Chapter 39: Transitions, Part II

05 June 1995 – Boston, Massachusetts

Jeff was excited. Today was his first day of clinical rotations, and he was starting with a bang. He’d train alongside other paramedic students, as well as with nursing students, physician’s assistant students, and resident physicians at one of the nation’s best teaching hospitals – Massachusetts General Hospital. It was one of the best hospitals in the country period and one of six Level One trauma centers in Boston. So Jeff could be very busy today.

The ER staff at Mass General would think Jeff was crazy if they could see his face, probably because he wore a grin a mile wide under his mask and face shield. Jeff wore the mask because he was currently in the Soiled Utility room, rinsing ‘waste’ out of disposable bedpans before putting them in the biohazard collection box. The other paramedic students put their noses in the air and scoffed when they saw him carrying the pans. Jeff’s philosophy was to do the little things first before asking to do the big stuff.

“Hey, Christi, I finished those bedpans. Do you have anything else you need me to do?”

Christi Newsome, Jeff’s assigned nurse for his shift, smiled. She couldn’t remember a medic student ever volunteering for the shitty jobs before being told to do them.

“Would you mind taking a couple of apple juices into Room Three? She doesn’t need to be NPO any longer. The doc said it’s okay for her to have something.”

“Sure. They’re kept in the fridge back there, right?”

“Right. Thanks, Jeff.”

Jeff brought the drinks to the woman in Three. He made sure the patient was as comfortable as possible before leaving the room and finding Christi again. Jeff did the little tasks that would have kept Christi from focusing on the medical side of her patients’ needs. In the end, though, Jeff knew that nursing included those little touches, too.

Jeff’s shift was three hours old before something ‘serious’ arrived in the ER. The regional air ambulance service called over the radio to report they were ten minutes away with a boating accident victim. Two boats had collided on a lake near the Massachusetts / New Hampshire state line from the report. Their patient had been a passenger on one of them and was severely injured.

Christi took Jeff over to Trauma One, where the trauma team would evaluate the patient. She explained their responsibilities to Jeff once the helicopter’s crew placed the patient on the exam table. Christi also made sure Jeff knew where to find any needed equipment. Jeff put a thin plastic gown over his clothes and donned another set of gloves and another face mask while the trauma team gathered.

A blue-suited flight crew entered the trauma bay. It was interesting to experience the familiar routine of an ambulance crew’s report from the receiving end. As soon the flight crew placed their patient on the table, Jeff stepped over to draw blood samples. The flight crew had already put two IVs in the patient’s arms, so Jeff didn’t need to start any others. Jeff saw the Emergency Medicine resident place a chest tube in the patient while drawing the samples. Jeff winced when one of the nurses placed a urinary catheter, called a ‘Foley,’ in the patient’s penis. Those were two things Jeff hoped he’d never receive while awake.

ER staff brought the patient to the CT scanner after their initial evaluation. Jeff pulled off his mask, gown, and outer pair of gloves before collecting the trash generated during the team’s exam. Housekeeping would clean the room once the patient went to the floor, but others could trip over the garbage or slip trying to avoid it, so Jeff picked it up anyway.

“Excuse me?”

Jeff turned to see one of the flight crew standing next to him. “Yes?”

“Is there any more of this cleaning solution? This one’s empty.”

“Sure. Let me grab it for you.” Jeff took the empty bottle from the man. He retrieved the new bottle of cleaning solution and brought it to where the flight crew cleaned their equipment.

“You’re a medic student? I’m sorry, I overlooked that before.”

“No worries. You guys need to get back in service, right? Can’t do that if your equipment is dirty.”

“Thanks.” The man looked at Jeff more closely. “Did you ever work out in Springfield?”

“Yeah. I used to work for Connecticut River Valley Ambulance until they got bought out. You look familiar, too.”

“That’s how I know you! I’m Aaron Sandoval, and I used to be a medic for Western General.”

“Jeff Knox. Good to see you again. Small world, isn’t it?”

“I’ll say. How’d you wind up out here?”

“Long story. I’ve been at Brophy in Malden for about two years now. I just started my clinical rotations for medic school today.”

“Well, I’m sure we’ll cross paths again.”

“ ... this parcel extends just past the crest of the hill in that direction,” their realtor, Kari Koivu, was saying, “maybe fifty yards past the tree line at the edge of this clearing in that direction, and back to the road. Plus, this trail here pretty much marks the property line on this side of the parcel.”

“How come there hasn’t been much development on this road until now?” Jeff asked the man.

“The gas company’s finally pushing a main up this road. Up until now, people had to have those propane tanks on the back of their house to live up here. Not too inconvenient, but not something that a lot of people wanted to deal with. Once they put that gas main in, they’ll finally pave the road, too.”

