Six months and change since I entered the blogosphere…

241 posts…

Countless fascinating people…

And 100, 000 visitors.

Just…WOW.

I am humbled, and honored that anyone would want to read.

Horseshoe Bay, Texas, whoever you are, you win a signed copy of The Book if you don’t already have one. Drop me an e-mail with your address.

Mielikki asked in comments on my last post:

If you find your keys, can you check for mine? Please?

Found ‘em, Ma’am.

Stolen from Fodder.

…I refer you to the following resources:

Back Talk is the blog found on Spine-Health.com, a clearinghouse of information, medical literature and advice on managing your chronic back pain, most of it written by the physicians and medical professionals who treat your back problems.

Rebuild Your Back is the website of Dean Moyer, a journalist, writer and possessor of a really bad back. Dean offers a lot of first-hand, common sense advice for those with chronic back problems who want to break the cycle of pain, medication and surgery.

Oh yeah, and he debunks a lot of the shamanism and quackery out there, which earns him serious credibility points in my book.

Give ‘em a read. They’re both good resources.

Do you hurt? Even just a little?

Do you have a few hundred dollars in cash?

Do you have friends who groove on the Houston Cocktail (Soma, Lortab and Xanbar)? Would you like to be the most popular person at the party?

Would you like to supplement your income by selling your pain meds on the street?

If you’ve answered “YES” to any of the above questions, Dr. Feelgood can feed your addiction ease your suffering!

Want pain meds prescribed in horse-killing doses?

No problem!

Want prescriptions supplied in huge quantities suitable for secondary distribution to your friends and customers, while still feeding your habit?

No problem! We’ll dole out happy pills in 120 pill lots!

Don’t have a referring physician? Does your referring physician exist only in your fevered imagination?

No problem! We’ll take referrals written on spiral notebook paper or the back of a lottery ticket! Heck, make up a name! We won’t even check! Besides, all those doctors have illegible handwriting anyway!

Previous convictions for narcotic abuse, DUI or prescription drug fraud?

No problem! As long as you can come up with a plausible excuse and can exchange oxygen for carbon dioxide, we’ll accommodate you! And we’ll prescribe you such ludicrous doses that you won’t feel the need to alter or forge a prescription!

Not a legal resident of Texas? No legitimate form of identification?

No problem! We don’t care where you’re from, and we’ll even take your library card as ID!

What’s that? No x-rays or diagnostic studies? Never even seen a specialist? No one can even pinpoint the source of your pain?

No problem! We’ll take your word for it, because we believe in YOU! After all, it’s YOUR pain! What do all those other doctors know? We don’t care how many physicians have turned you away for narcotic seeking or malingering, we’ll getcha whatcha need!

If you’re addicted to narcotics in pain, come on down to Dr. Phil Goode’s Soma Shack and Xanbar Barn today! See one of our professional enablers licensed professional staff today, and let us get you started on the path to death, financial and social ruin medicated bliss today!

We have locations all over southeast Texas! ONE NEAR YOU!

If the legitimate pain management specialists don’t start self-policing the Pill Mills in their midst, the government is going to start doing it for them.

And we all know how well that works out for the legitimate doctors and patients.

*Not to be construed as encouraging any EMT to deviate from their established protocols, no matter how regressive, restrictive or outdated, because medical directors, particularly the ones who write regressive, restrictive protocols, tend to get all pissy when some smartassed blogger exhorts their EMTs to do radical stuff like, oh, using critical thinking skills and clinical judgment.

Standard disclaimer aside, Anonymous asks in the comments from a previous post:

Hey, AD, I read in a previous post that you would like to answer questions to EMS related stuff — hope you are still interested . . . so my question is: there seems to be a wide disparity among EMS providers on what get spinal precautions and what doesn’t. What is your “rule book?”

In other words, the physical exam criteria is more accurate than the x-ray at ruling out a c-spine fracture.

A more important question to ask is not to whom should we apply spinal motion restriction (the term “spinal immobilization” is out of vogue because, well, they ain’t really immobilized no matter how hard we try), but should we perform spinal motion restriction at all?

There is strong evidence that it simply doesn’t work. One large study compared patients with spinal cord injury treated at the University of Malaya Hospital and the University of New Mexico Medical Center. All of the New Mexico patients arrived with professionally administered EMS spinal “immobilization,” while the Malaya patients arrived at the hospital via car, donkey cart or what-have-you, and none of them were immobilized in any way.

The Malaya patients had better neurological outcomes.

Most patients with spinal cord injury sustain their injury at the time of the accident, in what we refer to as primary cord injury. Patients with cervical pain and frank neurological deficits likely have primary cord injury. The damage is already done, and thus boarding provides no benefit. Most patients with cervical pain and no neurological deficits have, at most, a stable fracture and thus do not benefit from boarding, either.

The premise behind spinal motion restriction is to prevent potential secondary cord injury, resulting from manipulation of an unstable c-spine fracture. The Malayan study provides pretty strong evidence that the benefit of spinal motion restriction is only theoretical.

You also have to keep in mind the hazards of boarding, such as potential airway compromise from vomiting, 15-20% reduction in respiratory capacity, increased intracranial pressure, occipital, sacral and heel pressure ulcers, to name but a few. Boarding is not a benign intervention. It takes as little as 30 minutes on a board to cause a Stage I pressure sore. Ask anyone experienced in wound care which is easier – preventing decubitus ulcers, or stopping the progression once they’ve started?

In Maine, everyone from First Responder through Paramedic has been able to use their statewide spinal clearance algorithm for nearly ten years now. In over 16,000 patient encounters, the use of that algorithm resulted in only one missed unstable spinal fracture, and that patient had no long term neurological deficits. My sources also tell me that they no longer consider mechanism of injury as part of their criteria, since MOI is a notoriously poor predictor of injury compared to a thorough examination.

The NEXUS clinical exam criteria are as follows:

1. No posterior midline cervical spine tenderness

2. No evidence of intoxication

3. Normal level of alertness (for that patient. An Alzheimer’s patient isn’t necessarily excluded, for example, provided they are alert and lucid enough to be good historians)

4. No focal neurological deficits

5. No painful, distracting injuries. The devil is in the details on this one. Effectively, whatever the injury, if it distracts the patient from perceiving pain or participating with the exam, or distracts the EMT from conducting a thorough exam, that’s considered a distracting injury. Put another way, calm, alert 78-year old lady self-splinting her fractured arm and appropriately answering questions = not distracted. Hysterical teenager freaking out over his minor boo boo = seriously distracted.

Not to mention a 10.0 on the Wuss-O-Meter.

The Canadian C-Spine Rule ( an offshoot from the Ontario Prehospital Advanced Life Support Study, OPALS), also adds a couple more exclusion criteria:

6. Patient age over 65

7. Significant injury above the clavicles.

Generally speaking, if the above criteria are met (at the least, 1-5), you’re safe in not boarding the patient.

Now before I get a gazillion comments with the common refrain “Yeah but AD, even if it only saves ONE patient, it’s worth it…”

I say no. It is not worth it. We as a profession should be long since past the stage of doing interventions based on zero scientific evidence, in the hope that it benefits less than 1% of our patients. The same holds true for basing EMS system design on response time standards for cardiac arrest patients, which make up less than 1% of run volume in most systems.

If you’re routinely boarding people purely out of defensive medicine, protecting yourself from lawsuits, I feel your pain. Just keep in mind that standards of care change with advances in science, and we have plenty of evidence now to back us up in our decision to not board someone, and very little scientific evidence to support the practice.

I’ve also noticed that the EMS systems that expect their m
edics to board everyone also give you the crappiest tools to do it with; only three straps on the board and a flimsy cardboard head immobilizer.

This guy scares me, and not for the obvious reasons. Face it, Smilin’ Bob is about as non-threatening a purveyor of false hope quality wood as you’ll find on television. Compared to say, Ron Jeremy on the Extenz infomercials, Bob’s a muppet. A Beanie Baby. A baby duck.

The only way Bob can inspire fear and loathing is if he were your proctologist.

Unless of course, he possesses a weird psychic hold over your four-year-old daughter.

And that just makes him positively fucking creepy.

When my kid hears that whistling jingle, she will drop whatever she is doing and run to the TV and stare, slack-jawed, until the commercial is over. Doesn’t matter what she’s doing – playing with Dora, taking a bath, sitting on the potty – when Bob calls, she’s compelled to answer.

She’ll squeal with delight and do the Happy Feet dance whenever she hears the jingle – you know, kind of like Bob’s wife right after he pops the magic boner pill.

We even re-enact the commercials. She knows them all by heart, and God forbid I deviate from the script:

KatyBeth (squealing breathlessly): “Daddy, it’s Bob!”

AD: “I know, Sweetie.”

KatyBeth: “Bob’s so happy!”

AD: “Right down to his corpus cavernosum, Sweetie.”

KatyBeth (humming the jingle happily): “What’s a corpeth cavewnosa, Daddy?”

