At the end of this course I will have learned a number of things. IV cannulation, chest decompression, needle cric, thrombolytic therapy.

And the ability not to drown.

Because up until now I’ve considered the concept of being underwater absolutely horrific. Underwater is where dead people are found. Dead, blue, bloated people.

Me? I’ll stay pink and fat and dry. Thanks.

But the fact is that I WANT to be able to swim properly, I hate swimming “Like your granny” as someone once put it, my head and face arching out of the water. It’s knackering and inefficient and makes going to the pool a bloody chore.

So this week, I decided I was going to conquer it.

Thanks to Stingray and Sensei who’ve taught me to breathe out through my nose when I submerge, who’ve shown me how long I CAN stay down there for and have taught me ways to build my confidence without sitting on the bottom of the pool watching the second hand tick by on my watch.

Everything culminated on Thursday night when Midge and Stingray showed me how to hang my feet on the side of the pool and hang upside down in the water. Pinching my nose tight to ensure I didn’t irrigate my sinuses with chlorine, I sunk down slowly under the surface and stared around at this alien, wavy, underwater world.

I was fine. Not panicking, quite chilled in fact and highly entertained by how easy everything was.

And that’s when I laughed.

See if you’re trying not to drown?

Don’t laugh underwater.

-

Those of you who read my Twitter posts will know that my practical exam results came through and were just fine and dandy, thanks awfully.

So that’s nice, too.

I have no angst for you, guys. Move right on along.

Our trauma MCQ is…atraumatic. The mocks that we’ve been given beforehand have armed us well, gaps in knowledge have been identified and plugged, foibles of the IHCD’s questioning techniques are noticed and artfully sidestepped.

Our running order for the practical final exams are posted in the classroom, we gather around like high school students.

My name is second last.

That’s going to be a long wait.

We drink coffee and slide headphones into our ears. There is nothing to be gained by questioning each other, chatting about possibilities, or dissecting each others’ experiences. Music shuts it out and as long as we’re ALL listening to music, nobody feels abandoned.

We all listen to music.

Kappa is called in for her first practical and returns after 14 minutes (yes, I’m sure, we record the times).

“Piece of piss.”

Kappa is not the most confident student in the class. This is something of a revelation.

“For real?”

“For real. He never even asked me any theory, I was all ready to talk him through different presentations of shock and stuff when he went “Right, there’s the boy there, it’s a stabbing.”"

An electric thrill zips through us all; no theory? A simple stabbing? Fantastic! ‘Mon the schoosh.

We’ve been told to only return to classroom to collect our books once we’ve been assessed, so our numbers gradually dwindle. Midge, Stingray and I practice quietly in the corner while others read. I start making stupid mistakes, forgetting to perform the most basic checks, over complicating my treatment, getting ahead of myself.

Granny Chan pulls my shoulder away from the dummy andsets me straight.

“You’re over practicing. Stop it. Chill out.”

Headphones back in, Fratellis on. I stare out the window at the rabbits on the front lawn, my shoulders and head popping up and down. Holiday makers stare up at the window, bemused by the jigging ambulanceman.

Pumped up and ready, one of our tutors calls me through.

“The consultant’s having a wee break, so I’ll be running this one.”

Even better news! This tutor has winkingly mentioned that he “Doesn’t fuck about.” with his scenarios.

“Nae drama, right?”

I nod.

Into the exam room, a plastic dummy on the deck, our instructing consultant sits at the top table. He was friendly and chatty and receptive on Monday, so I flash him a smile and greet him warmly.

He nods stiffly, returning to his paperwork.

Oh.

Exam mode, then.

“Right Kal, you’re called to a firearms incident - I’m an ARU copper.”

I get him to explain what’s happened, a simple enough situation on the face of it, an eighteen year old male shot in the chest. Police don’t have any further information, but are out looking for the gunman.

The patient is supine, not moving but making gurgling moaning noises . I clamp both hands over his ears to protect his C-spine and in the same breath get a cop (disguised as my tutor) to take over for me. I’m buggered if I’m spending the entire scene holding the punter’s head still. The airway’s full of blood, but it’s nothing a little suction doesn’t clear and I teach the cop to perform a jaw thrust on the patient. The gurgling stops and I’m able to move onto the breathing assessment.

