Thanks for all the congratulations, but that was just the first module!

I’ve another three weeks at College to go.

And I’m leaving for that….

Now.

Administrative hiccoughs delay our results.

We sit in the classroom trying to distract ourselves.

Stingray and Midge are quick to guess phrases with minimal gallows.

Results in, we step into a side room individually and take a seat.

Bless me father, for I have sinned

-.

Matalan goes home.

We miss him.

I get pleasing results and complimentary comments from the assessors.

The sort of results that make me phone my parents..

If I could, I’d stick them to the fridge.

Well chuffed.

I’m first on the list for Airway Management…last on the list for Chest Pain/ACLS.

I’ve a long wait.

My airway skill station seems to go alright, the anaesthetist has me describe various bits of equipment. I drop my voice into a rhythmic, steady yet swift cadence. I’ve found in the past when being asked to rhyme off facts or figures, if you SOUND like there’s a lot being said, sometimes people will believe you’ve said more than you have.

I spot him nodding at me as I chat at length about ET tubes, I’m not telling him anything he doesn’t know, he’s an anaesthetist, for God’s sake. I drop my tone of voice as I reach the limits of my knowledge, best not to tail off into a shrugging mumble, but finish sharply, as though you’ve said all that could possibly be said. Just like juggling, or improvising stories. Start finishing when you feel yourself starting to lose it, rather than letting it run away from you and end in chaos.

The scenario I’m given was one of the few we’d predicted, thankfully. A young man pulled from a house fire, burned face and airway, not breathing. I intubate with a longer, thinner tube than one would normally choose for such a patient, allowing the tube to pass through his swollen larynx. Clamping a BVM to the tube I ventilate his chest, confirm my tube placement.

The patient recovers, but I’m damned if I’m taking the tube out. The tutors have battered this fact into us. Extubating a burns victim can exacerbate the swollen tissues, causing them to slam shut on you just as remove your patent airway.

I’m assuring the consultant of this point and getting somewhat concerned of his insistence that the patient is “Really very unhappy, distressed, thrashing about, trying to pull the tube from his mouth.”

I look down at his face.

Fuck.

I’ve left the BVM attached, the poor bastard’s suffocating in front of me.

Babbling apologies I unsnap the bag, chatting to the dummy, explaining that his tube has to stay in.

I’m quizzed further on various complications and my tutor turns to the consultant.

“Anything else?”

He looks at me, blows out his cheeks and shakes his head.

That doesn’t look so great.

-

There’s three hours between my airway exam and my cardiac. I pace about the classroom, trying to study. A tutor from Edinburgh, Aramis, catches me marching up and down the corridors. He bollocks me for PMing my exam, sends me back to the classroom to review my cardiac work. On the way up to the first floor I meet a classmate, Stingray, and we whisper about our scenarios to each other.

Benito catches us at it and reiterates Aramis’ instructions. Chastened, we return to our desks and drug books.

I try to relax with peppermint tea and Tori Amos, then panic that I’m too chilled out, so drink an espresso and listen to The Fratellis at high volume, catapulting me into the emotional stratosphere.

By the time I’m sitting in front of an assessment panel answering questions about morphine, I’ve got my head together. My chest pain management goes smoothly, with a couple of interesting conundrums.

“I’ll keep the patient monitored at all times.”
“You can’t, the staircase is too narrow to carry it as well as the patient.”

It strikes me that this course isn’t about knowing the ‘right’ answer, but about making decisions based on the information you’re faced with. I take the monitor off, run down the stairs with it, carry the patient down and hook him back up to the equipment.

(Then, leaving the fox and the grain together, I’ll sail back with the chicken….)

I’m thrilled when the cardiology nurse assessing me asks me for “The drug actions in your own words - I hate it when people spew the textbook answers back at me.”

A minor slip-up in my CPR is questioned and corrected by the panel and I leave for my lunch. The afternoon is spent in my room. There is no study to be done for this module. We’re officially ‘on shift’, so have to remain in uniform and can’t be seen hanging around the coffee lounge reading the paper.

I go to bed and watch day time TV, enjoying the absence of impending assessment and fretting over upcoming results.

The final multiple choice paper is over almost before it’s begun.