AD: “Ask your Mommy when she picks you up tomorrow, Sweetie.”

KatyBeth (in the cutest four-year-old TV pitchman voice): “…and Bob has a new burst of confidence and a healthy dose of respect from the neighbors, not to mention a happy Missus at home. Yep, Bob’s livin’ large and steppin’ easy…”

AD (distractedly): “Mmmm hmmm.”

KatyBeth: “Daddy, what does natuwal male enhancement mean?”

AD: “Ask Mommy’s boyfriend, Sweetie. He should know.”

KatyBeth: “Daddy, can you smile wike Bob?”

AD: “Not right now, Sweetie.”

KatyBeth: “Dadeee…”

AD: “Baby, for me to smile like Bob would require a jar of peanut butter, a deck of dirty playing cards, some fuzzy handcuffs, and for certain women to lower their standards a lot.”

KatyBeth: “Huh?”

AD: “Let’s see if we can find something else on the TV, Sweetie. Like maybe a Massengill commercial. “

GruntDoc notes that a common practice among several nursing homes in his area may negatively impact patient care, and Anonymous Respiratory Therapist tells of a nursing home medication error that had tragic results.

I wish I could tell you that such happenings are rare, but they’re not.

Hat tip to Kevin, MD for the link, which reports the FDA approval of Lyrica as the first drug officially approved for treating fibromyalgia symptoms. Sadly, it only works in 30-60 percent of sufferers. Lyrica has previously been approved for treating partial seizures and pain from shingles outbreaks and diabetic neuropathy. From the article:

The FDA estimated that three to six million Americans — most of them middle-aged women — have fibromyalgia.

There is, however, no clinical test to confirm a diagnosis. An exclusionary diagnosis is made after physical examination and symptom evaluation.

A more cynical person than I might suggest that, of the 40-70 percent of sufferers who don’t respond to Lyrica, a significant number are those poor misdiagnosed COWMAS sufferers that show up in the ER three times a week seeking narcotics…

Edit: 6-26-07 Lots of good comments from fibro sufferers in the comments, including a few experiences with Lyrica. Note how PT, exercise and NSAIDs helped most of them. These are the people dealing with their illness and not using it as a crutch or an excuse for narcotics. My hat’s off to them. I’d encourage other fibro sufferers (yeah, even those of y’all that hate my guts) to also check on this online community: Flying With Fibro.

…alternatively titled, “How Your Myocardium Gets Its Swerve On.”

When I teach, I’m always looking for new ways to make the material meaningful to my students. I can gauge an audience fairly well, and I adapt my presentation accordingly. I can be dry and reserved (although I don’t like to be) and fill my presentations with as much technospeak as the audience can stomach. Complexity is not a problem.

Oddly enough, some groups actually like that shit.

However, I’d much prefer to take a rather complex subject and break it down into terms my audience can not only understand, but laugh at. I’ve said it before, and I’ll say it again:

Learning is best accomplished between fits of laughter.

If I’m teaching cardiovascular hemodynamics to a bunch of firefighters, I talk in terms of pumps and hoses, flow rates and closed systems. If I’m explaining heart healthy living to a mechanic, I’ll do it in terms of engines and the importance of using good fuel and routine maintenance.

If need be, I can blather on at length about ion pumps, membrane thresholds, and the propagation of action potentials along conduction pathways.

And a few people actually appreciate that. Their enjoyment of the lesson, however, is significantly lessened by the snores of everyone else in the room.

So, being the shameless approval whore that I am, I play to the crowd. I seek to educate and entertain, and invariably that mean couching my lesson in terms to which anyone can relate.

Like sex.

If I have learned anything about emergency medical providers in thirteen years of teaching, it is this:

1. If you put two firefighters alone in a room with two steel ball bearings, in fifteen minutes one ball bearing will be broken and the other missing, and neither firefighter will have any idea of how it happened.

2. Firefighter medics are suckers for softcore cardiology porn.

3. Female ER nurses are even raunchier than the firefighter medics.

4. Seventy-five percent of the ER nurses and medics, even after years of experience, still struggle understanding AV blocks.

So without further ado, I give you Ambulance Driver’s Tale of The Marital Spat:

Sidney Sinus Node and Virginia Ventricle were a happily married couple. Sidney worked hard every day, Virginia stayed home and took care of the household. At the end of each work day, Sidney rushed home on the cardiac conduction freeway, past the AV node turnpike, came to a screeching halt in the driveway, rushed through the door and, well, depolarized Virginia, if you know what I mean (wink wink, nudge nudge). One might even say they had a Normal Sinus Rhythm kind of relationship. Some times, depending on Virginia’s willingness to wear a little something slinky and Sidney’s libido, it might even qualify as a sinus tachycardia kind of relationship.

Like all things however, relationships cool. It’s not that Sidney doesn’t appreciate Virginia, not at all. It’s not that he doesn’t still find Virginia attractive, either. It’s just all these bills and all this stuff, and well, someone has to bring home a paycheck, right? So Sidney throws himself into his work and puts in longer hours, but being a somewhat steady and reliable, if altogether predictable husband, still comes home every night and depolarizes Virginia, just like he used to when they were newlyweds.

And Virginia appreciates it, she really does. She knows how hard Sidney works. It’s just that he comes home late every night, and he seems so tired, and their depolarizations lately have become well, predictable. On the surface, nothing much has changed. Sidney still comes home every night like he used to. He just comes home late. But Virginia knows there is something missing. There’s no spontaneity any more, even when she meets him at the door naked and slathered in conductive gel. Their relationship has degraded into a First Degree Block kind of relationship, and Virginia just wants the spice back in her marriage. She’s even been considering doing a little self-depolarization, you know, because she has needs too, but the kids are getting to be that age, and she’s afraid they’d recognize those PVCs emanating from the bedroom.

Meanwhile, Sidney, being like most men, is not the most attuned to Virginia’s needs. All he sees is the mounting bills and the mortgage payment and college tuition and the inordinate amount of D batteries Virginia seems to be going through and I mean, really, does she have any idea how much those damned things cost???

So he works even longer hours, and still the work piles up. Mondays aren’t so bad, but the work piles up as the week progresses, until by the time Friday rolls around, he’s so overwhelmed he just sleeps over at the office in a vain attempt to get caught up. Every day of the week, he comes home a little later, until finally he doesn’t come home at all. Virginia, as you might expect, has become accustomed to regular, if slightly boring, depolarization. When she doesn’t get it, she gets bitchy.

So you can bet your ass that the very next night, Sidney drags his ass home on time. But men don’t get the easy lessons, so you can also be assured that this cycle will repeat itself. This Second Degree Type I Block kind of relationship is evidence of some serious cracks in this marriage.

Pretty soon, despite all signals from Virginia that she ain’t happy, Sidney has convinced himself that he is indeed the master of this relationship. He wears the pants. He’s got a toupee, he’s wearing the Mister T starter kit, he’s driving a red Miata, and he’s got a pneumatic little twenty-year-old secretary named Wendy Wenckebach who giggles at all his lame-assed jokes and says things like “Ooooh Mr. Sinus, you are so cute! I just adore older men. They’re so…experienced.”

So Sidney develops the disquieting habit of just not coming home on some nights, totally without warning. He doesn’t call, he doesn’t text, nothing. He just stays gone all night long, while Virginia stays home alone and cries herself to sleep.

Who knows what he’s doing on those nights? Certainly not Virginia. Sidney always has an explanation, and he doesn’t do it all the time. Not at first, that is. And on the nights he does come home, he’s always on time and bearing flowers. But eventually, he goes from an intermittent Second Degree Type II Block to a fairly regular one. After a while, it’s gotten so bad that he’s gone every other night, and the other night while he was depolarizing Virginia, he called her Wendy, that fucking tart!

I think we can all see where this is heading. Virginia is still a young woman, she’s got lots of young male admirers, and she doesn’t have to live her life like this. So one day, Sidney comes home to discover that the locks have been changed and all of his shit is laying out there on the front yard. Taped to his golf bag is Virginia’s official petition for AV Dissociation.

Yep, it’s come to that. Divorce. Splitsville. Third Degree Block. Sidney can do his own thing if he wants, but he’s just kidding himself if he thinks he has anything to do with Virginia any more. She has somebody else to depolarize her from now on, thank you very much.

The sad thing is, Virginia has options, but Sidney doesn’t. He doesn’t even have Wendy any more. It turns out she was only attracted to him when he was attached, and having a needy old man around all the time just isn’t her idea of a good time. And so Sidney comes to the bitter realization that he and the rest of his atrial impulses don’t even matter that much in the greater scheme of things. Women like Virginia can do just fine without him.

So he winds up reduced to a bitter old divorced man who drives by Virginia’s house every day and wonders who is depolarizing his wife these days.