Jeff looked at Keiko, and she nodded at him. “Kari, grab this lot before it disappears. Grab the one that you said runs behind the place, too. We won’t try to combine the lots or anything, but I don’t want someone building a house behind ours, either.”

A flight of four helicopters went thumping overhead.

“Blackhawks,” Jeff commented, recognizing the silhouetted UH-60s. “Are they from Fort Devens?”

“Yes. They occasionally fly over this side of Lancaster, but not too often since the South Post-training areas are over by Route 70. They’re probably on some sort of practice mission with the 10th Special Forces guys. Those guys train a lot.”

“Don’t I know it. I was in the 82nd. I remember how often the guys in the 3rd Group trained. I think half the ammo dump at Fort Bragg was theirs.”

“Hey, Beth. How are you today?”

“Better than you guys if I’m seeing you after six in the morning, Jeff. Rough night?”

“You and your intended have the same capacity for understatement, Miss Hargraves.”

“Speaking of my intended, where’d he disappear to?”

“Sean ran down to the cafeteria to get us some coffee before we head back to the station.”

She shook her head. “I don’t understand how you guys can drink coffee right before you head home to sleep and not have it affect you.”

“It’s a skill, one we’ve perfected through much practice.”

“Hey, good lookin’. You come here often?” asked a third voice.

“Yeah, but your fiancée is standing right here, and she looks like the jealous type,” answered Jeff before Beth could.

“Sean McNeil Brophy, you best learn some better jokes before we start having kids. I don’t want them learning your current supply from you.” She turned on Jeff. “And you! Don’t you encourage him!”

“Yes, Dear,” Sean answered. “You need to start learning that phrase, Jeff.”

“My fiancée is a black belt, Sean. I say that already.”

Jeff’s first shift at Mass General’s ER had been a seven a.m. to three p.m. shift. It started slowly before picking up a little more than halfway through. His second shift was a three-to-eleven afternoon shift. It was like trying to step on an already-moving treadmill.

“Jeff? I’m Chris. Drop your stuff and let’s head into Room Five,” his assigned nurse Chris Gadbois said to him as soon as he stepped into the treatment area. “We’ve got a chest pain patient coming back here from triage, and we’ll need an IV and blood draw. I talked to Christi Newsome earlier, and she told me that you work hard and know what you’re doing. I’m trusting her judgment here, so don’t let me down. Start the IV first. Try to get at least an eighteen gauge into the person. Smaller catheters will cause the red blood cells to hemolyse, to rupture, making the sample unusable. So before you take off the tourniquet and flush the line, draw the samples through the catheter, then connect the IV.”

“Got it, Chris.”

One of the triage nurses wheeled an older gentleman into the treatment area. Jeff and another medic student lifted the man out of the wheelchair onto the stretcher. Jeff tied the constricting band around the man’s arm after helping the man take off his shirt. Jeff finished before the other staff finished placing the EKG electrodes on the patient.

“All set, Chris.”

“Already?” Chris looked over, expecting to see a blood bath, but there was no blood visible anywhere. “The doc just ordered some nitro for the patient. Why don’t you give them to him and explain the side effects.” Chris was impressed, and the kid’s shift wasn’t even ten minutes old. “Do you need me to sign off on that line and nitro for you?”

“The line, yes. The nitro doesn’t count since it wasn’t an IV medication. Also, once I finish my assessment sheet for him, would you mind signing it?”

“I can’t believe you guys don’t get credit for med administration!

“We do, but only if it’s an IV push or infusion.”

“That’s crap! If Dr. Atherton orders a nitro drip, I’ll make sure you start it, so you get the credit.”

The pace of the shift never relented. Jeff needed to write assessments on the chest pain, a respiratory distress patient, a traumatic back pain, a broken wrist, and a fall down the stairs by 8:00 p.m. At 9:30 p.m., a Boston EMS BLS crew brought in a stabbing victim from the bus stop down the street. ALS was a good many minutes behind them, and it made sense to just bring the patient in from where they were. The man moaned and flailed as the ambulance crew placed him on the table in Trauma Two. Jeff’s job was to start the IV once more.

“We’re going to intubate,” the Emergency Medicine resident running the trauma announced to his Attending. The ER Attending stood at the edge of the trauma bay watching the assessment. Jeff finished up a second IV when he heard the announcement.

“Dr. Snow, any objections to having Mr. Knox attempt the intubation?” Jeff heard Dr. Atherton ask, which shocked the shit out of him.

“I’m here for another year, Sir. So one tube isn’t a big loss. I’ll coach him if you have no objections?”

“By all means, Doctor. Mr. Knox, the intubation is all yours. Dr. Snow will assist where necessary.”

Jeff’s mouth went as dry as Death Valley, and his pulse raced. The second-year resident caught Jeff’s attention and waved him to the head of the stretcher.