There’s only so neurotic you can get in an hour’s paper. Midge, Sensei and I pace around the coffee machine, shaking out our shoulders, before returning for the two hour slog of the short written paper.

More ECGs to identify, this one not as textbook as the 30 we’ve had to memorise for our cardiac practicals. I resist the temptation to look at all its features all at once and force myself to slow down and really analyse it.

“Junctional rhythm with multifocal PVCs and ST elevation”

Jesus….that sounds a bit complex. I wonder if I’ve talked myself into thinking its something far more complicated than it really is.

The remainder of the short written isn’t too bad, revision and study pays off. My wrist aches and once again we all return to the coffee machine.

Midge approaches me.

“I know we’re not supposed to PM the exams…but what did you put for that rhythm?  I put junctional with multi-…”

“…focal PVCs and ST elevation?”

“Oh thank heavens….”

Adrenaline burns off from my system, my chest tightens up, I feel sleepy and restless and tearful. As we sit down to lunch, eight faces stare into their soup, sloughing off precarious stacks of memorised facts. Our minds are overstuffed sofas, lumpy and ungainly, the main chassis below still firm and strong, but with clumps of horsehair poking out at angles.

We rehearse practical scenarios in the afternoon, CPR drills and drug dosages. Nerves are contagious and hang in the air like ether fumes, most of us slip headphones in as defence against others’ fearful chatter.

The day is spent practicing and practicing and practicing. We intubate and extubate. I consider transtubating, but can’t work out how to put the ET tube down sideways.

We digest theory, cramming details and figures into the farthest corners of our heads. Over the afternoon we’re taken out, one by one, to sit our mock practicals. A Chest Pain Management, an Advanced Cardiac Life Support and an Airway Management.

One of our number, Shatner, becomes quiet and troubled. He leaves for his own space at coffee breaks. We’re sufficiently tight as a group to spot it and intervene, flagging our concerns to our tutors.

Shatner leaves that afternoon, his decision and choice, with a plan to return at another date.

His empty chair and remaining name plate split the class into two fragments.

Public holiday makers stare and gawp at us as we march past them on the stairs. Not one day goes by without one of them stopping me:

“Excuse me? What’s the difference between the blue uniforms and the green uniforms?”

For the polite elderly couple, I took the time to explain Non-Emergency Services vs A/E and the two tier system between the Technician and Paramedic courses.

The woman who asked me, but continued to text someone while I answered? She got “They’re doing their basic training, we’re doing the advanced course.”

And the yuppies in their crushed linen suits and hilarious cartoon ties?
“About five grand a year.”

Some of the guys on the Technician course apparently asked Benito what the main difference was between our study. His response:

“You have drugs that save lives - these guys have drugs that kill people.”

I’m sat in the classroom, halfway through my mock written paper, question two.

The patient is described as pale, sweaty and drowsy. We’re given an ECG strip to analyse and identify, the ragged, even edge of ventricular tachycardia is an easy three points.

Following the strip is a question designed to challenge our understanding of cardiac physiology. We’re to grasp the concepts of cardiac output and stroke volume and relate them to heart rate.

These are not complicated theories - cardiac output equals the total volume of blood the heart can expel in a minute - it’s found mathematically by multiplying the heart’s stroke volume (the volume expelled by the ventricles in one heart beat) by the heart rate.

I’m chuffed to bits to see this question. I know the theory behind it, I can even explain to you why the patient is so ill. His heart is beating so fast the ventricles don’t have time to fill with b ood, so every contraction is pumping out less blood than normal. In addition to this, the top half of his heart just isn’t beating - he’s relying purely on gravity to draw the blood down into the ventricles.

Eight points, here I come.

The first chunk of the question asks me to explain the concepts, and illustrate them with a typical patient’s figures.

Nae bother, big man. A healthy adult’s heart runs at, say, 70PBM with a stroke volume of 70ml. Cardiac output is thusly 4900ml/m.

Now then, as for this patient…

The paper tells me that the patient’s stroke volume is reduced to 40ml, so I duly multiply that figure by his heart rate.

140 x 40 = 5600.

That can’t be right.

The patient’s in cardiogenic shock, he can’t have a cardiac output GREATER than a healthy patient.

I run my maths again, simplifying them (maths? it is not my thing.)