He hears rumors, of course. A mutual friend told him that Virginia had taken up with Jimmy Junction, the hunky pool boy. Jimmy is young and vigorous, so he can depolarize fairly often, but being young, he can’t depolarize for very long, even though the frequent depolarization seems to agree with Virginia. With Jimmy, her QRS complexes are as narrow as they were in her twenties, back when they first married.

Sidney isn’t quite convinced, though. Last week he saw Pete Purkinje’s van parked in front of the house. Pete’s an old man, and not all that stable, and he can’t depolarize very often. Of course, old men usually take a very long time to depolarize, and Virginia’s QRS complexes are starting to look a little wide in the hips, if you know what I mean. Virginia is starting to look her age. Hell, even Viagra atropine doesn’t work much on men like Pete Purkinje. He just doesn’t have the nerves for it. Never did, really.

Sidney, the petty bastard, finds it mildly comforting to think of Virginia relying on tired old Pete Purkinje for her depolarization these days. Serves the bitch right. If he had his way, none of the men in the neighborhood would have anything to do with Virginia, and she’d have to really solely on battery-operated mechanical depolarization to fulfill her needs.

That’s where I come in, of course. I’m a stud that way.

More to the point, is this something I can bring to the attention of the local police?

If not, maybe Strings can get some of his BACA brothers to pay Daddy a visit…

I drove back through my old ambulance district the other day, a detour from the route I drive every week to EMT class. This place holds a lot of memories for me. I met the woman who would become my wife here. Effeminate Partner and Farting Partner were both groomsmen at my wedding. I’ve been back in this area for six months now, and Monday was the first time I had ventured off the main highway in ten years.

Not that I don’t notice things as I pass through every week. The Death Tree has two more crosses hanging on it, and the trunk bears a few new scars. The field beyond it where we landed the helicopter now bears a row of miniature storage warehouses. The local seafood joint is still open, albeit in a new location just down the street. My old ambulance station is now someone’s house. I hope they got the wiring fixed. It’s a bitch when you can’t run the air conditioner and the microwave at the same time.

Monday I had time to kill before picking up KatyBeth, so I turned left instead of right on my way home, and cruised slowly through town.The ambulance service that covers this area now has their station in a strip mall downtown, but their rig wasn’t in the parking lot. Maybe they were on a call. The medic who used to work this station, one of my former students, died of cancer a few years ago. I don’t know the crews who work here now.

The town itself really hasn’t changed all that much; a few new businesses, a few less old ones. The local convenience store probably still gives free fountain drinks to the cops and EMTs. I stopped at the local Popeye’s and ate. I asked the manager, and she confirmed that they still send their leftover chicken and sides over to the Police Department after closing. I doubt the local ambulance crews hang out there as much as we did, swapping lies and mooching free food. The crews these days are far too busy to be up at midnight eating a midnight snack at the Police Department.

On my drive through, I found myself continuing onto the highway west of town. What used to be timber land and pastures has sprouted new neighborhoods and businesses like so many weeds. Not even the small towns are immune to urban sprawl.

The place just doesn’t have the same feel any more.

Without conscious thought, I turned off the main highway through a brick archway into an upper middle-class neighborhood. Ten years ago, the archway wasn’t here. There was no artfully manicured shrubbery, no wrought iron fencing, no neighborhood community center.

Back then, there were just a few nice homes on tree-shaded lots, separated by acres-wide tracts of hardwoods. It used to be quiet, peaceful. Now, every lot is taken up by very large, ostentatious homes on very small lawns. Most of the trees are gone, and there is traffic on these streets. No doubt soon they’ll form a homeowners association, maybe gate the community and hire a security guard to keep out the riff raff. You know, the same riff raff they were ten years before.

On a quiet street in the oldest part of the subdivision, a house sits at the end of the the cul de sac. The garage door is closed, but the lights are on inside. I slow down as I pass, wondering if the people who live there now know this house’s history. Did they meet the couple who built this house, maybe shake their hands when they closed the sale? Did they wonder why a young couple would want to sell a home they built only a couple of years before? Or did the neighbors fill them in on the whole story through neighborhood gossip?

I scan the mailbox as I inch past, and the name stenciled there stops me cold.

The Websters.

They still live here.

I stop my truck next to the curb and clench the steering wheel, breathing hard as my eyes cloud over. Through the rear view mirror and my tears, I can still see the house, but the image is of the same home ten years ago. It’s the same image I see in the occasional nightmare, the ones that make me call my ex in the wee hours to ask if Katy is okay.

“Dispatch to Medic Six, Quaint Little Hamlet Police are on scene. CPR is in progress.”

“Thank God,” murmurs Effeminate Partner. “Maybe there’s a chance.”

I say nothing in reply. I never like these calls, especially when the patient’s age is measured in months rather than years. I just lean my head against the hot window, close my eyes and mentally go through my checklist.

Broselow tape in the side pocket of the trauma bag…Epi dose is 0.1 ml/kg…first dose will be Epi 1:1,000 down the tube, then I’ll get a line, probably intraosseous…

Because I am outwardly calm, because I teach Pediatric Advanced Life Support thirty times a year, because the more tension and chaos on a scene, the more placid my demeanor gets, Effeminate Partner thinks I am all over this. He thinks I am unaffected.

No one is ever unaffected when they’re doing CPR on a six-month-old baby. Not ever.

It’s simply that I don’t do my praying out loud, and I don’t do my crying in public.

And so I continue running this call in my mind as EP navigates the winding roads on the outskirts of town. It will take us close to ten minutes to get there, all told. The address is outside of town limits, well out into the parish. QLH Police Department shouldn’t even be responding.

It doesn’t matter.

When you hear the call go out for a baby not breathing, you go. And you do not worry about petty shit like jurisdiction. Podunk Sheriff’s Office understands this as well.

Tom will be there doing CPR…I’ll get EP to set up a BVM and oxygen, and have him take over ventilation…once Tom can talk I’ll get the details of the arrest…try to question the parents if I can…I’ll need a #1 Miller blade for the laryngoscope, maybe the pediatric Magill forceps…lots of calls for kids that age are chokings…

EP makes the right turn from Parish Road 214 into the housing development. It’s quiet here, and peaceful. The sound of a siren is obscene here, so I lean over and switch it off. EP pulls into the driveway at 112 Mockingbird Lane directly behind the QLH Police cruiser sitting there with the driver’s door and trunk lid ajar.

We bail out of the rig and start fetching equipment, resisting the urge to rush headl
ong into the house. The front door is open, and we can hear a woman wailing in there, but these calls get even more chaotic when you start sending people to your rig for equipment you should have lugged inside in the first place.

Plus, I can focus on process rather than the fact that a six-month-old baby is dead and will likely stay that way.

Newly laid flagstones lead us to the front door. The sod in the yard, while obviously professionally done, has yet to fill in. You can still see the faint lines where it was rolled out. This entire place is brand new, no doubt the dream home of a young professional couple just starting a family.

Inside, we follow the wailing through the foyer and living room, past a Fisher Price activity gym set in the middle of the floor. Just off the living room, a young woman close to my age kneels just outside the door to the nursery, sobbing into her hands.

Her crying has waned to a ragged, soul-rending moan, and her blonde hair is plastered to her tear-streaked face.

“No, no, no…God please, please, please…nooo…Oh God Jesus please God…”

She rocks back and forth, shoulders shaking as she sobs her mantra over and over into her hands as if the words had the power to blot out the horror of finding her son face down and lifeless in his crib.

Words just don’t have that power. Mine least of all.

I duck past her into the room as Effeminate Partner gently takes her by the shoulders and scoots her aside.

She had decorated the nursery with loving care. Winnie the Pooh and friends decorated every surface. Eeyore decoupaged on the bureau, looking back forlornly over his shoulder. Kanga and Roo decorated the other side. One wall was a cheery fireplace, Christopher Robin sitting cross-legged in front of the hearth, Pooh at his side with his arm deep in a big jar labeled “Hunny.” The wall opposite the crib was a mural of the woods; Owl in his tree, Piglet and Tigger frolicking outside. Bees swarmed around a hole high in the trunk of the tree, and a little door was cut into the base of the trunk.

I can envision the mother lovingly tracing this mural on the wall, filling in the colors as the days passed and her first child grew in her womb. There are a few of Daddy’s touches here too. The Tigger doll on the bureau is wearing a miniature Saints helmet, and there is an Atlanta Braves banner pinned to the wall above the crib.

Amidst the cartoon cheer of a small child’s bedroom, Tom Tate kneels on the floor with a small body cradled tenderly in his arms. It’s a little male child, clad in yellow Winnie the Pooh jammies with feet, dwarfed by Tom’s burly frame. His body is limp, but his neck and hands are stiff with rigor mortis.

The AED case lies open on the floor beside him, the pads not even removed from their backing, the CPR mask not even torn from it’s wrapper. Both of them are far too large for the baby.

Tom is chanting his own mantra, but his voice is quavering.

“One and two and three and four and five and breathe…one and two and three and four and five and breathe…”

He looks up at me, and I can see the horror in his eyes, the horror that comes with being a father and being forced to do this job.