“Can we get two hundred milligrams of Succinylcholine, one hundred micrograms of Fentanyl, and twenty milligrams of Etomidate, please? Okay, Jeff, right?” Jeff nodded. “I’m Josh. We’re going to sedate and paralyze this guy for you so you can intubate. I’m guessing you’ve never dropped a tube on a real person before?” Jeff shook his head. “Same technique as when you use the mannikins, but this will be a whole lot easier. Okay, let’s get set up while they grab the meds. Got everything? All right, Tammie, go ahead and give the meds.”

As Jeff watched, the patient’s movements diminished while another of the ER nurses, Tammie, pushed the pain medication Fentanyl and the sedation medication Etomidate. The patient’s body twitched all over a minute later – a reaction to the paralytic Succinylcholine – and then went still. Jeff flicked the patient’s eyelash and got no response. Finally, he nodded at the respiratory therapist bagging the patient, and the man stepped back.

Jeff held the handle of his laryngoscope in a firm grip. He was thankful for the gloves on his hands since they kept his sweaty palms from being an issue. Jeff inserted the blade in the patient’s mouth, mindful of the man’s teeth, and lifted the jaw up and away from him.

The patient’s vocal cords glowed a bright white against the pink of the trachea. Jeff held his gaze on them while his right hand introduced the endotracheal tube. He watched while it slid between the cords. Once the balloon at the end of the tube was completely past the cords, Jeff removed the blade. He inflated the cuff and asked the RT to bag the patient while Dr. Snow listened to the lung sounds.

“Perfect, Jeff. Clear bilateral breath sounds in all lung fields with no sounds over the epigastrium, Dr. Atherton.”

“Good. Depth, Dr. Snow?”

“Twenty-three at the lips, Doctor. Sandy, secure the tube, please?” The respiratory technician (RT) secured the tube and connected the ventilator.

“Let’s give him twenty milligrams of Pavulon, please. How is his sedation?”

“Holding, for now, Dr. Atherton. It’s been about five minutes since we gave him the Fentanyl and Etomidate.”

“Dr. Bennington?”

“We brought down some Propofol. I believe we should start that before we head up to the OR,” the trauma attending stated.

Atherton nodded. “Okay, everyone, nice job. Mr. Knox, that was a well-performed intubation. Let’s auto-transfuse the blood in the Pleurovac before we hand off to Trauma Surgery, please,” Dr. Atherton ordered from the edge of the trauma bay.

“Thanks, Dr. Snow,” Jeff said in a quiet voice as the two left the trauma bay.

Jeff watched a nurse hang the collection device for the chest tube from a pole. She connected the drain line to a filter and then to the patient. Next, another nurse hung the Propofol, a milky-white medication that would keep the patient unconscious.

“What are they doing, Dr. Snow?”

“They’re giving the patient’s blood back to him. So you don’t have to type and cross that way. You can call me ‘Josh,’ by the way. How old are you?”

“Twenty-five, Sir.”

“I’m twenty-eight. No need to call me ‘Doctor or ‘Sir’ all the time. What do you need me to sign for you?” Jeff handed the resident his skill log. He nodded to the man and stepped over to the ER Attending while Josh signed.

“Thank you, Dr. Atherton.”

“Jeff, I’ve watched you bust your backside here all afternoon, and Christi told me about your first shift. So you earned this chance, plain and simple. But, unfortunately, most of your classmates are still standing around with their thumbs up their butts.”

“The resident gave up a tube?”

“Trust me, Sean, I was as shocked as you are. Josh reminded me he’d be a third-year resident when the new class arrives July first. He’s lost track of how many tubes he’s performed. Josh knows he’ll get more before he graduates, too.”

“Will wonders never cease?”

“I think Dr. Atherton’s beaten some humility into these kids. He’s a pretty cool guy. Anyway, are you sure you’re okay with us just going to a Red Sox game?”

“For my stag party? Yeah. It’ll be just you, me, and Dad. I don’t need a crowd of people or the whole strip club thing. It’ll be my first game at Fenway. Plus, you’ve seen how Beth looks! So why should I go somewhere to look at other women or to look at another woman at all?”

“I thought your dad would have taken you to a Sox game by now?”

“He did, but that was during a road trip we took to Toronto after we met. We haven’t found the time to go to Fenway since I moved up here.”

“They’ll reject your application for New England citizenship if they ever find that out! So we’ve gotta fix that!”

“So, how long does it take to get your paramedic license anyway?” Jenna, a nurse at the Mass General’s Cardiac Care Unit, asked Jeff the following week.

Jeff sat at the nurses’ desk with his class notes, reviewing them during some slack time in the shift. “You don’t get licensed as a paramedic in Massachusetts, Jenna. You get certified.”