14 x 4, add the two zeroes on later.

5600.

Fuck.

In desperation, convinced that my maths is screwed, I ADD UP four rows of fourteen, then add the two zeroes.

5600.

I’m running out of time for this question.

Fuck it.

I shove the answer in and hope for the best.

By the end of the day I’ve got my grades back.. They’re pretty good. Some of my colleagues ask me what I wrote, as though I had a secret answer. I’m buggered if I know - I thought I’d barely scraped by.

That evening I nip into Peebles to see a GP - my throat is killing me and Granny Chan wisely points out that I don’t want to risk getting properly sick just before my finals at the end of the week.

“So, Mr Trauma Queen? What seems to be the problem?”
“I’ve got pharyngitis.”

She peers in my mouth with a torch and lolly stick.

“Eurgh. So you do. Penicillin?

“Please.”

“Perfect - here you go. Bye then.”

In. Out. Done.

Drive-through GPs, they’re the future of medicine, I’m telling you.

By the end of the night, Midge and I are testing each other on drug protocols over gin an tonic in the bar.

On my Technician course we played giant Jenga and a ridiculous form of wrestling that involved lying on your back and tangling your legs in your opponents.

Not any more.

Sunday evening I dash back down the road, having spent the day helping Aarayan and Kiltreiser shift their gear to the storage unit from hell.

On arriving at College we scarf our dinner and knuckle down to scenario practice. The instruments becoming less alien as the days pass, abandoning their original manifestations of intimidation and fear and snuggling into our fingers as our kit.

Our gear - with which we do our jobs.

We know the job, we know the patients. Our hands fold without thought into compressive fists for stopped hearts, our fingers nestle gently against pulse points.

This course just extends that. We’re not learning our job as we were in the Technician course.

We’re building on it.

A fair amount of our time is spent practicing for our final practical exams next week. We have a list of problems that one can face while intubating a patient and so this morning I asked Midge to set me something challenging. I’m finding it more educationally valuable to flunk my practice scenarios, as it tells me where I’m weak. Nothing is learned by doing everything perfectly every time.

So the scenario that Midge set me was as follows:

“You are called to a dentist’s surgery where this patient has been enduring a difficult extraction. On arrival he’s GCS3, bradycardic with wide spread facial swelling and flushing. He’s breathing at 3 breaths a minute, with audible stridor. On laryngoscopy you note his larynx is florrid and swollen, with the laryngeal aperture closing before your eyes.”

I duly maintain the patient’s airway, getting my partner to give 500mcg of prophylactic Atropine to protect us against dropping his heartrate any further. We chase that with 500mcgs of Adrenaline, IM, to attempt to reverse what looks like some form of allergic/anaphylactic reaction.

Using a longer, thinner tube than usual, I manage to intubate the patient, but because I’ve been fannying about with drugs, forget to insert a bite block. Midge shakes her head sadly.

“Sorry, the patient bites down on the tube, occluding it completely.”

Right. I pass a nasal airway and it takes a moment for both of us to realise that I’ll have to deflate the ET cuff if I’m to pass any oxygen AROUND the occluded tube.

Thankfully the patient’s bite reflex rapidly eases off and I’m able to secure my tube, but Midge has another card up her sleeve.

“You’re not getting any air entry in the left lung.”

Aha! I’ve intubated the right main bronchus, an easy enough error to make and easily rectified. I pull the tube a little further up the patient’s throat.

“Nope, that hasn’t fixed it.”

I check for pneumothorax.

“The left side of the chest is hyperresonant, with wide spread surgical emphysema.”

“How did THAT happen.”

“I dunno…just not this guy’s day.”

I stick a needle in the patient’s chest and reinflate his collapsed lung, before Midge ends the scenario and I return to my desk.

See if Midge is running the exams on Wednesday?

I’m fucked.

-

Later that day Matalan is defending himself.

“Youse just thing I’m a Govan wide boy, but I’m not, I’m an intelligent guy.”

We nod.

“Absolutely, Matalan. When you come in the room, I have to double check that you’re not Noel Coward.”

“Fucking right, I fucking love Noel Coward.”

Midge and I are stunned.

“You do?”

“Yeah, him and that other boy from The Mighty Boosh - fuckin’ magic man.”

