Random Thoughts on Reindeer Games

There are a few ways that medics screw with each other. Some pranks or tricks are pretty universal. Defib gel on a windshield wiper, so it smears when the wipers are turned on. Turning everything on in the ambulance, so when it is started the lights, siren, and radio start blasting.  Putting an extra bag of saline in a jump kit, to make it slightly heavier.

This reindeer looks like he is fed up with your games... Source

I knew a medic who took his partner’s favorite, lucky shirt. He spent days putting it on "urban outdoorsmen" (the filthier the better) and taking a picture with a disposable camera. He then froze the shirt in a five-gallon bucket of water and gave it back, along with the camera.

One of the agencies I worked at planned pranks like an evil combination of Wiley E Coyote and a demented engineer. We would put flour into an inflated glove and hang it over a doorway, with a needle taped to the doorjamb. When the door swung open, the glove would hit the needle and pop, spilling flour onto the unsuspecting rube who just wanted to walk into a room. Evil geniuses took it further, starting with a glove full of saline, to make their mark wet. Then a glove of powdered sugar was hung at the bathroom door, where they would go to clean up. Then the mark would be angry and would be expected to stomp upstairs to clean up. So another glove of something sticky at their bedroom door. Evil, I tell you.

It got to the point that you had to enter rooms at a sprint, with a leaping shoulder roll.

One time, before I was even allowed to be an EMT on an ambulance, I was dispatching for pay and riding for experience. On one call, the ALS firefighters had missed several IVs on a lady with chest pain and shortness of breath. The paramedic I was riding with missed a line or two, as well. I got one on my first attempt. Jerk that I was am, I started doing a little dance and chanting about how genetically predisposed I was to be the world’s greatest medic. When we arrived back to the base, I was given bad news: “Who started the IV on that patient? They found a big chunk of IV catheter in her lung. Catheter shear killed her.”

I was crushed. I had killed a young patient. I was despondent. I didn’t know what to do, except to start writing a combination incident report/letter of resignation. The medics let me wallow in despair, quietly trying to hide my tears, for several hours before telling me they were screwing with me. I didn’t think it was funny then, but now I can see some humor there.

One of the best, low-grade pranks is to introduce a new caregiver to the deep end of the EMS pool. Let me give you an example.

Years ago, I was working with a new EMT. He was new to his EMT cert, as well as being new to the agency. But he was a good guy, wanted to learn, asked great questions, and paid attention. I liked to work with him – still do. One day, we got assigned to a nonemergency call in an alley. I think the nature was a foot injury, or something similar. We arrived to find our likely patient, standing in the alley with a single crutch. (As an aside, I love the single crutch. It screams patriotism, with the addition of needing to keep one hand free to hold a drink.) As we approached, I became convinced there was a second call nearby.

The smell of “dead guy” was strong in that alley. I told my partner to start taking care of the patient with the sore foot while I checked the nearby dumpsters for what I was convinced was a poorly disposed of murder victim.  After searching for a few minutes, I came to a horrible realization.

It was Mr One Crutch’s bandaged foot that I smelled.

I was glad I had an EMT partner to handle this call. We put the patient into the bus, on the bed, and took a set of vital signs and a history. The guy had cut his foot “a while ago” and had been trying to keep it bandaged since. That day was the day he had had enough and decided to get it checked out. It didn't hurt, his vitals were normal, and it had been like this for several days.

We were only a block or two from the hospital. If it were me, I would have added additional layers of blankets to the patient’s foot so that I could cut down on the cheesy offgassing. But I wasn’t attending; I was driving. As additional pertinent background information, I need to explain that I have an angel and a devil on my shoulders, each whispering ideas into my ears. My problem is that I don’t know which is which. They switch sides randomly, and I can’t see them. In this case, though, one voice whispered, “Make him unwrap the bandage, tee hee…” The other voice said: “Yeah! Make him unwrap and examine that foot! He he he!”

Who am I to argue with my shoulder voices, especially when they are in agreement? Certainly not me! I looked my novice partner in his eyes and gave him my serious face. “Hey, brah, you know a complete exam means that you gotta unwrap that foot and take a close look, right?”

My partner gave me a look that seemed to say he knew I was joking and wouldn’t fall for that. “I’m very serious. We’re professionals here. Man up,” I told him, maintaining my serious face.

