Chapter 38: Transitions

15 March 1995 – Lowell Street, Wilmington, Massachusetts

“ ... connect the IV tubing ... tape it down using a chevron and a Tegaderm ... make sure I’ve released the tourniquet ... dispose of the sharp in the sharps container. Done.”

“Well done, Jeff,” Devon Aguilar commented.

Devon was a paramedic for Wilberforce Ambulance Service, a family-owned company which provided service to many towns around Burlington, Massachusetts; he was also the teaching assistant evaluating IV skills today.

“Thanks, Devon. It’s starting to feel like more of a natural process, less herky-jerky, when I start IVs. I’ll be interested to see how I do on real arms and not these practice ones.”

“That feeling, that’s your muscle memory getting up to speed with the skill, Jeff. You’ll have to adjust a little if your company switches equipment brands, or if you change companies and they use something different, but the process doesn’t change. These arms are good, but live arms are hard to beat. What else do you have to consider before you dispose of the sharp?” Jeff thought for a second.

“Do I need a blood sugar reading? I can take it off the catheter, right? So I don’t have to stick the patient again?”

“In most cases, yes. The monitoring strips some services still use are calibrated for capillary blood samples while most glucometers seem to give reliable readings from either capillary or venous blood sources. If a patient is peripherally clamped down, you may not be able to get a true ‘finger stick,’ while you can still get venous blood off the IV catheter, especially if you do an antecube IV. Anyway good job, head over to the next room for intubation practice with Tara.”

“Tara’s on the airway station today? Excellent!” Devon laughed.

“You might be about the only one in this class who is happy when Tara’s evaluating them. She’s tough as nails!”

“True, but I’d rather screw up a million times in front of her here than on one actual patient out there.”

“Right you are, Jeff. That’s why we don’t give you as much grief as your classmates, because you understand that. Go on, get going!”

Jeff gave Devon a wave as he exited. He stepped into the airway training room and Tara Bergeron glared at him; she did this to every student, so Jeff wasn’t concerned. Nine months into the class, and some of his fellow trainees hadn’t figured that out.

“Alright, Knox,” she said without preamble, “I know you can handle oral intubation, so today I want to see you do a nasal intubation.”

“Right,” he answered in the same no-nonsense manner. “Unlimited helpers as usual?”

“Correct.”

“No trauma suspected?” Tara shook her head.

“None.”

“Okay, Universal Precautions,” he said as he pulled on a pair of gloves. He also donned a surgical mask with a clear face shield attached; it would keep the patient’s fluids out of his eyes and mouth.

“Scene is safe?” Tara nodded. “Okay, first...” Jeff went through the process of nasally intubating the mannequin as he narrated the procedure.

“My assistant keeps the patient oxygenated using high-flow O2 via non-rebreather. I check my equipment, preparing the appropriately-sized ET tube by lubricating it with two-percent Lidocaine jelly or sterile water-based lubricant; insert the tube into the larger nostril, usually the right; direct the tube straight back, perpendicular to the face.

“Gently rotate the tube ninety degrees clockwise when I hit the back of the throat; listen for the patient’s breath sounds as I advance the tube; when I’m in the right position, advance as the patient draws a breath as the vocal cords will be open the widest; if in the proper position, the patient will attempt to cough and be unable to speak. Inflate the tube’s cuff, provide positive-pressure ventilations, and coach the patient to breathe in time with me.”

“Well done. Good technique,” Tara said. “What are the contraindications to nasal intubation?”

“Absolute contraindications are suspected epiglottitis, midface instability, any form of coagulopathy, suspected basilar skull fractures, and apnea or impending respiratory arrest. Relative contraindications include large nasal polyps, suspected nasal foreign bodies, recent nasal surgery, upper neck hematoma or infection, history of frequent episodes of epistaxis, and prosthetic heart valves, due to the increased risk of bacteremia during the insertion.”

“Why can’t you place a nasal tube when the patient’s not breathing?”

“You need the patient’s breath sounds to help you know you’re in the right place when you’re not performing direct laryngoscopy.”

“Why is a suspected basilar skull fracture an absolute contraindication?”

“Because you run the risk of the tube passing through the fracture and into the patient’s brain.”

“Which potential complication is common to both oral and nasal intubations?”

“Vocal cord damage.”

“What’s the most common complication?”

“Epistaxis; a nose bleed from abrasion of the nasal mucosa.” Tara looked at him, narrowing her eyes.

“‘What is the air speed velocity of an unladen swallow?’”

“‘African or European?’” Jeff shot back. “And my favorite color is blue.” Tara smiled.

“‘Alright, we’ll call it a draw.’ Good job, Jeff. If I could, I’d recommend to Jackie that you start your clinical rotations now while we continue to beat up your classmates.” ‘Jacklyn’ was Jacklyn Simmons, the program coordinator and lead instructor. Tara gave him a look.

“You know you’re hurting my feelings, right? I intimidate every single student who comes through here for the six years I’ve been an assistant instructor and then BAM! You come waltzing in here and blow my reputation! You’re not intimidated by me at all!”

“Hell yeah I am! You scare the crap out of me!”

“Huh? I do?”

“Um, YEAH! And why do you think I always find the skill station you’re running when you’re here?”

“You like my sparkling personality?” she asked sarcastically. Tara knew her personality was often abrasive.

“Yeah, that’s it,” he snorted, answering in the same tone. “No, it’s the same reason you scare every single member of this class: you won’t accept less than perfection, and you won’t let us accept less than perfection, either. The consequences are the same in this job as they were when I was jumping out of airplanes for a living: death.”