The day starts with a MCQ - multichoice questionaire.  A mock exam.  Supposed to be a hundred questions but a photocopying balls-up leaves us with only 60-odd.  I get 94%, though I have my suspicions that this may be due to the reduced number of questions.  I am not a statistician, so can’t comment.  Are percentages constant, or would my grade drop in indirect proportion to the number of questions asked?

Over the past few days we’ve been studying pharmacology, 12-lead ECGs and pre-hospital thrombolysis.

The lectures on 12-lead ECGs have been fantastic and I’m starting to really understand those squiggly lines. So far I’ve known to watch out for ST-elevation, but I’ve not REALLY known why. In essence, I’ve been taught to cook an apple pie by being told “If it’s broon it’s cookit, it it’s black it’s buggert.”

Now, however, I’m the 12-lead equivalent of a sous-chef. I know what happens and why and can translate that little pink slip of gridded paper into a conceptual three dimension heart in my head, complete with infarcts and ischaemia. And I can even fix them with thrombolytic therapy.

Thrombolytics such as Tenecteplase are scary, scary things. You may know them from the media as “clot-busting drugs”. When administered to someone suffering from a heart attack due to a clot occluding their coronary arteries, these drugs break that clot down so blood can flow to the cardiac muscle. This stops the pain and damage of the infarct, keeping you alive and producing amazing results.

We give it in conjunction with Heparin, which is closely related to Warfarin, which is what they put in rat poison. It stops clots forming in your blooding, making you a chemical haemophiliac. People who cut themselves while taking Warfarin or Heparin tend to bleed a lot.

In addition to these two, we prime the pump with a simple aspirin, just like you buy over the counter.

Its a triad of wonder drugs.

But somewhat indiscriminate.

Because you can’t tell Tenecteplase “Go to the coronary artery and break down those clots that are in there, but stay away from any other clots. We want those ones left as is.”

Nope, it runs around the blood stream finding ALL your clotted blood and breaks it down.

So if you have a cut on your hand and you take this drug?

That cut will start bleeding. A lot.

And because we’ve given you Heparin, it won’t stop naturally.

If you’ve got inflamed or sensitive gums that make your toothpase pink in the mornings and you take this drug?

Mouth full of blood.

And say, for instance, that you’d had yourself a wee TIA (”mini-stroke”) that had presented as a headache for a day, but resolved itself.

And that in your brain there was a blood vessel that was just tenuously holding itself together.

Yeah.

If we give you this drug while you’re having a heart attack, it’ll save your life.  But, in the words of our cardiology lecturer, it “may lead to an adverse cardiac event.”

Yeah - it carries a chance of turning your insides into bolognaise, or utterly frying the electrics of your heart.

And that, dear readers?

Scares the shit outta me.

Today is my 27th birthday. I swore to myself I’d be a Paramedic before I was 30.

With any luck.

I’m realistic about birthdays, I realise that I’m older now, that with greater occurence, your birthday becomes diluted.

My course wishes me happy returns, Benito too. It’s nice to hear; they’ve even nipped out to buy me a cake for dinner. Everyone sings, it’s cool and lovely and I’m blown away by their thoughtfulness.

But it’s not family, or home.

Lessons are disturbed by repeated fire evacuations, by the second one I’m able to roll call the public guests - “We’re missing the old couple, and the fat bloke with the really ugly wife.”

Turns out the alarms were due to kids trying to toast danish pastries in the dining room. That’ll do it, I guess.

Back in the classroom I reach for a sweetie from the pile in front of us to find that Midge, sitting to my right, has delicately stapled them all shut. Apparently she lives only to fuck with my head.

After dinner I borrow Kappa’s car and blow the joint. Sarge had warned me before I left that “Most of the pressure will come from yourself.” so I choose to vanish from the Castle for a while. Don’t misunderstand me, it’s comfortable and pleasant; my tutors and classmates are all nice folk.

But sometimes you need to spend time with folk who aren’t talking about cardiac arrest protocols and drug dosages.

I make the half hour run to see the Nerfs in Kappa’s car and get an adolescent thrill from its German badge and engineering. Overtaking people just cos I can, I return to the Castle relaxed and smiling, joining my classmates for pints in the bar.