When you’re a father as well as a cop or EMT, your particular curse is that you see your child’s face in every tragedy. You see your teenager in the bloody, broken face you pull from the wreckage of their graduation present. You see your wife’s face when you knock on a stranger’s door at 3:30 am to tell them their daughter has died. And you see your infant’s face somewhere in that purple, mottled face wearing the fuzzy yellow pajamas, and you start CPR even though your rational mind reports that you are far too late in coming.

I can see all of that and more in Tom Tate’s eyes as he looks up at me mutely, mouth still silently mouthing his CPR cadence, hands still moving on the baby’s chest. For all intents and purposes, he’s been doing CPR on his own child.

“Tom,” I say gently, putting my hand on his shoulder as he once again lifts the infant’s stiff little body to his mouth. His muscles are corded with tension. He is literally shaking.

“Tom,” I say more forcefully this time, but my voice is quavering too. “You can stop. He’s dead.” I reach out and pry his hand away from the baby’s chest and take the stiff infant from him as he lets out an explosive, shuddering breath and rocks back on his heels.

He sits there silently, chest heaving and hands shaking, hollowly staring at the floor, and I sit beside him cradling this boy’s stiff little body to my chest, both of us wondering if we’ll ever be able to banish the memories of this day.

Behind us, the mother’s cries begin anew as she realizes what our stopping means, and EP kneels on the floor behind her and pulls her back to his chest. She dissolves into a heap, burying her head in his chest, clutching at his arms, wetting his shirt with her tears.

EP just holds her and croons in Cajun French, something I can’t understand. This isn’t how we are taught to deal with grieving family, but Powerpoint presentations and case scenarios in a sterile classroom cannot prepare you for days like these, and so EP holds this woman in his arms and croons to her, professional distance be damned.

I stand up, still holding the infant against my chest, keeping my back to his mother in an attempt to shield her from the sight of him. It doesn’t occur to me that she has already seen what he looks like.

I walk on wobbly legs over to the crib and peer down into it. No thick blankets, no fluffy toys or pillows lie there. The only thing in the crib is a light, thin coverlet and a pinkish, foamy stain on one end of the mattress, forming an obscene blot directly under a mobile clamped to the headboard, brightly colored fish dangling from monofilament line strung on the ribs of an equally cheery miniature umbrella.

They did everything right. Nothing for the kid to roll over on, nothing to bury his face in, not even a pillow. The mattress is firm enough, and there are no gaps between the mattress and the frame. No thick blankets or toys in the crib. No baby monitor, but he is a little old for SIDS.

I pull the infant away from my chest and notice the same bloody purge dried on the infant’s face, marring his features. The rigor has started to set, and his face is flattened a bit where he had lain on the mattress, his nose and one cheek mashed a little out of shape. Dependent lividity renders his face and chest mottled and purple. He has been dead for hours.

No mother should ever have to find her child like that. No parent should have to live with that memory.

Some of that purge is smeared on Tom’s lips and cheek, and I gesture silently toward my face, finger pointing as if to say “wipe that off before she sees.” Tom absently wipes his lips with the back of his hand and stares at the foamy, blood-tinged smear.

I gently place the baby back in the crib, away from the bloody stain on the mattress, and cover his body with the pale yellow coverlet with blue trim, the one with Pooh, Tigger and Eeyore embroidered on it. Tom stands next to me, alone with his thoughts as he stares down at the body in the crib.

“Body in the crib.” Even thinking it sounds obscene.

Tom is the first to break the silence. “Call the coroner?” he asks softly.

“Yeah,” I sigh. “Probably need to cancel anybody else that is still responding, too.”

He nods his head, agreeing. Takes a few deep breaths. His hands are clenched on the crib rail so tightly I can see his knuckles whiten.

“You okay?” I ask, looking at his face. His eyes tell me everything I need to know.

“No,” he says simply, “I’m not. But I can handle it.” And his carriage tells me that, too.

Neither one of us wants to turn around and face the mother. That task falls to me, and I help EP pull the mother to a standing position in the hallway as Tom packs up his AED and gently closes the door to the nursery behind him.

We steer her into the living room and ease her into a chair. She sits there, arms wrapped across her chest, staring vacantly at the baby’s activity gym still sitting in the living room floor. I kneel down in front of her, blocking her view.

She looks at me, eyes searching mine, and EP gently brushes back wet hair plastered to her face. “Is…is he…”

“Yes Ma’am,” I tell her softly. “He’s dead. He’s been dead for a few hours.”

Her eyes well with fresh tears, and her lower lip trembles, but she sniffs loudly and holds back the sobs. She nods her head in affirmation, as if admitting to herself that what I’ve told her is true. She looks back down at my face, and asks in a cracked, hoarse whisper, “Did he suffer?”

I share a look with EP, and Tom makes a choking noise and turns abruptly away, walking quickly back into the foyer. “No Ma’am, I think he died in his sleep. What is your baby’s name?”

“Bryon,” she answers softly. “With an ‘O’. It’s an old family name.”

“Bryon,” I say approvingly. “Good name for a little boy. Had Bryon been sick lately? Did you have any problems with your pregnancy? Was he premature, for instance?”

“No, none of that,” she shakes her head. “I was on bed rest for the last couple of weeks because I’d been having premature contractions, but I carried him to term. He’s always been so healthy…” At that, her voice trailed off and the sobs began again and she buried her face in her hands.

I waited silently, kneeling there in front of her as EP stood behind her, his hands on her shoulders as her body heaved with every sob. EP stared mutely at a spot on the wall ten feet over my head, his jaw clenched and his eyes moist.

I put my hand on her knee and squeezed gently. “Ma’am? Is there someone we can call? A family member or a minister? How can we contact your husband?”

“Our minister, at First Baptist Church,” she nods. “You can reach him through the church directory…” Her voice trails off, and then her head snaps up and she looks at the clock over the mantel. “Oh my God, my husband will be home any minute now! He works at one of the plants, and he gets off work at four o’clock, and Oh my God, what will I tell him?”

“We’ll take care of that,” I assure her, not at all sure how. I flash a look at EP. He nods in understanding, takes his hands off the woman’s shoulders and turns toward the door. He makes it only a few steps and then turns around. “Ma’am,” he asks uncertainly, “what’s your name?”

“Karen Webster,” she answers. “My husband’s name is Kyle.” EP says nothing, just nods and walks outside.

“Karen, we’ll get your minister down here as quick as we can,” I tell her gently, moving to a seat on the couch beside her chair. “I need to tell you what’s going to be happening in the next few minutes, okay?”

She says nothing in reply, just looks at me questioningly.

“The coroner will be here asking questions. There may be Sheriff’s Deputies here taking pictures and gathering evidence. Just try to answer the questions as best you can.”

She just nods vacantly, staring at the Fisher Price activity gym on the living room floor.

There will also be an autopsy, mandated by law in infant deaths, I don’t say. A pathologist will be photographing and x-raying Bryon’s body, cutting him open and examining his organs, doing toxicology tests and myriad other indignities in the faint hope of determining what killed him.

I quietly ask her a few more questions and pray that her minister will arrive her before her husband. I don’t want this responsibility.

She had been working outside all morning. Her husband had left for work at 7:15, and she had slept in until Bryon woke at nine. She had fed him, changed his diaper, and played with him in the living room until nearly noon.

She read The Green Mile as she nursed him, and then put him to bed. She went outside to work in her flower beds, checking on him once before two o’clock. She said he had rolled over onto his belly and was sleeping peacefully, so she had gone back outside. Three hours later, she had gone back inside and found him dead.

I sit uneasily on the couch, looking around the living room. A cordless phone handset sits on the mantel in front of a family portrait; Kyle standing behind Karen, hands protectively on her shoulders, Karen holding Bryon in her lap. Everyone is smiling, even the baby. My pager buzzes angrily on my belt, jarring the silence even in vibrate mode. I try to ignore it, but in a few minutes it buzzes again, reminding me that I have to pay it heed. I quietly slip the pager from its case and check the display.

10-21 dispatch.

I clear my throat apologetically. “Karen,” I ask, nodding toward the phone on the mantel, “may I?”

She nods her assent and retreats back into her thoughts, and I pick up the phone and walk around the corner into the dining room to call dispatch.

“Medic Six,” I tell the voice that answers. “You paged?”

“What’s the holdup there?” Satan demands nastily. “I got your partner on the radio and he said it was a Signal 61. You’ve been on scene for thirty minutes!”

“And we’ll probably be here for a while longer. We’re waiting for the coroner.”

“Thirty minutes on scene
for a natural death?” Satan snorts derisively. “There’s a cop there to handle things, isn’t there?”

If I had worked this kid, I’d be tied up on the call for an hour, minimum. You can give me another thirty minutes, at least.

I say as much to the dispatcher, trying to keep my voice calm and professional.

“You need to stop playing social worker and savior and get your unit back in service,” he tells me curtly. “I’m logging you as available in the computer right now. Advise when you get back in town limits.”