Central trachea, distended jugular veins, 40BPM, shallow and irregular; far too fast to inflate his lungs properly and supply oxygen to his lungs. I shove a mask over his face and squeeze oxygen into him.

But now I really AM buggered.

Looking up at my tutor and the consultant, I shrug -
“I can’t go beyond breathing. I need back-up to transport him and without another medic on site there’s little I can do beyond here.”

My tutor disagrees.

“What else can you do?”

I’m staring down at our four hands on the patient’s head and face.

“I suppose I could teach this cop how to bag the patient…”

“Or you could find another way of immobilising him.”

“Ummm…yeah, I suppose.”

There’s a beat while they wait for me to speak, my instructor takes pity on me.

“What’s the most definitive C-Spine care?”

“Board, collar, head huggers and straps. But we can’t do that with two people, we need a whole crew.”

“Right. Ok. Let’s say you’ve done that and he’s on the board.”

Eh? I’m not sure how the patient has magically levitated onto a spinal board, but I’m not about to look a gift horse in the airway.

“Cool. I’ll teach this cop how to bag the patient and move on.”

As I strip the patient’s chest there’s a small entry wound over his left nipple which is bleeding a little, but he’s otherwise unscathed. I push his ribs and sternum together to no effect, but when I listen to his air entry there’s nothing but dull sounds and gurgles in his left lung.

His chest is filling up with blood.

There’s nothing I can do in the field to deal with a haemothorax, so my next step is circulation. The bloke’s pale and sweaty, with a radial pulse at 140bpm. Too fast, but still producing enough pressure to perfuse his brain and kidneys. I prod and flex his belly, pelvis and long bones and confirm once more that there’s no massive blood loss onto the floor.

The tutor shakes his head - “Nothing to note…but his crotch is wet.”

Right, maybe he’s bleeding from his genitals, or his arse, maybe he’s been shot in the gut and is bleeding out through an orifice. Maybe I’ve missed a wound.

Or maybe….

“Blood, or urine?”

My tutor laughs.

“Looks like urine, smells like urine…”

“Probably urine then, huh? Well…he’s 18 and he’s just been shot…I’d say that’s an appropriate response.”

There’s a snort of laughter from the consultant.

“Right. So he’s got a diminished GCS, his airway’s safe, his breathing’s supported by the BVM, he’s got a developing haemothorax but is otherwise stable. I’m going to reassess him from the top while I wait for my transport.”

I do so, finding nothing. I’m beginning to run out of things to say.

“Let’s have bilateral wide bore cannulae, just in case he loses his pressure…”

They both just stare at me.

“And…ummm…since I’m waiting for my transport, I’ll get my Lifepak out and get a full set of obs. ECG, BP, SpO2, BM.”

“His ECG is sinus tach at 148, his BP is 70/40, SpO2’s 97% and his BM’s 4.3″

“BP’s down to 70/40?”

“Yup.”

Right. I’m fully expecting him to have lost radial pulses, but still assess him starting at “response”, working my way down.

He still has a feathery pulse at both wrists.

Shit.

Our aim in giving IV fluids in trauma is to maintain a systolic BP of 90mmHg. Below that your radial pulses vanish and as such we use this as a quick way to assess a patient’s circulatory capacity.

This patient has a crap BP, but present pulses.

Yesterday I over infused a patient because I cocked up my assessment.

I’m terrified of doing the same thing today. Just for something to do while I think, I confirm a carotid pulse as well. My tutor just stares at me, I’m sure it’s only his professionalism that stops him sticking his tongue into his lower lip.

Fuck it. He’s losing blood, as I ausculate his left lung its now completely dull, all gurgles are gone. He’s pissed a good couple of litres into his chest.

All or nothing time, I squeeze saline into his veins, 250ml at a time. A litre of fluids later he’s still not responding. His BP still crap.

“You did say he wasn’t lying in a pool of blood, right?”

“Yup.”

This is weird, so I strip the patient right down, confirming that I’ve not missed any other injuries.

My tutor cuts in.

“The police say they’ve found a 9mm casing on scene. What does that tell you about the type of weapon he was using? A rifle?”

