit, travel a few more meters, hit the shoulder and begin it's aforementioned end-over-end flip dance to finally rest another 150-200 meters further on. It's an impressive display of physics, biology and plain stupid.


Jolly and I are shaking our heads as we get back in the ambulance and head home, leaving all three bodies for the police to deal with.


And, Oh! The smell!


--maddog

Night shift is a b***h!

Car vs. Camel. (Well, I think we can ALL figure that one out!)

Bedouin babies!

USA vs. KSA:  Who gets the patient????

Stay tuned!!

-maddog

Pretty Lucky Guy

His name is Ali and, according to the ER doctor, he's a pretty lucky guy. I have to agree. 

We got called to an accident down the road. About 20 minutes later, we arrive at a crest in the road, made notable in the moonless night by the collection of cars and police lights. 

About 30 to 50 meters off the road away is a bashed up compact car resting in the rocky sand. Our patient is the driver and he's secured to a backboard in a Red Crescent Society ambulance. 

Here's a wierd bit: since the patient is an employee of my parent company the Red Crescent Ambulance waited on scene for about 10 to 15 minutes for us to arrive and take the patient to our company hospital which happens to be a few kilometers from their base. 

Oh well. That's how thing are done over here. 

The Red Crescent ambulances around here are staffed and equipped at a very basic level. Some have the ability to start IVs, administer glucose checks and give nebulizer treatments but that's about as advanced as they get. The Red Crescent guys had secured my patient to a backboard but hadn't secured his head, applied a cervical collar, conducted any examination or even taken vitals. They pulled their stretcher out as we approached with ours and I had to wade through the typical crowd of well-meaning but dangerous bystanders grabbing, pulling and trying to "help."

The Red Crescent guys don't speak English and my Arabic is not much more advanced beyond "Yes, no, thanks, hello," and "Where do you have pain?" but I immediately see that they want to lift the patient off their backboard and onto ours. I use a little pantomime, make eye contact, smile and then grab each of their hands and out them where they should be for a proper logroll. They get it right away and we do it by the numbers. It's neat to see that common training show up even across such wide gaps in culture and geography. 

In short order, we get Ali transferred to my backboard and cot. I quickly move him into the ambulance so the nurse and I have room to work without being crowded by the bystanders, onlookers, police and anyone else. The nurse I'm working with this night, a strong-willed, unflappable and solidly competent Jordanian woman, makes the call to take this patient to our company clinic in the nearby city instead of our tiny "camp" clinic. I think she realizes that there is an emergency physician on duty at the city clinic and only a general practitioner on call at our "camp" clinic. 

I do my assessment en-route and find that he's got a painful left hip but no shortening or rotation of the leg. This would indicate a break in the thigh or dislocation or break in the hip where it meets the pelvis. His thighs are pain-free when I push on them and his pelvis is stable. All the rest of him is fine. No signs of head trauma, lungs are good and clear, extremities are intact and give good pulses and motor/sensory response. All his vitals are fine. The only thing is this hip pain and the fact that he doesn't remember a big chunk of the accident. I wrap a folded sheet around the upper part of his thighs and tighten it like a band. This produces immediate relief from his pain. Other than an IV and monitoring, that's about all I can do for the guy until we get to the hospital. 

From what Ali tells us, he went off the road, not wearing a seatbelt, and rolled "many, many times." During all this rolling he said he "went out the window" and landed in the sand. So, we're looking at the unbelted driver of a car involved in a multiple rollover with ejection. All he's got is a painful hip and a few cuts on his hand and thigh. 

Yep, he's a pretty lucky guy. 

--maddog

These hands

There are times when I look down and see my hands. Yes. Of course. We all see our own hands all the time, but there are times when I see them.

My fingers are pretty long. Sometimes I think they're too long to be "manly."

My fingernails grow too fast. I want short, unobtrusive nails that don't look shiny or pretty. However, they just grow that way (and fast!).

"Clip...clip...clip...,clipclipclip"

Herself tells me that my hands are big and strong and make her feel safe. When she's not there: I don't see that.

What I see is my hands being wrong for what I want them to be.

I want my hands to be strong, every time. I want my hands to do the perfect thing, every time. I want my hands to be absolutely and perfectly "right on" every moment they touch someone.

Every time I touch a patient, I question that. It doesn't matter how well I do my job. It doesn't matter how well (or poorly) my patient ends up. I will always look at my hands as if they belong to someone else.

This is the worm of doubt. 

How did I do that?

Did I do that right?

Are these my hands?

--maddog

"And so I reach out my hand, and he grabs it"

This guy is a 'medic. And this post is a clear indication that he's a GOOD medic.