I carefully consider what to say next, and say the only response I can think of. “Fuck you, dispatch.” I thumb the button to end the call before he can reply.

I walk back into the living room, but before I can say anything to Karen, her husband bursts into the living room. He is wild, frantic, desperately trying to shake Tom’s grasp of his arm.

“Get your Goddamned hands off of me!” he roars. “That’s my wife in there!”

He pulls up short in the living room, looking first in bewilderment at his wife, then at me. Karen runs to him and collapses into his arms, sobbing hysterically, and I edge between him and the nursery door. He reflexively wraps his arms around her and stares over her shoulder at me accusingly.

Tom Tate moves closer behind him, and I can see EP standing in the foyer with his back to us, talking urgently into the radio.

Never taking his eyes off mine, he grasps his wife by her arms, and slowly, deliberately moves her to one side. I stand in front of the nursery door, hands at my sides and palms open. Tom lays a restraining hand on his arm and he shakes it off.

“Let me in there,” he commands, his voice low and menacing. “Now.”

“He’s dead, Mr. Webster,” I say softly, confirming what he already knows. “There was nothing we could do.”

Kyle Webster’s reply is to sweep an entire row of pictures from the wall in a frightening, splintering crash, and he buries his fist in the drywall just a few inches to the left of my head.

“OPEN THE FUCKING DOOR AND LET ME SEE MY SON!” he screams, and I flinch as spittle flecks my face.

“You don’t want to see him, Mr. Webster,” Tom says gently, wrapping him from behind in a bear hug. “Not right now.”

Kyle Webster’s face starts to contort, and his voice breaks as he asks again, this time pleadingly. “You have to let me in there. He’s my son.”

I just stand there mutely, not moving. I don’t know what to say, or do. I only know that he doesn’t need to see his son as he looks right now, and I would spare him that pain if I could. If he were to shake loose of Tom and swing again, I am not sure I would duck. His shoulders start to shudder, and I watch as he folds inward on himself, going limp in Tom’s grasp. His mouth opens and closes, and his throat works, but no sounds come out. His wife lays a trembling hand on his left shoulder, and Tom lets him go as they both collapse into each other’s arms and sob out their grief together.

We stand there together watching them, and presently we are joined by a dapper little man wearing black slacks and a light blue polo shirt. EP trails behind him. “Brother Combs, from the church,” EP whispers by way of introduction. “I already filled him in.”

Brother Combs politely shakes hands with each of us and whispers a word of thanks. His hands are soft and slightly moist, but his grip is firm. He nods to us and turns his attention to the Websters, placing a hand on each of their shoulders and leaning his head close, talking softly to them.

“Come on, let’s go outside and wait for the coroner,” Tom whispers huskily. “I don’t think I can be in here much longer.” EP nods in agreement.

I say nothing, looking around at the Websters, whose world has all but ended, standing forlornly in their living room with their firstborn son dead in a room twenty feet away. Glass crunches under my feet as I turn and look at the hole Kyle Webster punched in the wall beside my head. I sigh, and begin picking up the shattered pictures Kyle swept from the walls in his brief explosion of rage.

I pick up the biggest pieces of glass, and gather the remnants of the broken frames. A few are still intact, and I delicately pick the broken shards of glass from the frames, taking extra care not to damage the photographs they house. Tom and EP watch for a moment and then join me, literally picking up the pieces of a couple’s shattered memories. We deposit the broken glass in a can found in the kitchen, and quietly stack the frames on the dining room table. Brother Combs looks up from his prayer as we turn to leave, and smiles his thanks.

Outside, Tom slumps on the trunk of his cruiser and EP lights a cigarette. None of us speaks for several minutes. I finish writing my run report sitting on the bumper of Tom’s cruiser with my clipboard balanced across my knees, straining to see in the gathering dusk. EP flicks his butt onto the pavement, grinds it under his heel, and checks his watch.

“We should be getting back into service,” he reminds me. “I’ve gotten three pages from dispatch in the past twenty minutes. The last one said to call the shift supervisor.”

“I’ll call him in a minute,” I reply. “Frankly, they can all kiss my ass.”

EP nods but says nothing. He knows I’ll take whatever heat we have coming.

“Either one of you have kids?” Tom asks.

“Nope,” I answer. “Just got married, myself. I hope to, one day.”

“Me neither,” EP offers. “I’m divorced, and not likely to get married again any time soon. How about you?”

“Two,” Tom sighs, “both of them girls. The youngest isn’t much older than that kid. She just turned one in March.”

“Go home and hug them both tonight,” I suggest, tearing off a carbon copy of my run report and handing it to him.

EP grunts his endorsement, “That’s what I’d do.”

“Oh, I intend to,” Tom says quietly. “Believe me, I intend to. You boys be careful tonight.”

EP and I drive back to the station in silence. The phone rings in the station not sixty seconds after we mark back at station with dispatch. EP answers, and wordlessly hands the phone to me.

The shift supervisor isn’t quite breathing fire and threatening jobs like I’m sure the dispatcher had wanted, but he is not pleased. Mainly he wants to hear my side of the story, and I tell him, leaving out nothing. In the end, he’s at least partially mollified, but chastises me for telling the dispatcher to fuck off.

“Next time, just call me and clear it first,” he urges.

I lie to him and promise to do just that in the future, not bothering to point out that the dispatch supervisor is the one responsible for relaying those messages, and the only ones that get forwarded are the ones he wants to, and since the company only records the 911 line, it’s always our word against his.

I kick off my boots and sit on the side of my bed, totally drained, unable to get Bryon Webster’s mottled, lifeless face out of my mind. I can still hear his mother sobbing her prayers into her hands, kneeling in the doorway and rocking back and forth.

I check my watch, and note that The Missus’ shift begins in an hour. She’s probably already awake. I dial the hospital and ask for her room, and the tears start to flow before she even answers. By the time she picks up, I can only cry brokenly into the phone. I’m making absolutely no sense and I know it, but it doesn’t matter. In five minutes she is opening my bedroom door, and she holds me until I fall asleep.
<
br />

I blink the tears away as I look at the house in my rear view mirror, and my vision clears. Even now, ten years later, the memory is still raw enough to make my breath catch in my throat. After the fear surrounding Katy’s birth had passed, after we thought we had put most of her health problems behind us, I could go months without thinking about it. But occasionally it surfaces, and the fear it engenders still chills me. Mostly it comes when Katy is in another room playing and I can’t hear her. I’ll get up to check on her, and invariably she’ll be playing or watching a DVD, and she’ll look up at me and smile, and the fear passes. There are nights when I’ll get up and tiptoe into my daughter’s room and bring her to bed with me because I’m the one who had a bad dream.

EP is remarried now, and he and his wife are still childless after years of trying. I know he has held her through long nights of disappointment, tears and frustration, but they haven’t given up. I wonder if, on the nights he holds his wife and comforts her, does he remember doing the same for Karen Webster the day she found her son dead in his crib? Would they have traded places with the Websters, if only to have a child for six months? Did the Websters think those six months were worth it?

I look up, and a neighbor’s front door is open, a man framed in the light with a phone pressed to his ear. He’s staring intently at me, no doubt calling the police to tell them there is a strange man parked in front of his house, crying and staring in his rear view mirror.

I wipe my eyes and put my truck in drive, and slowly pull away. A last glance in the mirror almost makes me stop again. Above the top of the privacy fence, silhouetted against the setting sun, I can make out a swing set in the Webster’s back yard.

I hope that means what I think it means.

Red haired, Scotsman….

Hmmmmmm.

Actually, it ain’t. Just ask Marko. My friend Gary has long accused me of stealing his best lines, right down to the title of my book, to which I have always replied, “Yeah, but I always deliver ‘em so much better!”

To which Gary replies something that I’m quite certain is meant to be derogatory, but I can’t quite decipher the Boston accent.

But today in the comments of another blog, our favorite Scotsman/Texan/LEO/wordsmith introduced me to the scientific name for an ambulance chaser: Carcharadon legalii.

Dude, I am so stealing that.

Scott, body builder, cancer survivor, and possessor of a mildly disturbing Klingon fetish (just kidding, Scott. No, seriously. Put down the Bat’Leth!), gives us the recipe for the typical 21st century snake oil pitch:

1 cup of charismatic speaker / product inventor
2 tablespoons of pseudo-scientific medical jargon
1/2 cup of testimonies of miraculous cures
1 dash of celebrity name drops
1 medium-sized fresh metaphysical babble, pitted

Preheat oven to 375. In a large bowl, mix charismatic speaker /product inventor with testimonies of miraculous cures. Mince the metaphysical babble and mix into bowl. Butter a small pan and spread mixture into the bottom. Drizzle the pseudo-scientific medical jargon and celebrity name drops on top. Cover pan with tin foil and bake on middle rack for 20-25 minutes.

Ah, smell that aroma?

