Chapter 39: Transitions, Part II

05 June 1995 – Fruit Street, 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 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 nation, period, as well as one of six Level One trauma centers in Boston. He could be very busy today.

Jeff was sure the ER staff at Mass General thought he was crazy. He wore a grin a mile wide under his mask and face shield; he wore the mask because he was in the ‘Soiled Utility’ room, rinsing ‘waste’ out of disposable bed pans prior to 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 to get to do the big things.

“Hey, Christi, those bed pans are taken care of. Do you have anything else you need done?”

Christi Newsome, the nurse he was assigned to for today, smiled. She couldn’t ever remember a medic student volunteering for the shitty jobs before being told to do them.

“Would you mind taking a couple 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. The fridge they’re kept in is back there?”

“Right. Thanks, Jeff.”

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

He was there three hours before something serious arrived. A regional air ambulance service called over the radio to report they were ten minutes away with a boating accident victim. From the report, two boats collided on a lake near the Massachusetts/New Hampshire state line; their patient had been a passenger on one of them and was badly injured.

Christi took Jeff over to Trauma One, the trauma bay where the patient would be evaluated. She explained what their jobs would be once the patient was placed on the exam table by the helicopter crew; she also made sure he knew where to find the equipment they’d need. He put a thin plastic gown over his clothes and donned a second set of gloves and another face mask while the trauma team gathered.

A blue-suited flight crew entered the trauma bay. The familiar routine of the crew’s report was interesting to see from the receiving end. As soon as the patient landed on the table, Jeff stepped over to draw the blood samples; the flight crew had already placed two IVs in the patient’s arms, so no more were needed.

Jeff watched the Emergency Medicine resident place a chest tube in the patient while he finished drawing the samples. He winced as 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 have to receive while he was awake.

A team took the patient off to the CT scanner after the initial evaluation. Jeff pulled off his mask, gown, and his outer pair of gloves before collecting the trash generated by the trauma team. Housekeeping would clean the room once the patient went to the floor but others could trip over the trash, or slip trying to avoid it, so he 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 the area where the flight crew cleaned their equipment.

“You’re a medic student? I’m sorry, I didn’t notice 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 closer. “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 where I know you from! I’m Aaron Sandoval, 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. 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, explained, “maybe fifty yards past the tree line at the edge of this clearing in that direction, and all the way back to the road. 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 you’ve had to have those propane tanks on the back of your house if you lived up here; not terribly inconvenient, but not something that a lot of people wanted to deal with, apparently. Once they put that gas main in they’ll finally pave the road, too.” Jeff looked at Keiko; 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 by overhead. “Black Hawks,” 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 much the guys in 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 and not have it affect you right before you head home to sleep.”

“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, before he turned to Jeff. “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 off slow 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 a treadmill which was already moving.

“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 you know what you’re doing and you work hard; 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. 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 they took his shirt off. Before the other staff finished placing the EKG electrodes on the patient, Jeff was done.

“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. But, once I finish my assessment sheet for that patient 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, 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 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; it was again Jeff’s job to start the IV.

“We’re going to intubate,” the Emergency Medicine resident running the trauma announced to his Attending, who stood at the edge of the trauma bay, after the initial assessment. Jeff was finishing up a second IV by that time.

“Dr. Snow, any objections to having Mr. Knox make the attempt?” Jeff heard Dr. Atherton ask. Jeff was shocked.

“I’m here for another year, Sir; 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 was as dry as Death Valley and his pulse raced. The second-year resident 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?” Doctor Snow asked the other staff. “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 the mannikins, but a whole lot easier. Okay, let’s get set up while they grab the meds. Got everything? Alright, 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 -- the fasciculations from the paralytic Succinylcholine -- and was then still. Jeff flicked the patient’s eyelash and got no response. He nodded at the respiratory therapist bagging the patient. The man stopped bagging and stepped back.

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

The patient’s vocal cords gleamed 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 he removed the blade. Inflating the cuff, he asked the RT to bag the patient while Dr. Snow listened to the lung sounds.

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

“Good. Depth, Dr. Snow?”

“Twenty-two centimeters at the lips, Doctor. Sandy, secure the tube, please?” The 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 prepared to leave the trauma bay.

He watched as a nurse hung the collection device for the chest tube from a pole; a drain line was connected to a filter and then to the patient. Another nurse hung the Propofol, a milky-white medication which would keep the patient unconscious.

“What are they doing, Dr. Snow?”

“They’re giving the patient’s blood back to him; 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. You earned this chance, plain and simple. Most of the other paramedic students 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. He reminded me he’ll be a third-year resident when the new class arrives July first; he’s lost track of how many tubes he has. He 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 know what Beth looks like! Why do I need to go somewhere to look at another woman, 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. Just 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! We’ve gotta fix that!”

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

“You mean you’re up here practicing on our patients without a license?”

“No, I’m operating under a license.”