I took a few steps back in case things were splashy while my partner began unwinding dirty bandages. It was horrifying. The guy’s foot looked like an anatomical drawing of a foot, with the skin layer removed. It was muscle, tendon, and bone. But wet. Juicy. Greenish. And rotten-smelling. My partner began to retch and heave.

I told him I would see him at the hospital and slammed the back doors.

I had to drive to the hospital with all the windows down, my head out the driver’s window, and occasional gagging of my own. But it was worth it. I still smile, thinking of that partner.

What makes a good prank? First, a prank or trick needs to not hurt, break, or injure anything or anyone. That includes psychological scarring, sorry. Second, it needs to not interfere with the job. This is why I’ve never done the defib gel thing – it could possibly take an ambulance out of service. Could you imagine running with lights and siren, turning on your wipers, and having everything suddenly smeared? Not cool. Third, a prank needs to be played on people in a position to return the favor. They need to be able and willing to play back. It isn’t fun to trick someone who is frightened of returning a prank, or if they are struggling in their job. In those cases, it is the equivalent of a professional boxer grabbing an elderly nun off the street as a sparring partner. Pick yourself a sparring partner that can punch back.

Checked Out

Recently I was called onto an aircraft on the report of a head injury. I rode down to the correct gate and headed down the jet bridge to the plane. At the door, I met five or six flight attendants and airline representatives. It didn’t seem like they wanted to let me on board until they talked to me. They were acting very conspiratorial. So I let them explain the situation to me.

“The pilot hit his head in the bathroom. It isn’t bleeding or anything, and he wasn’t knocked out, but we thought you should check him out. But, listen, he said he doesn’t need medical attention. So he may be irritated that we called you…”

I asked if there was a specific worry due to the man’s position driving a metal tube at a significant percentage of the speed of sound near the edge of the stratosphere. “Is there an FAA regulation that he gets checked or something?” Nope.

“Was he knocked out?” Nope.

“Knocked down?” Nope.

“Has be been acting weird since the event?” Nope. They just wanted him checked out.

I think I held eye contact too long. I just stared, mouth slightly open. I was wishing I could perform a Vulcan mind meld or some other form of telepathy. I want to know what the people who call me to “check out” a person who doesn’t want to be checked out are thinking. What do they imagine will happen? How do they picture the EMS response going down? What is the expectation? I want to know, so I can meet the expectation. I never know what to do with calls like this. Unwanted. Unneeded. I treat it like a customer service thing.

I stepped into the plane, turned left to find the captain, smiled, and asked how he was doing. He sighed and looked vaguely irritated. “I asked them nicely not to call you,” he told me.

I smiled like we were sharing a secret. “I know. You’re fine, then? Head still attached? Free checkup not needed?”

The pilot declined the offer of aid, we chatted for a second about the upcoming flight, and I stepped back off the plane. One of the airline representatives seemed disappointed: “That’s it? You just ask him one single question and leave?”

I smiled at her and went on about my day, “checking out” people. It is how I spend time between EMS calls.

Dogs, Part 1: Hurt Dogs

I think most people who read this are paramedics or EMTs. So I feel like I can open myself up to you and let you all in on a secret.

When I see a person (adult, of course) get hit by a car, it is like letting the good times roll. It is probably a little funny, and I know that I am likely about to do a lot of fun stuff to them. Fun for me, at least. And I’d be willing to bet most ambulances who witness an auto-ped hear some form of conversation that begins with: “Ha! Holy crap, did you see that?!? That was awesome! Pull over! Pull over and set me up!” It is a little bit funny to see cars hit adults. But keep that between you and me.

It is not even a little funny when we see a dog get hit by a car. The last dog I saw get hit staggered around like it was head-injured, snapping at the air and dragging its back legs. I couldn’t sleep for a week. When I would close my eyes, I would think about that poor dumb dog. Terrible. Sad.

Once I responded to a jogger who had been hit by a car. He was jogging along a sidewalk when a car came out of an alley. The car broke the jogger’s ankle, but ran his Rottweiler the hell over. We had to extricate the dog from under the car, and found it to have a massive avulsed scalp wound, burns over its right flank, and an unstable pelvis. I couldn’t believe the jogger – he was mad that we were taking care of the dog and had only splinted his ankle.

“Take me to the hospital!”

“Go to hell! You’ll go after your dog gets taken care of!”

Triage, fools!

