March 2005

Back from the hospital.

My first IV start on a real patient was on an inmate from the local state prison. Apparently the guy got into a fight with the guards; at least, that’s what I picked up from the paperwork that came with him. He cliamed he didn’t know how his shoulder got dislocated. Crazy world. Anyway, I popped a twenty gauge into his antecubital fossa. It went in easily, just like it was supposed to. I was stoked that I managed to occlude his vein with my pinky while advancing the catheter, perfect. Not a drop of blood spilled. I got the IV drip onto the hub and everything taped up.

My preceptor, a nurse, gave the guy some morphine through the IV drip set to sedate him. He was a wiseguy, mostly. Interestingly, he seemed a little embarassed about his situation and denied various things the two guards with him said in regards to his behavior back ‘at home’. Anyway, he seemed to like the morphine pretty much. The morphine, though, turned out to just be the beginning of the sedative. In order to do the heavy-duty second part, they had to bring in a respiratory tech just in case the guy went bad. The tech got out a bag-valve-mask and sized an oropharyngeal airway. They were ready. Then they dosed the guy with 3 mg of Etomidate via IV push, in other words, through the tubing.

After about ten seconds, the guy said, “Wow.” Then his eyes rolled back in his head. Poof, gone. The nurse and a PA put his arm back in, a task that took about a minute of pulling traction on the arm. The guy moaned a bit. Then we waited about two minutes and the guy’s eyes opened up again; back in the world. He had no idea his arm was back in until we told him.

The marvels of modern medicine.

I watched a guy have a wound in his thigh cleaned and sutured. Cool, but I must admit that I still have some habituation to do in terms of being able to watch that sort of thing without negative reaction.

I started my second real IV on a young woman with stomach issues. She complained when the nurse told her that she was going to have to have an IV; she said the last one she had had was very painful. A bit later, during the assessment, she noticed my photo ID that clearly states I am a student and asked if I was a student. I said that I was. She was fine when I came into the room with the IV gear and started setting it up. I got it in (pop!) and drew four tubes of blood for the lab, then started the drip. Unfortunately, I was not completely ready for the start (I’m new, still) and hadn’t got the tube dealie ready; while fumbling to get the cap off, my pinkie fell off the vein and consequently a bit of blood was spilled. It was messy, but the woman said the start didn’t hurt at all; was way better than the last one she had. “Props for the IV,” she said.

I like being able to sort-of read a cardiac monitor. I have a lot to learn, of course, but now I understand how to look at a tracing, I understand what is meant by different ‘leads’ (I am most comfortable looking at lead II), and can identify the different waves that make up the rhythm. We had a guy in for atrial fibrillation, but as far as I could tell looking at the monitor, he didn’t have it. It turned out that he identified it from the way he felt (having had it before) and drove himself to the ED. On the way, it went away. So I was right, the guy wasn’t displaying afib. He did have a lot of bizarre squigglies, but I figured they were non-organic artifact, and they were. Yea for me.

I got to listen to a geezer’s rhonchi. The geezer was awfully cute and told me about getting to hold a bunny at senior day care.

I saw a bunch of other cases; nothing that interesting.

I made myself useful at the ED; I changed several beds, swept out several rooms, and ran every errand I was asked to.

I saw a bunch of EMTs that I work with ‘in the street’ bringing in patients. Most of them knew I was going for EMT-I and were not surprised to see me in the ED.

I’m going to the hospital tonight… Gonna start poking real patients. The first couple are going to be weird.

Cool… Class is over. It was long and hard.

Here’s some images…

Pig Lungs (3.4 MB MPEG)

External Jugular Cannulation (120 K JPG)

Something a friend posted got me thinking about long-term misunderstandings.

Several years ago, I took an excellent mountaineering trip into the glaciated backcountry of Alaska. Our mode of travel was randonee skis. We had to observe precautions for crevasses. This combination of factors meant that I spent literally days more or less by myself, separated from my ropemates by eighty or so feet of rope, as we skied across improbable distances on huge glaciers. The length of rope was necessary in order to have the best chance to react if one of your ropemates went into a hidden crevasse; you’d have to instantly clue in and self-arrest or be scraped along the ice and snow by the weight of your plummeting ropie and plunged into the crevasse yourself, to be encased forever several hundred feet below the surface. Actually, your remains would be slowly pulverized and eventually make it to the sea in molecular form after several centuries, but you get the idea.