“Skydiving instructor?”

“Paratrooper. No, the standard was: you do it the right way, every time. That’s the way you train. Three hundred maybe a good batting average in baseball but it’s a lousy percentage in this job!”

A week later and the class practiced live IV starts on each other; if you wanted to stick someone, first you had to agree to get stuck. There was the usual hemming and hawing from any large group along with the folks who often stepped forward first, like Jeff.

Jeff was methodical as he prepared his equipment prior to the attempt. He donned gloves before tying a constricting band around a classmate’s wrist. A vein popped up and Jeff swabbed the area with alcohol. He pulled the protective cap off the catheter, lined it up, and inserted the needle.

Jeff felt a slight ‘pop’ as the needle pierced the vein he targeted; a small chamber attached to the needle filled with blood. He removed the band and occluded the vein as they’d been taught. He removed the catheter’s needle, leaving only the Teflon catheter, and flushed the catheter with sterile saline.

“Nicely done, Jeff; very smooth,” Tara commented. “Harv, how’d it feel?” She took a gentler tone tonight. People were already nervous; very nervous people holding sharp objects is a bad combination.

“I barely felt a thing,” Harv replied.

“Okay, your turn. Jeff, your hand please?”

Jeff placed his right hand on the desk in front of him for Harv -- Harvey Goldman -- to perform his IV start. Harv’s gathering of equipment wasn’t as organized as Jeff’s was. Jeff could also tell Harv wasn’t as confident as he could be -- his hands shook as he tied the constricting band around Jeff’s lower forearm; it took three attempts to get the tension in the band right.

Jeff’s poker face was much improved from 1992; he hid his trepidation well while Harv swabbed his hand with alcohol. Harv identified the vein he wanted to cannulate and swabbed that area again. Satisfied, he put down the alcohol wipe and picked up the twenty-gauge IV catheter. The sound of the catheter cap being removed seemed quite loud to Jeff. Harv positioned Jeff’s hand and took a deep breath as he brought the catheter to bear.

Jeff bit back a gasp as the catheter tore through his skin. Harv hadn’t drawn the skin of his hand tight before making the IV attempt, so the needle didn’t pass through it cleanly. Harv didn’t hit the target vein on the first try, either; he fished for the vessel, moving the end of the needle back and forth under the skin. Sweat began to bead up on Jeff’s forehead as he fought not to cry out.

Jeff lost his battle when Harv tried to cannulate a tendon in his hand. Jeff could see the catheter bend when Harv attempted to enter what he thought was the vein. The pain was excruciating.

“And, you’re done!” Jeff yelled as he pulled his hand away.

The catheter remained in Harv’s hand when Jeff’s jerked back. The needle tore open the vein Harv originally targeted as it exited. The tight constricting band allowed arterial blood to enter Jeff’s hand, but blocked the venous return. That blood now poured out of his hand and onto the disposable absorbent pad on the desk.

Jeff tore the band off his forearm and slapped a wad of gauze over the puncture wound. He walked out of the classroom without another word as everyone watched. He continued down the hall to the building’s lobby; he sat on one of the benches there while holding pressure on his hand. His right ring finger twitched occasionally as he stared at it.

“Jeff? Are you okay?”

Jeff looked up to see Tara Bergeron standing there with a look he’d never seen on her face: concern. He knew that thought was unfair to Tara; by all accounts she was an amazing medic and cared deeply about her patients, often visiting them in the hospital after transporting them days before.

“I’ll be fine, Tara, thanks.” His finger picked that moment to twitch three or four times.

“He didn’t try to cannulate the tendon did he?”

“I’m afraid so. Don’t be too hard on him, Tara; he’s a good kid.”

“‘Kid?’ You’re all kids to me! Why, how old are you, Jeff?”

“Okay, so I’m only twenty-five. I feel old beyond my years sometimes, though.”

“Your knees must hate you after jumping out of planes like you did.”

“I only did one hitch with the Army, so they’re not as bad as they could be, but I do run to keep in shape. I’m sure that won’t help over the long-term. Really, Tara, I think I scared Harv enough; don’t go all ape-shit on him on my account, okay?”

“Christ, I’m getting soft in my old age,” she muttered while she shook her head. “I’ll play nice. I won’t even yell at him!”

“I’m sure that’ll be a first.”

His right arm went numb when Tara punched him in the shoulder.

“So how much longer do you have left for medic school? Five months?” Sean asked one night in early April.

“Until we test, yes. I’ll be done with didactic the middle of next month, have two weeks off, start clinicals the first full week of June, and should start my ride time after July 4th if everything goes well.”

“Have they told you how fast you’ll get your medic schedule once you pass the test?”

“What’s up, Sean? You trying to get rid of me?”

“No, I’m coming off the road the week before Labor Day,” Sean told him.

“’Off the road?’ Where are you going?”

“I’ll be a management trainee after the holiday, Jeff. I’m stepping out of the shadows and gonna start working with my dad.”

“Are you worried about possible backlash?”

“I’m sure there will be some. Luckily, I’ve only worked with you, so I don’t have to worry about having worked with some of the malcontents here. I don’t have to worry about you screaming that I was just working the road to spy on folks.”

“No, you don’t. Not if you pay me you won’t.”

“Such the comedian you are!”

“So, we’ve only got those five months on the farewell tour then, huh?”

“Yeah, though it’s not like either of us are going far, Jeff. We’ll still both be working for Brophy.”