Anyway, we got the Rottie muzzled with some Kerlix gauze, called a supervisor to transport the dog, and wound up using a cop to transport the dog to a nearby emergency animal hospital because the EMS supe was taking too long. The police officer was as worried about the poor dog as we were.  On the way to the human hospital with Captain Ankle Fracture still complaining about my triage choices, I called in a trauma set-up to the animal hospital: “Hi, you have a police car coming to you lights and siren with a… Dude, how old is your dog? Four? Okay. Coming to you lights and siren with a four-year-old male Rottweiler, struck by a car. He required extrication from under the vehicle and presented with a large scalp avulsion, partial thickness burns to his right flank, and...” According to the cop, the vet hospital had a bed and a team waiting out front when she squealed into their parking lot.

The dog lived. I assume the human did, too, but I didn’t care enough to check.

Occasional canine veterinary care is required of paramedics. It could be a dog hit while his owner was jogging, but it could also be a police dog wounded in the line of duty. Are you willing to look at the police canine’s handler and shrug? I’m not. But I am also limited in my ability to transport dogs. My boss would have a stroke if I transported every injured dog I found to a veterinary hospital. I am a paramedic, not a mobile vet. (Wait. Am I a mobile vet? That would explain a lot.) But some basic principles of veterinary trauma care are helpful knowledge.*

First, most of the concepts of trauma care work for all mammals, dogs or humans. Keep airways open, stop bleeding, and so on. Trauma is trauma. Dogs get tachy as they hemorrhage. Their gums will show pallor. You can increase your comfort level greatly if you understand that you are a skilled caregiver to human victims of trauma, so you are probably a fairly skilled caregiver to traumatically injured dogs.

Second, understand that humans (for the most part) don’t bite their caregivers. I know there are exceptions to that. Most dogs will bite when they are hurt. Secure them so you aren’t chomped.

 

Try to convince this dog you're there to help when it is hurt or in the red zone.
U.S. Air Force Photo by Josh Plueger, via Wikimedia Commons

When it comes to airways, my suggestion is to not intubate animals. That being said, understand that dogs can take big honking endotracheal tubes, in the 7.0-10.0 mm range, and intubating them is as easy as lifting the hypomandibular flesh on a supine dog. It is supposed to be easy, but I haven’t done it. There are a few websites, videos, and articles that explain how to do it if you care to learn. But you can also get control of that big airway without the tube by pulling the dog’s tongue out of its mouth, keeping the neck straight and inline with the head and body, and not hyperextending the neck. Oxygenate via blow-by O2. Don’t try to screw around calculating the tidal volume and minute volume for a dog. Straighten the anatomy, pull the tongue out without being bit, and blow some oxygen past. Move on.

If you feel the need to start an IV, the best spot is usually on the forelegs. The cephalic vein is on the middle of the foreleg and can even been seen without shaving. For the hind leg, consider the saphenous vein running from the back of the knee to the front of the shin. Secure the line with a ton of tape and make sure the dog doesn’t pull the line. (Lampshade of shame, anyone?) Saline is fine, but most veterinary websites seem to prefer lactated ringers as the initial volume replacement fluid. Dogs can handle big volume, so don’t worry about volumes like 60 ml/kg if it is warranted. Click here for more IV information on hypovolemic dogs. Subcutaneous infusion is an option, as well, but that seems to work best as pretreatment before putting a dog to work in a hot, dry environment rather than a treatment for moderate-severe hypovolemia.

Dogs can handle medications like morphine, antibiotics, Zofran, Benadryl, and such. But don’t be that medic. Don’t screw around with medicating dogs.**

Normal heart rates for dogs are in the 60-80 range. It would be normal to find a heart rate up to 130 bpm after exercise, though. Normal respiratory rate is between 10 and 40 per minute, again depending on exercising and panting. Capillary refill should occur in under two seconds and mucus membranes and gums should be pink. Tachycardia, pale gums, dry membranes, and poor skin turgor are signs of hypovolemia or dehydration.  Pulse oximetry is reported to be possible on the tongue or prepuce. Good luck with that.

Hope this helps, if it ever comes to it. In Part 2, I plan to discuss how to operate around police dogs. Part 3 will cover service dogs.

*This isn’t about cats. Screw cats. There ain’t no such thing as a police cat. We’re here to talk about dogs.

**As an aside, the morphine dose for dogs is 0.5-1 mg/kg. I can only imagine the look on my boss’ face if I told him I used all my narcs on a German Shepard with a broken leg. Apoplectic would be a good description. Any supervisor would flat have a stroke. That conversation is funny to even think about…