When you pull the pan out of the oven and remove the foil, you either have an EVIL GENIUS SOUFFL’E, or a PLACEBO EFFECT POUND CAKE, depending on your particular level of stupidity.

Heh. Does it cure fibromyalgia, too?

Somewhere, in an unnamed town, in a small rural hospital (cough*Podunk General*cough) in the middle of nowhere, in a totally generic Emergency Department, there may or may not be the following patients right now:

A man with an ingrown toenail. For the past month. He doesn’t have a primary care physician, and says he doesn’t need one. He just comes to the ER for the rare occasions he needs medical care, like for ingrown toenails. Three times this year, as a matter of fact. To the ER. For the same ingrown toenail. I’m thinking it’s time for an amputation.

A patient who came from the psych rehab unit for intractable seizures. He has the remarkable ability to convulse for five minutes, yet still follow verbal commands the entire time, and wake right up and hold a lucid conversation! Oh yeah, and he keeps wanting to know when he’s gonna get his Ativan. [Side note: Peeing your pants doesn't convince me you're having a seizure. It merely means you're a dedicated faker. And I appreciate the performance, really. Two thumbs up!]

A nineteen year old girl with cramps and vaginal bleeding. She’s had this condition before. About twenty-three days ago, in fact. And again twenty-three days before that. It’s spooky how these symptoms return so regularly. It’s almost, I dunno, like it’s on a cycle or something! Weird.

A really sick little old man who has been progressively worsening over the past two weeks. Right now we’re struggling to keep up his BP, and he’s got a wicked anion gap acidosis going. I keep bribing his nurse to switch patients with me.

A woman with an abscessed spider bite. It’s right in the crack of her ass. So were the last three. Funny how the spider always bites her in the same place. It’s amazing how spiders are attracted to places where, judging from the looks of things, washcloths and toilet paper fear to tread.

A man with upper respiratory symptoms. He was here last night and was diagnosed with bronchitis. He didn’t get his prescription for antibiotics filled until this morning, so he has only taken one dose, about four hours ago. He hasn’t gotten any better. He thinks the antibiotics may not be strong enough.

A kid with ant bites all over his feet. Sure enough, there’s probably a dozen little papules down there. He’s a little fussy. Oh, by the way, they’re 48 hours old, and he has absolutely no other symptoms. And no, Mom hasn’t given him any Children’s Tylenol or Motrin. I want a Polaroid so I can give this woman a picture of what a $500 dose of Tylenol looks like. Of course, she could always take the picture herself at home. It’s the same stuff.

Yep, another day spent saving lives and stamping out disease and pestilence. That’s just how I roll, people.

Because it helps to keep me sane:*

To Foot Pain Woman in triage, after I had inserted the thermometer probe in her mouth: “I should warn you, I keep getting the rectal and oral thermometers mixed up. But if this one tastes bad, just grunt and I’ll swap it out for the other one.”

To Stubborn Little Old Man with ventricular bigemeny and CHF symptoms, after breaking the unwelcome news that he was being admitted to a telemetry bed: “Well, I do have good news… I just saved a buncha money on my car insurance by switching to Geico.”

After finally convincing Macho Guy that a gram of Rocephin would really be nasty in the deltoid, when he reluctantly dropped his pants and bent over for a gluteal injection: (lisping) “Oooh, tasty. You must work out.”

To Drug Seeker Dude with non-traumatic shoulder pain for one week and a reported “10” on the pain scale, after he told me I could shove the prescription for Naprosyn and Flexeril up my ass: “Actually Sir, these are pills, not suppositories. And they work much better if you take them, not me.”

To the same guy as he stormed out, cursing: “Was it something I said?”

To Zero Pain Threshold Guy, on the third and finally successful IV stick, because he kept whimpering like a wuss and jerking his arm away: “There now! That wasn’t so bad was it? And since you’ve been such a brave boy, the cute female nurse will bring in some Snoopy Bandaids for those boo boos, and she’ll even roll you over and pull the sheets out of your ass.”

To Non-Compliant, Smokes Like a Chimney Won’t Stick To Her Low-Sodium Diet CHF Woman, who protested the insertion of a urinary catheter: “This is what we call our CHF Trifecta Special. For anyone who gets CPAP, Nitroglycerin and Lasix, we throw in a Foley catheter at no extra charge. It’s our way of saying ‘we value your patronage and want you to come back’.”

To the lab tech as she was drawing blood on the Apprehensive Urinary Tract Infection Woman: “Consuelo! How many times do we have to tell you that wearing scrubs does not mean you are a medical provider? You’re a housekeeper fer Chrissakes! Now where did you leave your damned mop?”

To Apprehensive UTI Woman who chuckled and called me evil after the lab tech assured her that she was indeed a credentialed medical professional: “Yes Ma’am, I am indeed an agent of Satan. But my duties are largely ceremonial.”

To Podunk Parish EMS Operations Manager, after he refused an out-of-town transport to another psychiatric facility for a young catatonic woman, because ‘she doesn’t meet stretcher criteria and catatonia is a psychiatric condition, not a medical one’: “You know, you shouldn’t ever let your mind wander, because it’s too small and weak to be let out on its own.”

To Smokes Like A Chimney COPD Lady With Respiratory Distress, who wanted to interrupt her nebulizer treatments to go outside and smoke: “Why don’t I grab the weed we found on the guy in Room Four, and you can smoke that? I’ll wheel you out to the smoking area personally, and that way we can be stupid together!”

*relatively speaking.

If you read any of the med bloggers, pay a visit to CodeBlog for your links to this week’s best in the medical blogosphere.

And welcome to y’all visiting here from Grand Rounds!

Aaawwwww.

And y’all thought I had a monstrous ego before today…

…is posts like this.

You know, there’s a lot of women like this on my blog roll; Holly, Phlegm, Flo, Mair, Night Lightning Woman…

…genteel women all, with tempered steel in their spines. When I think of Southern women, I don’t think of delicate Jawjuh peaches or Olympia Dukakis with her ridiculous Southern accent in Steel Magnolias. I think of women like this.

They’re not really all that rare, but the world sure needs a lot more of them, and men worthy of their affections.

Ladies, do any of you have hot single sisters or friends in the 30-45 age range that are remotely like you? If so, could you hook a brutha up?* I’m even partially housebroken.

*But only if I am unsuccessful in my quest to win Babs’ everlasting love and affection. Relocating to Louisiana is a must, but in return I promise to cook, clean, do laundry and put the toilet seat down.

From the Kevin, MD weblog, I found this:

Waxahachie resident Allen Nelms says a call to 911 to get medical attention for his diabetic seizure got him Tasered by police instead.

After reading the article, I’ll have to say I have some major problems with the reporting in this story. Aside from the blatant yellow journalism, standard “jackbooted thugs stepping on the neck of the innocent and infirm” slant to the story, it leaves out most of the facts.

First of all, in thirteen years of working closely with police officers, I have yet to meet a small-town cop who fits the classification of a jack-booted thug. They may sometimes lack the training and experience of their brethren in larger municipalities, but the vast majority of them fit the textbook definition of peace officer; they keep the peace, which involves about 75% diplomacy and creative conflict resolution, and 25% enforcing the statutes. More importantly, they usually know the people they’re policing.

In short, they’re uniformly nice folks, and decidedly lacking in the paramilitary, adversarial bent common in some larger police departments.

So from the get-go, this sort of incident rings untrue, even in a town of roughly 20k like Waxahachie.

Secondly, this incident doesn’t ring medically true. The purported victim here had a “diabetic seizure,” which typically is brought on by a sudden drop in blood sugar. Hypoglycemic patients can be quite violent and combative. I once cared for a 50-year-old black preacher who received a world class beat down with a PR-40 baton when he erupted from his vehicle when a possum cop game and fish officer attempted to render aid. The fellow’s blood sugar had bottomed out, and he ran off the road into a stand of pine saplings. When the officer tried to render aid, the heretofore non-violent grandfather erupted from his truck and attacked the officer by swinging at him with two-inch pine saplings he ripped from the ground with his bare hands.

So yeah, I can totally see some hapless diabetic doing the burnt worm on the floor at the end of two Taser barbs.

But here’s the quote from the girlfriend that I don’t buy:

“Allen was shouting, ‘Please don’t do me like this. I just need help.’ Next thing I heard some ‘zing’ noise and Allen was shouting,” she wrote in her statement. “I asked what were they doing to him. One policeman replied, ‘We just took care of him.’

Riiiiiiggght.

Profoundly hypoglycemic patients, particularly those who are either seizing or recently postictal from a seizure state, do not make coherent statements like “Please don’t do me like this. I just need help.”

They either say nothing at all and lie there, pale, cool and comatose, or they babble incoherently. Sometimes, they growl like the Incredible Hulk and swing pine saplings.

The image in my mind’s eye here looks something like those videos from Cops where the suspect is struggling violently with the police, ignoring all commands to lie down and hold still, shouting all the while “I ain’t resisting! I ain’t resisting!”