"What's a good medic?" You ask?

Well, that answer is complex, nuanced and full of opinion. I ain't ready to fight that battle in the blogsphere yet.

However:

All of us paramedics get the same training, to a point. We all have to pass the same (or similar) test to be blessed as a paramedic. There are folks who will argue the contrary but, please, for the sake of my posting, let's assume my statement is true. I'm sure I'll get a bajillion comments when I finally do post on what makes a "good 'medic" but today, I want to talk about one thing that makes this guy a "good medic."

Some of the best in our profession don't try to be doctors. We don't try to be nurses. We recognize that this is what we do and we put effort into doing it better and into improving the efforts of those who come after us. There's a lot to be said for being a paramedic. There's a bit more to be said for being a good paramedic. There are volumes to be told for being a great paramedic.

What is "that thing?" What is the one thing (if we can condense it down that much) that makes the difference between a paramedic and a "good" or, even, "great" paramedic?"

The short answer for me is, "I don't know."

But I do know what I've seen in the paramedics, EMTs, Firefighters, Cops and public servants that I've met in my job.

We care.



When we do our job, no matter how busy our county/system/service/company is, we treat one patient at a time.

When we have the privilege to treat them, they are the ONLY patient we've ever seen and ever will. It's the zen, hokagare, samurai way, or whatever you choose to call it, but it's what paramedics do. We are called upon to consistently deliver the compassion, care and individual feeling that makes that difference. Everyone who needs a paramedic becomes a member of our family. Some of us want to do well. Some of us are just tired of the dying and killing and some of us, honestly, want to really, REALLY, help.

When the public (yes, you!) see us. You are at your worst. That only challenges us, further, to be at our best.

Nobody is a 'medic for the money.

Nobody is a 'medic for the groupies.

We do it (and keep doing it) because we care.

This guy? I hope someone like him comes to my house when I have to make "the call."

--maddog

Resistance is Futile!

Let's talk a little about combative patients:

A combative patient is one that fights treatment or control. This can happen for a variety of reasons. When we talk about combative patients in EMS, typically, we're talking about folks who have a brain injury or are hypoxic (brain's starving for oxygen) and they start flailing about. You see, when the brain's in trouble, i.e. starved for oxygen, the body kind of goes into "freak out" mode and starts lashing around in an attempt to somehow correct its oxygen starved state. When you're the paramedic in a small box that's moving down the bumpy road at high speed with said combative patient, this is what is sarcastically referred to as, "fun."

Now, there are patients that are combative because of a physical injury. Then there are patients who are combative due to a chemical insult (too much booze, pills, or whatever they ingested, snorted or shot up) and then there are patients who are combative just because they're ornery! Yep. The injured a**hole. Now, technically, we shouldn't refer to these patients as "combative." That term is usually reserved for folks who do not possess the ability to make an informed mental decision and we've got to fight 'em for their own good. The very reasons they are in such a combative state also usually alters their mental faculties so that they can't give or withhold their permission for treatment. That's when we get "implied consent." and proceed to do the things necessary (we hope) to save their lives, etc..

Now, let's go  back to the ornery ones:

Some folks are just a pain in the butt. They get themselves all banged up, cut up, sick or otherwise in a bad way. Not enough to alter their mental state, mind you, but enough so that someone calls for a paramedic and they actually need some treatment. But they get stubborn and it's a constant argument to get them to let us do the simplest things. For example, I had a patient a while back who had an unfortunate meeting with his lawnmower. This 80-year old gentleman got tired of waiting for, "them darn kids" to show up and cut his grass that he went out, sandals and all, to do it himself. Well, needless to say, the mower somehow rolled back and he's a bit stubbier on his left foot than his right as a result.

We arrive, find him bleeding  a bit, uncomfortable, furious, ornery and in full possession of his mental faculties. No, he doesn't want us to take him to the hospital. No, he won't let us bandage his foot. No, we can't start an IV and hook up the monitor. Who cares how many cardiac medications he takes, "I ain't goin!" All the while he's swatting at my partner and I when we get close, waving his arms around and being a pain.

In the time It took his wife, daughter, my partner and I to convince him to let us treat and transport him, I could have driven him back and forth to the hospital 4 or 5 times. Yes, I could have taken a refusal from him but I would have been back later when he finally gorks out! This happens more often than I'd like in the USA.

Now I'm over here in the Kingdom and there are a lot of differences. I don't see as many drunk, high or chemically altered patients as I did in the USA. I know they exist in the Kingdom but not where I practice, I guess. I also expected a lot more distrust and even open hostility to my white face and lack of Arabic language skill from many of my patients. However, that's just not so.