The landscape was staggeringly beautiful but changed slowly, allowing great gulfs of time for reflection.

One day I was thinking about ‘The Wizard of Oz’, replaying the movie in my head. When the Witch of the West does her skywriting, she writes ‘Surrender Dorothy’. I realized that there is no comma in the statement; the entire meaning of the movie changed for me at that moment. The witch is not speaking to Dorothy, but to the Wizard. That completely alters the character of his change of heart; I had always seen him as a bumbling con man but essentially good, as per his character before the storm. The missing comma reveals him as a weak and wicked, content to sacrifice the young girl to avoid a confrontation with the witch.

I was crushed.

More sharp items today; subcutaneous stick with 0.3 ml 0.9% NaCl via 27 gauge needle, intramuscular stick with 2 ml NaCl through a 23 gauge, blood glucose with a lancet. My blood glucose was highish at 140 mg/dl; I’d been pounding peppermint patties all afternoon. I did a full IV setup on a fellow student today giving him 250 ml of normal saline; in exchange, he gave me the same. I also set up for and drew two tubes of blood from another student. So, now I’m done with my lab sticks though I owe my arm one time to another student; he may get me tomorrow.

Don’t believe what they tell you; an eighteen gauge catheter hurts more than a twenty, though you can put a lot more fluid through it. Size does matter.

I’ve been doing well on the daily quizzes; today’s was especially fun… Given a condition, state the expected symptoms and treatment. The conditions were all big-ticket items; closed head injury, flail chest, congestive heart failure, open pneumothorax, cardiac tamponade, open femur fracture. Understanding the anatomical and physiological processes really helps both with coming up with the list of symptoms as well as the treatments. Treatments at the Intermediate level are similar to the treatments at the basic level with advanced life support add-ins; IV access for fluid replacement and medical administration, a few more meds, better airway management, cardiac monitoring.

Many Intermediate treatments start with oxygen and IV access. Oxygen, of course, helps in any situation with shock; IV access is usually obtained by an ALS practitioner (Intermediate or Paramedic) even if no fluids or meds are to be given immediately since access may be more difficult to gain at the hospital in worsening hypotensive (low blood pressure) situations, also, having an IV in place makes med administration by the Intermediate, an intercepting Paramedic, or the hospital much more straightforward if the patient should ‘crash’. Oxygen is actually a Basic medication and most patients get it; good perfusion is crucial to good patient outcome.

Today was day nine; two more to go. Seven of the days have been eleven hours, one was eight hours, one was seven. We’ve had one day off. Tomorrow is a half day each of classes and labs and will be another eleven hour day; Friday we will have practical testing in the morning and the written in the afternoon.

I ran into a SOLO instructor in town yesterday; he was an instructor on my Basic course in ’02 and at a wilderness refresher I took last year. He is an Intermediate and graduated from ALSI, the school I am attending. He asked how my EMS life was going; I told him I was in Conway at ALSI. He asked me what week I was in (week two), laughed, and asked if I was burned out yet. I’m not sure ‘burned out’ is the right term; I am enjoying what I am doing although, to be honest, I am ready to break up the monotonous schedule of sleep, school, study, sleep. I miss my family, though it’s a good thing they are not here.

Everything is starting to gel; I feel that taking this course will allow me to provide a much better standard of care even before I can apply the Intermediate treatments. Clinicals, the Registry exam, and applying for Vermont reciprocity will take several more months, of course, during which time I must operate as a Basic. I think I will feel less like a blind person groping in the dark, though, especially at medical calls.