Now, on the face of things, an oxygen-dependent diabetic with Lou Gehrig’s Disease and rheumatoid arthritis should not pose a physical threat to a cop. Most patients like this wouldn’t pose a physical threat to a ninety-pound nurse’s aid, unless the aide injured her back rolling them over to change their bedding.

But if there’s one thing I’ve learned in this bidness, it’s that everyone is an expert about somebody else’s patient, and that most newspaper reports lend themselves better to avian enclosure liner and osteicthyes sheathing than they do to credible journalism.

I particularly loved the opportunity afforded the local ambulance chaser to begin his opening arguments in the Court of Public Opinion:

“This police department has a bad history of disparate treatment on the east side,” Ramsey said. “They’re not treated fairly. They’re not treated justly.

“I bet the police wouldn’t kick in a white man’s door on Spring Creek at 4:30 a.m. and Taser him three or four times,” said Ramsey, saying he will seek justice on Nelms’ behalf.

Heh.

Of course, I’d never accuse a lawyer of resorting to half-truths and hyperbole to aid his client’s case, particularly when the police department in this case is constrained from speaking publicly about a case where litigation is pending. Meanwhile, Mr. Ramsey is free to stand before a bevy of willing reporters and wax eloquent about coercing the City of Waxahachie into a hefty cash settlement truth, justice and the American way.

I’d normally hesitate to play the race card, but since Barrister Ramsey here already dealt that particular joker, I’d bet substantial money that the police officers in question were white, Mr. Ramsey is black , and most of his practice’s advertising can be found emblazoned on bus stop benches with some variation of the slogan “Rodney will get you paid!”

At least know when I tell people to “Eat me!” they can be assured that I’m part of a heart-healthy diet…

Okay, so I’m browsing through Who Links to Me, and in a Technorati search, I unwittingly stumble across the motherlode of sarcasm.

I mean, you mine the intarwebz, and occasionally you find a nugget or two. You dig and you sweat, and you find some fairly rich veins. Tam’s always good for some serious snark. LawDog couches his sarcasm in prose elegant enough to almost hide his disdain, which is an art form in itself.

Squeaky Wheel is always good for a good rant, if you like your sarcasm in the frontal assault, blunt instrument variety.

And then, with a single mouse click, you discover the motherlode.

Here’s just a couple of small excerpts:

We’re all overwhelmed with your manliness, Mr. Rev-Your-Rice burning-Crotch rocket up and down the street. Surely, your penis must be staggeringly vast. Could you be sure to do it again this evening, around eleven, as well — just to reaffirm your studliness?

Or perhaps this one:

Neighbor lady — I appreciate you hanging your wash out to dry, to save electricity. Please do what the rest of us do, and shield your intimates with the sheets, towels and other clothes. That’s not a teddie you hung out, it’s a grizzly. It frightens me.

If you can’t form a picture in your mind’s eye of the poor saps who have incurred this woman’s wrath, sitting bewildered on the curb pondering the bleeding from their verbal eviscerations…well, you just have no imagination.

Heck, she can draw blood with just the title of a post:

Y’all welcome Cranky Epistles to the Blogs I Read Every Day, then go gorge yourselves at the all-you-can-eat snark buffet.

It’s delish.

“So how many intubations have you done?” asked Retired Surgeon.

“More than you’ve done in the past twenty years,” came my good-natured retort. “Maybe more than you’ve done, period. After all, you had the gas passers to do your airway procedures for you.”

“Seriously, how many?” he pressed.

The question stumped me, I’ll admit. I never really kept count, other than during my paramedic training, when I was required to.

“Probably a couple hundred?” I ventured a guess. “Maybe a handful more? I’ve been a medic for thirteen years. I did thirty-four tubes during my anesthesia rotations in medic school. I worked in rural EMS for ten years, but I averaged a tube a month for the first three years I worked at Mom and Pop EMS, and that was back in the days when our run volume was a third of what it is today. I did two or three tubes a month at Big City EMS.”

“So how do you compare your level of expertise with, say, an anesthesiologist or CRNA with a few thousand tubes?”

“Well first of all, I don’t compare my experience level to theirs,” I explained. “But I will say that I’m more accustomed to working in, shall we say, austere environments than your typical anesthesiologist or CRNA. Besides, experience on live patients isn’t all it’s cracked up to be.”

Yeah, that last sentence garnered a raised eyebrow from Retired Surgeon, too. I know what you’re thinking:

Does Ambulance Driver actually mean that you can become proficient at endotracheal intubation by practicing solely on a manikin?

Yeah, that is what I’m saying, at least to the extent that constant manikin practice builds the hand-eye coordination and muscle memory necessary to develop the skill of hitting this target:

See, here’s the thang. Hitting this target consistently is really no different fundamentally than punching holes in paper or knocking over steel plates with your projectile weapon of choice. Laryngoscopy even shares some common elements with the shooting arts; grip, sight picture, etc.

Heck, you can even consider a laryngoscope a weapon, in the sense that when used correctly, it can save a life, and when used by the unskilled or foolhardy, it can also kill someone.

Regular manikin practice with that laryngoscope and endotracheal tube is akin to range practice with your firearm. You practice the fundamental skill set in a set of controlled conditions, and you build those psychomotor skills until they become an unconscious reflex. If you have to think about it, you haven’t practiced enough.

Mastering the skill is easy enough, if your end goal is simply slipping a tube between those two pearly white vocal cords under ideal conditions. Heck, my friend Gary once dressed a janitor in scrubs, gave him some rudimentary instruction in endotracheal intubation over the lunch hour, and then set him to teaching medical residents and nurses how to intubate.

And they never had a clue that their ACLS airway management module was taught by the guy who mops the floors.

Edit: Turns out Gary used a kitchen worker, not the janitor. So, the doctors and nurses in that class were taught to intubate by the lady who makes the sloppy joes and that weird hospital Jello with the fruit chunks in it. Apparently, if you take off the hairnet and slap on a surgical cap, a short order cook can can easily pass for an anesthesiologist. Comforting, ain’t it?

That’s how easy the skill is to master, yet I constantly encounter people who mythologize the ability to effectively wield a laryngoscope.

This manikin practice has to have a purpose, though. You have to be critical of your performance. Every marksman worth his salt wants to hit the bullseye on every shot.

When you’re a new shooter, just getting all the rounds in the black is a thrill. After a while though, you naturally want to tighten those groups.

Sadly though, hitting the bullseye (glottic opening) on an airway manikin is easily done even with piss-poor technique. All too many paramedics think they’ve achieved mastery at this point, only to find out that a tough tube on a real patient exposes flaws in their technique they never knew they had. You have to practice how to deal with clenched teeth, blood, vomit, and laryngospasm. All of these things can be simulated on a manikin.

You don’t want your first encounter with these things to be in a muddy ditch somewhere, with someone’s life on the line. To do so is akin to going to the range very day and shooting your carry sidearm, yet never practicing drawing it in a hurry. The ability to punch very small groups in a classic duelist’s stance won’t do you much good if your weapon is on your hip when you encounter the knife-wielding thug on a dimly lit street.

I’m not saying however, that practice alone is sufficient. It’s not. But experience is not going to magically increase your hand-eye coordination or your psychomotor skills.

Experience will teach you the mindset.

One of my favorite authors, W.E.B. Griffin, wrote in his books that the only marksmanship medal that counts is the Combat Infantry Badge – the one you earn when your target is shooting back at you.

LawDog wrote an excellent set of posts on the combat mindset. The airway mindset is no different. Constant practice may hone your skills, but only real-life experience teaches you how to effectively utilize those skills when the feces have struck the thermal agitator.

The question then becomes, how much experience is required to develop that mindset? Is it two hundred tubes, or two thousand? Personally, I think it depends upon the attitude and learning curve of the individual.

People who hold up x number
of successful intubations as the defining measure of proficiency fail to consider the mindset of the person holding the scope. It’s as ludicrous as saying a cop has to be in a shootout every single day in order to be proficient with his sidearm. It’s as laughable as saying a soldier must be in a firefight every day to stay sharp.

For me, the most important part of the airway mindset came about a hundred tubes in. I learned that the most important thing about airway management is knowing how to secure an airway without resorting to the tube. As a result, the number of times I’ve chosen to intubate people has actually gone down, because I have other, less invasive tools in the toolbox now.

It’s not about numbers. It’s about learning from your experiences.

I know a few medics with twenty years of experience. I know a lot more with one year of experience, twenty times.

The same holds true for anesthesiologists and CRNAs. Some have two thousand tubes under their belt. Many others have twenty tubes, repeated a hundred times.

P.S. I got the tube that precipitated this conversation, after Retired Surgeon had tried several times and failed. I’m also convinced that, had he let me handle things from the beginning, the tube might not have been necessary in the first place.

…or a boon to those of us suffering from blogger’s block?