The men who have fallen under my care seem to be in one of two states: Dramatic flailing, wailing and hollering over the tragedy and pain or completely limp as if they had swooned. Usually, if they're in the first state, they quickly swoon with a melodramatic sigh as soon as a medical person shows up. I'm always so surprised at how uncomplainingly they put up with any of my treatments. A patient may cry out at an IV stick, sure, but he usually doesn't pull back, strike out or otherwise act "ornery." It seems to me that, once medical help is perceived to be on scene, the patient just gives all into Allah's hands and sighs all the way to the hospital. After fighting ornery, bloody lawn-mowing 80-year olds, It's a nice change!


I haven't had any Arabic women patients. Usually, they are brought in by their husbands to the ER directly. I'm sure if I ever do have an encounter with a female patient over here, It'll be seriously blog-worthy!

--maddog

Surfing the Chaos.

We get called for a motor vehicle accident (MVA) a few kilometers away on the nearby desert highway. Though we are a company EMS service that exists to provide medical care to our own facilities, we are often called upon to help out the general public. No problem. I like the work.

My Arab partner, AJ, and I both hop on the responding ambulance since it was reported there were multiple patients. AJ gets in the back and I ride up front. Neither of us is driving. Over here, the ambulance drivers are, typically, company workers from other departments who are nearing retirement. They have no medical training, limited usage of English and, other than getting the cot in and out of the unit, aren't very useful to a paramedic on-scene. 

We arrive at the place where two ribbons of asphalt meet in a "T" in the middle of the rocky waste of the desert. A small pickup truck carrying two young men went barreling into the intersection without considering the large lorry that had stopped to make the turn. That is typical of how men drive over here. Just go fast!! The rest is in God's hands!

By the time we arrive, there are at least fifty men all standing around the accident scene, looking, talking to the victims, pulling them out of the car; It's chaos. The front of the pickup is trashed. The driver is sitting in the front seat looking dazed. There's a nice star on the windshield over the steering wheel. Ok, Got it.

The passenger is lying on his back next to the truck. AJ and I can tell that he got out himself and laid down. He's pretty bloody from what looks like a busted nose but it's hard to tell what else. More on that in a bit. AJ and I have to physically push people out of the way to get to our patients. There's no concept of "stand back, the paramedics are here" in this country.

The driver is swiveling his head back and forth and talking to people. I figure he's been there for about 20 minutes before we arrived, he can wait 5 more. (yes, It takes us that long to get there sometimes). I quickly decide to help AJ package the passenger.

Now. My USA readers must understand some key differences here: there is NO rescue squad, no fire engine blocking traffic, no reliable and competent rescue techs briskly deconstructing the wreckage to allow us easy access to the patient. Also, there is no concept of "get out of the way and let the paramedics do their job" either. Everyone who shows up either wants to get close and look or feels they can contribute by grabbing the nearest thing and pulling, pushing, hollering and getting in the way. I get more than a few angry looks as I use my 230 lbs to shove people out of the way between the patient and me.

Oh, police? Yes, the police are there.  Probably the ENTIRE shift has come to the scene and parked their cars everywhere. Only about half of them have put their lights on. Are they controlling the crowd? No. They are a part of the crowd: equally shoving, pushing, jostling for a look and so on.

Like I said: Chaos.

Back to AJ and I with the passenger: AJ is chattering in Arabic with the patient. I do a rapid trauma assessment and find blood everywhere. Is the patient bleeding everywhere? No. He's wearing a Thawb. A Thawb (or Thobe) is a long, white garment that is traditional with Arab men. Imagine a white dress shirt that goes all the way to the ankles. They come in many colors but the most common is white and they're almost always made out of finely woven cotton. Which makes them an excellent blood sponge. I'm serious. Get a nick on your wrist and before you know it, your entire sleeve will be red and drippy.

This guy's got a bloody nose, a busted lip and a cut on his elbow. It's making him look like an extra from Shaun of the Dead. Talk about challenges to patient assessment! Awesome!

AJ and I quickly get this guy collared, boarded and loaded in the ambulance. Now, there's two patients and we're basically the only available ambulance for about 150km. We move the patient from the stretcher to the bench-seat and secure him with the seatbelts. He's maintaining his own airway, able to answer my questions and, since we have no other choice, is left in the ambulance while AJ and I go get the driver.

Yeah, I know. I'm sure some of you who are EMTs and paramedics are shaking your heads and thinking, "Abandoned your patient?" or "The driver should not have been left. He should have been boarded and collared too!"