All I can think about is Schwarzenegger talking about uzis. They’re not rifles, are they? Are they?

“That would be a smaller weapon, a pistol, or revolver?”

“Uh-huh. And if the patient was shot at a range of 15 metres with that weapon, what size of exit wound would you expect to find?”

What? *I* don’t know! What am I, a fucking siege engineer now?

I plump for honesty.

“I don’t know enough about ballistics to answer that question, I’m sorry.”

He shrugs.

“Fair enough.”

The scenario ends and I hand over to the consultant, summarising the patient’s condition and my treatment before arriving at hospital. I try my best to gauge their responses to what I’ve done, but there’s none. Just blank faces and a dismissive “thankyou”.

I stomp off around the garden before having my lunch, double and triple guessing what I did against what i think i should have done.

Chan and I are cursing our instructor at the lunch table (she had a similarly grim scenario to face) when he wanders up, slaps us on the shoulder and grins.

“Did you guys enjoy that lot, then?”

Our responses are not recorded, but he shall be known from here on in as…”Uzi”.

The morning begins with mock MCQs and Practicals. They warned us that the week would creep up on us and suddenly we’re twenty four hours away from our finals.

Shit.

My mock practical does not run well. Airway and breathing in my assault victim are easily stabilised, but when he loses his radial pulse I batter fluids into his arm far too fast.

Without checking for a carotid pulse.

Two litres of saline later I realise I’ve been merrily pouring IV fluids into a dead dude who probably could do with some tips towards a healthier lifestyle, like, you know, five pieces of fruit and veg a day, or 20 minutes brisk exercise…or a pulse.

Benito laughs at me as I slink from the room.

The afternoon is largely empty. No more lectures and (despite the crashing and burning motif of my mock) Benito seems to think we’re all doing alright. I do a little reading in my room, watch some day time TV and head down for dinner.

That evening I’m lying on my bed when Midge wanders in, we’re both claustrophobic and bored and frazzled.

I decide I need M&Ms, Midge decides she’s coming along too.

Halfway down the drive we find a snowy white lamb running up and down the fence. He’s something of a independent wee thinker, because every OTHER sheep is on the OTHER side of the fence.

We can’t leave him out there. It wouldn’t be right. He’d end up inside a fox come dark.

I turn to Midge.

“You grew up on a farm, right?”

“I grew up in a farm-HOUSE.”

“Oh. Ok. Well, we go one on each side and when he runs past, you grab him, k?”

“K.”

I start off running up the hill to head the lamb off and slowly herd it back towards Midge.

It is at this point that I learn some important lessons about Midge.

1. Midge has greatly underestimated how fast lambs can run.

2. Midge has greatly overestimated the intelligence of the average sheep.

I watch, dumbfounded, as Midge lifts the bottom of the loose fence up and points at the gap. The lamb looks at her as though she’s mental, and tries to ram itself through a square in the fence four inches across.

Midge walks towards the lamb, the lamb runs like fuck.

I run back around the lamb and herd it back towards Midge; trying not to be that guy who goes “No! Like *this*!”

The lamb bolts past me. I fail to catch it.

I run back around the lamb and herd it back towrads Midge, wondering to myself how come it’s me that’s doing all the running up and down the hill.

Midge is laughing at me.

We slowly corral the lamb into one wee corner and I’m just about to grab him when he tries to run past me a second time. Realising that I’m going to get him, he does that “leap in the air without bending your knees” thing that lambs can do.

And headbutts me firmly in the eye.

I’m not sure who was more taken aback by the experience, myself or my wooly assailant. I do know that only one of us said “Ooohya little fucker.”

Thankfully our meeting of minds stuns the little bugger sufficiently for me to catch him by the front legs and swing him over the fence. I’m just lowering him into the grass when Midge pops a hand under his back legs.

“I’ve got him,” she says “He’s fine.”

Thanks mate. Pleased you’re here.

We fail to find M&Ms in Peebles and so undertake the 36 mile round trip to Galashiels, ostensibly in search of chocolate in candy shells. In reality, it’s just nice to be out of the Castle for a bit.