Since I’m suffering from blog constipation, and my next post is gonna be about *yawn* airway management, I figured I’d throw this out there so y’all won’t think I’m dead…

They call this one the LALOLKFATYK meme, cleverly titled to mean Learn A Lot of Little Known Facts About Those You Know.

And here I thought it was what an alcoholic overdose patient said when they felt the cold Betadine, right before that Foley catheter enters their urethra…

WERE YOU NAMED AFTER ANYONE? Yep. I’ve been called by my middle name all my life, and Mom got it from a soap opera character, a black doctor on a long since forgotten soap opera. But she liked the name, and I have since spent my life explaining, “No, it was originally a boy’s name…”

WHEN WAS THE LAST TIME YOU CRIED? Can’t remember, but not because it was so long ago. I write a sad story, I tear up remembering it. I cry occasionally, and I ain’t ashamed to admit it. Hear that ladies? Single, smart, moderately funny, and sensitive. I’m the total package, baby!

DO YOU LIKE YOUR HANDWRITING? It’s readable, that’s the best I can say for it, but classic Palmer Penmanship it ain’t. I print everything in formal documents.

WHAT IS YOUR FAVORITE LUNCH MEAT? Roast beef, thickly sliced.

DO YOU HAVE KIDS? Just one…that I know of, heh heh. I was a bit of a ho in my twenties.

Then again, I was also an ethical ho with a healthy fear of STDs, so I’m pretty sure it’s just the one. Wouldn’t mind another one though, with the right babymomma.

IF YOU WERE ANOTHER PERSON WOULD YOU BE FRIENDS WITH YOU? Of course. I’m a loyal friend, and a dedicated enemy.

DO YOU USE SARCASM A LOT? Me, sarcastic? Never.

DO YOU STILL HAVE YOUR TONSILS? All original parts here. Still have my tonsils, appendix, vas deferens, all my fingers and toes, and all of my visible teeth (minus a couple of molars). Which is pretty amazing, now that I think about my redneck childhood…

WOULD YOU BUNGEE JUMP? Not. On. Your. Life. All I see when someone bungee jumps is visions of herniated discs, vertebral subluxations and all sorts of bad things. On the other hand, I am itching to parachute from a perfectly good airplane, and as soon as I get this body to less than 240 pounds, that will be my present to myself.

WHAT IS YOUR FAVORITE CEREAL? Toss up between Sugar Smacks and Honey Nut Cheerios. KatyBeth’s therapists used to entice her with food (they even made her a shirt that said “Will work for food”), and Honey Nut Cheerios were a favorite reward. The therapist spent as much time slapping my hand when I reached into the treat cup as she did working with KatyBeth.

DO YOU UNTIE YOUR SHOES WHEN YOU TAKE THEM OFF? Nope. I just kick them off – sneakers or Crocs. My EMS duty boots have side zippers, so I don’t untie them either. All of the footwear in my closet (save for dress shoes) have knots tied in the end of the laces so they won’t slip out of the eyelets. I can stomp my feet into my shoes and have them tied in ten seconds.

DO YOU THINK YOU ARE STRONG? I used to be. Legs were always stronger than upper body, but I could bench press my weight fairly easily. I can still bench press my weight, too. My 1993 weight, that is.

WHAT IS YOUR FAVORITE ICE CREAM? The Butterfinger Blast from Sonic drive-in. It calls to me in a sweet siren song, and I am powerless to resist.

WHAT IS THE FIRST THING YOU NOTICE ABOUT PEOPLE? Eyes and smile for women. Seriously. Without warmth in their eyes or smile, it doesn’t matter how big their hooters are.

Okay, maybe it doesn’t matter as much how big their hooters are.

For males, it’s the handshake. I cannot stand a limp handshake.

RED OR PINK? I am secure enough in my masculinity to wear pink. As a matter of fact, I have a few pink shirts in the closet. Can’t stand red, though. If I had to pick a favorite color, it would be navy blue or hunter green.

WHAT IS THE LEAST FAVORITE THING ABOUT YOURSELF? My tendency to procrastinate. I’ve been meaning to join a support group, but just haven’t gotten around to it. No biggie, though – they still haven’t scheduled their first meeting.

WHO DO YOU MISS THE MOST? My brother, probably. He practically raised me, but we’re not as close as we once were.

WHAT COLOR PANTS AND SHOES ARE YOU WEARING? Neither pants nor shoes. I’m in bed typing this on my laptop. [Note to self: get a chill pad for the laptop, or burn cream for the naughty parts] But last night, it was navy blue scrubs and New Balance running shoes.

WHAT WAS THE LAST THING YOU ATE? Grilled shrimp, red beans and rice, and a pistolette from a local restaurant.

WHAT ARE YOU LISTENING TO RIGHT NOW? My Windows Media Player on shuffle. Last song: Michael Buble’s Home. Currently playing: Simple Kind of Man, by Lynyrd Skynyrd.

IF YOU WHERE A CRAYON, WHAT COLOR WOULD YOU BE? I’d be burnt ochre, just because the name conjures up a funky smell, and if you work in EMS or the ER, you’re all about the funky smells.

FAVORITE SMELLS? In no particular order: Tanned leather, cigars, bourbon, cypress swamps, Hoppe’s #9, the smell just before a rainstorm, and freshly mown grass. Oh yeah, and the smell of a freshly bathed baby.

WHO WAS THE LAST PERSON YOU TALKED TO ON THE PHONE? My teaching partner, confirming the dates for some classes we’re teaching.

FAVORITE SPORTS TO WATCH? Football. Saints football first, followed closely by Indianapolis Colts football and LSU football.

HAIR COLOR[S]? Brown. Right now though, it’s tanned scalp, with just the hint of a recent sunburn. I shaved all my hair off last week.

EYE COLO
R? Blue green.

DO YOU WEAR CONTACTS? Nope. I did once, but I suppose my eyes were tired when I took my eye exam. I was diagnosed with mild astigmatism, but I can see 20/20 when my eyes are well rested.

FAVORITE FOOD? Steak, and whatever comes with it. Rub it in spices and peppercorns, throw it on a hot grill, maybe thirty seconds on one side and fifteen on the other. When you cut into it, you should hear a faint moo and blood should run across the plate into your garlic mashed potatoes.

SCARY MOVIES OR HAPPY ENDINGS? Happy endings. Not many movies scare me anyway.

LAST MOVIE YOU WATCHED? Hannibal Rising, on DVD. Bleh.

WHAT COLOR SHIRT ARE YOU WEARING? No shirt. Sunburned shoulders and hairy man boobs are currently bared in all their glory. Earlier today, it was a tee shirt with a laryngoscopist’s-eye view of the human glottis and the caption, “Just tube it, baby.”

SUMMER OR WINTER? Neither. For me, it’s fall, the time of year I get to indulge my inner predator and go slay some of God’s furry little creatures. Run Bambi, it’s Ambulance Driver!

HUGS OR KISSES? I believe in long, slow deep wet kisses that last three days. I believe that the novels of Susan Sontag are pretentious bullshit. I also believe in the sweet spot, the hanging curve ball, good Scotch…and the fact that I’m having yet another Bull Durham flashback.

FAVORITE DESSERT? Other than the aforementioned Sonic Blasts, I’m not much for sweets. If I had to choose, I’d say apples and caramel.

MOST LIKELY TO RESPOND? Jay G. Brotha’ can’t resist a good meme.

LEAST LIKELY TO RESPOND? Tamara, most likely because she’s above this kind of crap. Lucky for you though, my standards are much lower.

WHAT BOOK ARE YOU READING NOW? Galleys of the thoracic trauma chapter of Paramedic Care: Principles and Practice, 2nd Edition by Bryan Bledsoe. It’s riveting.

WHAT IS ON YOUR MOUSE PAD? At work, a Ducks Unlimited print of Lab puppies. Someone stole my New Orleans Charity Hospital mouse pad that says “Charity ER: Where The Life You Save May Take Your Own.”

WHAT DID YOU WATCH ON T.V. LAST NIGHT? Lady and the Tramp. Again.

FAVORITE SOUND[S]? My kid laughing. The sound of a raspy mallard hen doing a hail call. A bullet strike on a metal backplate. Bilateral breath sounds after an intubation.

ROLLING STONES OR BEATLES? That’s like asking me if I prefer shit or vomit. Can’t really stand either one.

WHAT IS THE FARTHEST YOU HAVE BEEN FROM HOME? In terms of mileage? San Francisco, California. In terms of politics and ideology? San Francisco, California.

DO YOU HAVE A SPECIAL TALENT? I do a dead on Stevie Wonder impression, and I’m pretty good at Granny Klumpp, too. And I can recite all the dialogue from Forrest Gump.

WHERE WERE YOU BORN? St. Francis Medical Center in Monroe, Louisiana. I’m still working on getting them to erect a commemorative plaque. My people are talking with their people, but no luck thus far.

WHOSE ANSWERS ARE YOU LOOKING FORWARD TO GETTING BACK? Sumdood’s. I’m hoping his answers will yield a clue to his whereabouts.