Yeah, I know, I know, I know!!! I was thinking the same thing! I had just arrived from the USA and had not yet grown accustomed to being completely unsupported. Yeah, we had about 50 bystanders but they were all medically useless. Even if I had additional resources to call upon, even the most basic of them would have taken 30 -90 minutes to arrive. If a Mass Casualty Incident is one which the number of patients exceeds the capacity of the local EMS to handle, then this was an MCI.

And that's how we do it over here.

So, back to the driver: AJ and I again have to wade through the crowd to get to this guy. Collar on, lay him down onto the board. Slide board onto cot. Re-assess ABCs and we head for the ambulance. The crowd is getting so pushy and curious that we need some isolation to work. We get to the ambulance and I'm astounded to see it full!! There are about 5-7 Arabs in the ambulance. They're all talking to the passenger, kissing him, touching his head, one or two are weeping and one or two have a look of morbid curiosity on their faces.

Now, I've learned that my size and strange appearance (bald, beardless, big and, dare I say it?, burly) scares most of the Arab men I've met. I use this to my advantage. Out comes the "Sarge" voice and, even though I'm hollering in English, they get the message and clear out of the ambulance pretty quick as I go charging in.

We get the driver into the ambulance and divide our efforts. The passenger speaks a little English. He's mine. AJ discovers that the driver is asking the same questions over and over again and, though he denies losing consciousness, can't remember why he's there or how the heck he got into an ambulance. Both these guys are boarded, collared and can only look at the ceiling of our ambulance but they can hear each other. The driver is worried about the passenger. He keeps asking where he is and reaching out to touch him. The passenger keeps repeating that he's okay over and over again.

Yep! Driver's got him some head trauma!

Neither of these patients were in a hurry to die so, AJ and I didn't have too much of a challenge managing them medically. Our biggest challenge was physics. The driver of our ambulance (remember him?) has gotten so excited by all the drama, blood and people that he's driving the ambulance as if he were being chased by the devil. In all my years of having to deal with over-enthusiastic volunteer firefighter drivers, I've never encountered a ride as chaotic, bumpy, swervy and generally crazy as this!! Even in 35-foot (10 meter) seas in the Bering Sea, I had an easier time.

Keep in mind that, even though each of our patients presented with signs of pretty serious injuries, our treatment plan was constantly being adjusted and re-evaluated based upon priority, safety and the vagaries of the situation. If chaos is a sea, we do our best to surf the swells and keep from capsizing. Really!

Somehow, we managed to start a couple IVs, get some vitals, assess the patients, immobilize and bandage some injuries.

We survived the trip to the hospital which was chosen, not on the nature of the patient's injuries and the closeness of the facility but, as it works over here, by the employer of the patient. More on that later. In fact, my whole experience in a non-company hospital (we have our own) was so surreal and interesting that I think it deserves its own post with its own ruminations.

Suffice it to say that it was an eye-opening welcome to the world of EMS in the Kingdom.

My thoughts at the end of the call? "This is going to be a blast!"

--maddog

Holy crap! I'm back!

I went on a short trip to India. Kolkata is INTENSE.

In the mean time: my laptop died, my home computer died and I got assigned to a remote area clinic even deeper in the desert.

At this Remote Area Clinic (RAC), I've had very limited computer access. The only computers available at work are the ones in the general emergency room and the attending doctor is is VERY nosy. I've stopped him a few times from reading over my shoulder. More on that later.

Well, now we finally have an office for the paramedics where I can blog in privacy. I have a few days off in about a week. Herself and I are discussing a drive to The Big City to get a replacement laptop. There's an Apple-authorized reseller and I need to see what the price difference is 'tween them and the USA.

Ok. I've actually had some calls and such. I'll be posting about that and paramedic life in the Middle East soon! I promise!

--maddog

Traveling

I'm heading out for a week of knocking around the Near East. Nothing EMS related, just going to visit some pals. Probably won't be any posts until I get back.  See ya!

--maddog

Chicks Dig It

I had made some raspberry ice cream with dark chocolate chips. I brought it in to work to share with my fellow medics and the ER staff. My Arab paramedic partner is amazed that I can cook and loves the soup and bread I've brought in to work. The ice cream prompts the following from him:

"How come you only have one wife? Chicks dig this kinda stuff, you know?"

I swear, the funny moments are going to kill me.

--maddog

Search Keywords, Oh my!

I use a software to track visitors to my blog. It gives me all kinds of useful information, including what search terms people entered that brought them to my site. Often they relate to EMS, sometimes people find me who were looking for another "maddog" and, every once in a while, I get a doozy.


Here's my favorite from this week:


"i am pee out of the wrong hole is that okay"


We live in a strange world.


--maddog