Roaming around Tescos, we buy supplies for our classmates and pop in on the Nerf family for a cup of tea. Back at the Castle later that night we make Party Bags for everyone else in the class, little fiddly plastic games, sweeties, energy drinks and ascerbic notes. Last week everyone fiddled and stressed while waiting for their practicals.

At least this week they can play mini pinball in between times.

Cannulation is one of those essential skills in what we do. The ability to pour liquid into your patient’s bloodstream means we can speed up or slow down their heartrate, depress their immune and nervous systems. We can knock people out and wake them up. Bulk up their blood vessels when they’re running dry on the pavement.

It’s a big deal.

Time was the only way to practice IV cannulation was on other students. But that was before the invention of the monstrosity pictured here. It’s an arm, in a box, with a bag of ‘blood’ running through it. It bleeds when you stab it and has veins like the contours of a mountain range. Practicing on it makes me feel like I’m abusing Thing Addams.

The black coffin with silver clasps doesn’t help either.

We spend the day being drilled by Benito on our Advanced Trauma Life Support - it feels like my old first aid days - Danger, Response, Airway, Breathing, Circulation then D(isability) and E(xposure/environment/evalutate). When I came out of my Techy course I was told “It doesn’t matter what you know or don’t know, as long as you can look at someone and decide if they’re ill or not.”

That snap decision is a major skill on our belts, so being made to slowly evaluate things now seems retrograde.

We’re working slower, but deeper. Listening to lung fields, assessing not just “Are you breathing?” but “Are you breathing ENOUGH?”. It’s not enough to have a pulse, you’ve got to have it in certain places and know that when i vanishes from one place, it’s no longer supplying oxygen to other organs. We learn the volumes of the body cavities - if you can tell one lung is full of blood, roughly how much blood does that mean has been lost from the circulation?

Bit by bit the methods become second nature, though we still mutter under our breaths as we perform the examinations, keeping ourselves right with a litany of memorised tactics.

I’ve eaten breakfast and am sat in the lounge, hunched over The Herald, failing to do the crossword. This is my morning tradition. One day I’m going to complete the crossword. And on that day, my brains will come down my nose.

A Techy course chatters on the couches behind me. One of them slumps into the upholstery.

“Oh GOD - I feel like I’ve been here FOREVER.”

An artery begins to twitch in my temple as I turn round.

“Forever?”

“Yeah.”

“You’re on….what? Week three?”

“Yeah.”

Synapses fire, I wrestle to keep my voice even.

“I’m starting week thirteen, total time here. After three weeks WE’RE allowed to start going crazy; YOU should still be bouncing about and having fun. Your tolerance should still be high enough to be smiling through it all. I, on the other hand, am beginning to fantasise about riding a tricycle up and down the geometrically carpetted corridors upstairs. I’ve got a typewriter all inked and ready. I’m super fly TNT. Another ten weeks in here? Fuck no, not today, thank you kindly.”

They stare at me. I smile, pop the creases back into the paper and stride off to class.

An A&E senior doctor delivers an excellent lecture on trauma, explaining and illustrating all the hellish complicated physics bits with real life examples. He then talks us through assessing a trauma patient, we feverishly scribble down notes and points he raises as “important”. He’ll be assessing us at the end of the week, so it’s only wise to do it ‘his’ way

He’s friendly, easy-going and pragmatic - “We’re nothing more than inflated mechanics, we just put air and water in the machine in increasingly clever ways.” - and when we laugh at his attempts to draw pictures he laughs back and invites us all to fuck off.

Lecturers like this, I could get used to.

We spend the afternoon revising his lesson, I discover “Don Juan Syndrome” - a combination of bilateral broken heels and spinal damage, most commonly found in people who jump from upstairs windows and balconies.

Ahhh medics, sick fuckers to the end.

Benito rolls into the classroom and asks me - “Aramis? Who’s that?”

I tell him.

“Why Aramis? We googled it, it’s a wee bird thing with long legs and a big nose, he’s not happy.”

I realise I’ve mispelled it - I KNEW I couldn’t spell D’Artagnan (see?) but thought I’d made a good stab of it. I explain the situation and avoid having my head kicked in by the teaching staff.

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.”