So, after much practice, I’d finished the supervised mannequin IV sign-off starts on the IV trainer; two ‘flash’ starts (tourniquet, alcohol wipe, catheter insertion, looking just for the ‘flash’ of blood on the catheter injector that means that the catheter has been properly placed in the vein), two full setups (flash, plus IV bag selection, setup, and start), and one ‘bloods’ (same as above, but drawing tubes of lab samples). Tonight, I had no excuse but to move to live subjects. I started three ‘flash’ and had three started on me. One of mine, the second one, didn’t count because I threw the sharp bit into the trash rather than the sharps container, even though I placed the catheter properly. The rule, of course, is ‘give one, get one’, so I had to give myself up in exchange for my make-up poke. The guy I traded with for my make-up flash turned out to be tenative with the needle. He wasn’t able to get a flash. He did manage to give me a major hematoma on the back of my left hand. It didn’t hurt much while he was mucking about but it sure does now. Anyway, now I’ve placed catheters in live human veins three times. It’s pretty weird. By the third time, I had the technique down fairly well and was able to occlude the vein with my ring finger before pulling the needle out of the catheter; my subject didn’t end up covered in blood. Sweet.

For what it’s worth, it’s more difficult on a psychological level than giving sub-q fluids to the cat.

I have one more live flash, one live full setup, and one live bloods to do before the end of the class. One nice thing about moving on to hospital clinicals is that my patient doesn’t get to poke me in exchange for my starting an IV on them.

I’m almost done with the airway lab sign-offs; I have one left to do. I’ve placed endotracheal tubes, laryngeal mask airways, and combitubes into mannequins using various techniques; with c-spine precautions, without, using laryngoscopes, using just fingers to feel the epiglottis(!!!), on the table, on the floor, face-to-face. If you have a sick mannequin with a compromised airway, give me a call. I can’t actually place tubes into human airways in Vermont until I’m a paramedic.

I still have a number of simulated trauma and medical (i.e., sick, not injured) assessments to do before Friday; four each. Those tend to be fairly straight forward; follow the A-B-Cs, treat what you find. I had an interesting medical assessment last Friday where I had to differentiate between asthma and anaphylaxis. It came down to skin tone; anaphylaxis is a systemic condition leaving the patient diaphoretic and pale where asthma is localized to the respiratory system. The simulated patient had multiple allergies and the history I was gathering was leading me to suspect anaphylaxis; he was in respiratory distress on my simulated arrival and not able to speak real well. Conveniently, I picked up on the pink, warm, and dry skin before I pumped the simulated patient full of simulated epinephrine. He’d have survived the epi, most likely, and his bronchiols would have been dilated, but albuterol was what was really called for.

By the way, if anyone says that you have ‘great EJs’, that’s your cue to get up and run.

I’ve been having a pretty nice weekend.

Yesterday, class let out early; around 3:30. I stayed late, the only student to do so, and played with a cardiac monitor and a really cool cardiac simulator for another hour and a half.

The simulator is pretty neat; you take the leads from the cardiac monitor and, instead of snapping the leads onto gel pads on a patient’s chest, snap them onto snaps on the back of the simulator. The simulator then feeds the monitor different rhythms and aberrations. The simulator comes with a remote control that allows the instructor to select the output; there’s also a mode where the student presses a button and the simulator sets up the output. The student then figures out the rhythm and any other modifiers; the unit tells the student if they guessed correctly and lets the student guess again if the previous guess was wrong.

The instructor was puttering about doing administrative stuff but was happy to come over and answer my questions. So, faced with a bunch of squiggly lines, I could ask for help and the instructor would help me work through it. We had spent the morning going over cardiac arhythmias; by the end of the day I felt like I had half a clue towards identifying arhythmias from the monitor.

This morning, I slept until I could sleep no longer, then went and climbed partway up Mount Washington. I was hoping to go all the way but got started late; I just couldn’t bring myself to get out of bed with nothing but entertainment pressing. So, I finally got on the mountain just before noon. I stomped up the Tuck’s trail from Pinkham and on up Lion’s Head. I had set myself a loose 3 pm turnaround time and a firm 4 pm turnaround time but decided to turn back when drifting snow started to obliterate traces of the trail as I was reaching tree line. The wind was quite strong and cloud was moving in. I decided it wasn’t wise to continue on by myself so I turned back. I did get to use axe and crampon, the only time this year due to work constraints.

On the way back, I stopped at a scary townie place and had dinner while watching NASCAR.

Then I came home, or rather, back to the hotel. I’ll be spending the rest of the evening doing Firefighter I homework and drinking beer.

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