the Hammer

We were waiting in line at the deli when it all started.

"13 Zebra," the radio crackled.

Hesitating for a moment, I answered back. "13 Zebra."

"13 Zebra you are backing up 26-Boy at 137 East Main for a 51 year old male having seizures."

I looked hard at the man behind the counter. "Any chance you could finish making my sandwich in the next 30 seconds?"

He shook his head.

Damnit, no dinner for me.

I whistled to my partner, the Angry Black Man, as I headed for the bus. Driving to the call, he was worried about the alternator on his car, which had died that morning in the snow.

"Yo B, I hope it starts again," he said. "That's another $500 if I have to get it replaced."

"Well maybe it was just a wire or something," I said.

"Maybe, but if it doesn't start I'm going to have to call a tow..."

Just then 26 Boy, the BLS unit that had called for us, pulled out 100 yards ahead of us.

"What the fuck is this?" ABM said, slapping the steering wheel. He got on the radio. "Central, this is 13 Zebra. Tell 26 Boy to pull over. We're right behind them."

A voice from the radio responded, "Ten-Four."

"I know these guys, B," explained ABM, "they're idiots. The one EMT who was on the radio is called 'the hammer.' He's a fucking moron."

Great, I thought, just what we need: the Hammer.

We pulled up behind 26 Boy. The hammer opened the back door. "What the hell are you leaving for?" ABM asked, angrily.

"Uhh, ya see..." but the ABM pushed the Hammer aside before he could finish.

"Shut up."

I peeked inside. Lying on a backboard made of red plastic was a man in his fifties. A hard grey collar held his neck firmly in place. I stepped closer to look at his face. Hmm. I squinted my eyes.

"Umm, dude," I said to ABM, "get our shit. We need to start bagging this guy." Bagging is medic-speak for artificially breathing for someone, so called because of the "bag" you squeeze to push air into their lungs.

"So what the fuck happened to this guy?" I asked.

"He had a seizure," stuttered the Hammer, "he fell, hit his head, had another seizure, then had another seizure when we showed up. I was just going to start bagging him..."

"Uh hu," I said, reaching for my intubation kit. "I see."

ABM threw our keys at the Hammer. "Drive...but first give us a minute."

As I started bagging the man, I looked at ABM. "Why don't you get a line," I said, motioning with my head to the IV start kit, "and then let's get some Lidocaine on board before we intubate this guy. Just...a 100 milligrams should do."

ABM was breaking a sweat. I yelled for the hammer. "Hey, rip me a piece of tape like 24 inches long." I needed it to secure the ET tube once it was in place. The ET tube is what I was about to stick in the guys throat. I would use it to breath for him. If the tube became dislodged, it might go into his stomach, and he would stop breathing. That was the worst case scenario. Paramedics get in trouble for stunts like that.

A few seconds after ABM announced that the Lidocaine was on board, I unstrapped the grey collar from the man's neck and stuck my flashlight-tipped laryngoscope into the man's mouth. I pulled the blade--a long, straight plastic piece--towards me. After a second, the little squared-off tongue shaped flap that protected the opening to the man's lungs came into view. Theoretically, I was supposed to see the man's vocal cords and place the tube in between them. But to do that, I would have had to crank the man's neck back, changing the allignment of the spine, forcing spinal damage if their was a hidden fracture.

It's a game we play, this guess-work. Am I in? I think I'm in, but I didn't see it go thru the cords. Hmm. It was a dangerous gamble, but when I squeezed air into the tube, I felt the man cough. He came around a little bit, meaning he started to fight us, which problematic but was also good. All signs pointed to yes, I was in. This may not seem like a big thing, but I hadn't done this particular skill in over a year and a half, and if I wasn't in, I was in the the stomach, and that would have been very, very bad. Besides, I was rusty, and it was a bad skill to be rusty on.

"Okay," said ABM, wiping sweat from his brow. "Let's get this shit on the road!"

We started moving.

"You alright man?" I asked him. "You look a little diaphoretic there?"

"Shutup," he said. "I get that way."

I chuckled quietly as he wiped himself dry.

At the ER, a group of young doctors sat casually around a table. "Whatcha got?" they asked, sounding bored.

"Intubated head trauma," I said, their eyes growing wide as we wheeled past them on our way to the trauma room.

"Call Respiratory! Call a Trauma Alert!" a doctor yelled. "Nobody called us!"

"B. We're here now," said the Angry Black Man. "Whatcha want me to do about it?"

Comments

[Doc Shazam]

Practice doing external laryngeal manipulation. You need a third hand, though, for it to work, but I've never had it fail when I can't see the cords. Just get into the habit of doing it every tube (even on a mannican). Take your right hand and put it on the adams apple. When you look with the scope, push down and to the right on the adams apple. This usally pops things into view. If not, push and wiggle until it does. It always works. Now ask the Hammer to put his hand where yours is and hold it there. Presto, visualize tube through cords. GReat for suspected neck injury. So, what did he have?

[Tyson Lewis]

I didn't mention it in the post, but I actually did get a little help in the form of cricoid pressure from the ABM. External Laryngeal Manipulation--or BURP as I call it (as in Back Up and to the Right Pressure)--we did not try, although thiniking back, we probably should have. I'll keep it in mind for next time.

[Doc Shazam]

Yeah, it works, but it's more than BURP. BURP is what an assistant can blindly do that will probably help you out. In "external larygeal manipulation" you just grab the layrynx in your right hand and put it where you need it. No need to remember any mnenomics. ;)

[ar]

you write very well, tyson. first time here, and i'm already a fan. i went and voted for you and all. say, in the field do you fellas bag and listen to the stomach and watch for the chest to rise and all that stuff? often helps. awesome work anyhoo. i often can't believe the things paramedics manage out there. we're lucky to have you. Merry Christmas new year and all.

[Tyson]

yeah yeah, we listen for stomach sounds, lungs sounds, slap on the end tidal co2 detection thing, and in some places, they have the full on capnography deal. the hardest thing is preventing tube migration during patient movement. That's a bitch, especially with the little guys (peds), because not everyone involved in patient movement is well versed in tracheal tube management or even know what the thing does.

I don't always include the technical details because this site is geared for both medical professionals and the general audience. I want to convey not just the cool technical/clinical stuff of the job (which is fairly abundant nowadays anyway), but convey the pithe of the medical experience (from an EMS perspective) to people who might normally find it foreign, strange, and incorrectly idealized. I want my dad to read what I write and and not be confused. I want people to understand what EMS is about, in all its complexity, tradegy, and humor.

Ultimately, i believe that through medicine, a healthcare provider is able to experience a compressed and distilled version of the human experience many times over, and because of that priveleged insight, we have the ability to think more deeply about not just our own lives, but of society and humanity itself.

I believe in the uneveness and incoherence of human beings, of which I am one and as are the characters in this blog. I can't say it's all factual, but I try my best to make it true.

-Tyson

[ar]

I hear you. by the way, I hope I (and shazam!) didn't come across as an arrogant prick. I agree about not putting in all the technical details of what you'd do in real life - your posts read very well the way they're written now; good balance. I was just scratching an itch :)