49 Years

The man is breathing like a fish cast up on land. He is quiet, then with all the effort of his chest, he gasps. He's quiet, then he gasps again. His wife says he started losing conciousness an hour ago. He has terminal lung cancer. It has all been very quick. It started with back pain a month ago.

I tell her she can come with us, but she'll have to ride in the front. She says we've let her ride in the back before. Okay, I say.

We put him on oxygen by nonrebreather. My preceptee puts in an IV. He looks at me and says, "I'm thinking he needs to be intubated."

I ask the wife if she has discussed what measures they want taken. She looks like she isn't certain she understands.

Your husband's breathing is getting to the point where we may need to put a tube down his throat to help him breathe. I don't know for certain, but from his pattern of breathing, he may close to the end. Did you want everything done?

No, no, she says. He has suffered enough.

Do you have a DNR ? Do not resucitate order?

She shakes her head.

Have you discussed it with a doctor?

Yes, she says. He was going to put an order in his chart, but its been so quick.

When we get to the hospital, I say, they are going to need to know how you feel about this.

She nods.

When we get there, I will introduce you to the doctor, and you are going to need to tell him how you and your husband feel, and the name of the doctor you've discussed this with.

I tell my preceptee to call the hospital and explain the situation. Man with agonal respirations, terminal cancer, no DNR, but wife doesn't want advanced measures. We're holding off on intubation.

When we get to the hospital, we go to the critical care area of the ER. As we move him into the room with its space aged medical equipment and waiting medical staff, the wife bursts into tears. A family services worker puts her arm around her and leads her away. While my preceptee gives his report, I excuse myself and walk quickly down the hall after them.

She needs to talk to the doctor, I tell the aide, and turn them around and bring them back to the room.

I catch the doctor's eye and introduce her as the patient's wife, and tell him they have discussed measures with his physician. He nods and then talks quietly with her. The medical staff has the intubation tray out, and is waiting on the doctor.

The doctor and the wife speak for several minutes, then the doctor tells the staff to give the man morphine and some ativan.

"No intubation?"

He shakes his head. "Supportive measures. Let's at least make him comfortable."

The wife turns to me. "We've been married for forty-nine years," she says, her voice breaking. I put my arms around her. Her chest heaves as she sobbs.

Credit

I'm precepting a nice young man who is very on the ball. He knows his protocols better than I do. I ask him the dose for Cardizem. He rattles it out. .25mg/kg first dose. .35mg/kg second dose after fifteen minutes if the first dose didn't work. Once the rate slows, you run a drip at 5-15/mccg/min. I glance down at my cheat sheet. "Yeah, that's right. Very good," I say.

He is as advanced as anyone I have precepted. He hits all his IVs the first week, runs the calls smooth as can be. I mean we are not doing codes, but still, he handles the routine ALS like a pro. In the second week, I bail him out on two IVs, but at least as far as treatment goes, he is still right on the ball, and the IVs were hard ones. I was lucky to get them myself.

"You know you're going to have a puckercall one of these times," I say. "Don't get too comfortable. Things don't go this smoothly."

"I know," he says. "I'm waiting for it."

We get called for difficulty breathing. When we pull up, we see the garage door is open. A cop comes out of the door in the garage and says, "Bring it in here. She's a little short of breath. Feels a little dizzy. I've got her on O2."

I let my preceptee go in to assess the patient while I help our other crew member try to manuever the stretcher in. We take the moniter and bag off the stretcher and set it down on the concrete floor.

The woman doesn't appear too badly off. She doesn't want to go to the hospital. She says she just passed out, and doesn't know why, but she is all right now. She appears extremely anxious about leaving her home.

My preceptee is persistent and gets her to agree to go. We get her into a johnny-top and while our crew member folds her clothes and tells her she will bring them with us to the hospital, the woman gets anxious again, and says she needs clean clothes, so we have to help her get clean clothes from the dresser by the door. We finally get her on the stretcher, and she is now worried about locking the house.

She tells me I need to hit the garage door button on the inside of the garage door, then go out through the front door. I tell her not to worry about it, I'll take care of it.

As they wheel her out into the garage and then out onto the drive where the ambulance is parked, I hit the button that closes the garage door, then I go upstairs and out through the front door, making certain it is locked behind me.

I open up the back doors of the ambulance to see how everything is going. "Where's my gear?" my preceptee says frantically.

"Ahh, You don't have it?"

"No, I thought you had it."

"I don't have it."

We look back at the garage door that is closed. I walk over to it and peer in through the window. There is the monitor and gear pack that holds all our medicine and ET supplies. I lean down to try to lift the garage door up. It doesn't budge. I walk over to the front door. I try to turn the knob. Locked. I walk back to the ambulance.

"They're in the garage. It's locked. Does she have a key?"

She doesn't have a key. Who does? Her daughter. They can't reach her on the phone. The cop has left the scene to respond to a car chase in progress. I look at the patient. She is definately short of breath despite the oxygen. My preceptee looks panicked.

"Let me check the windows," I say.

I am pretty good about holding off panic. Not admiting trouble. Besides, I tell myself, I didn't leave the gear. But then I think, well I am sort of responsible. I was the one who locked the doors and I am the preceptor.

The windows are all locked. There is no key under the flower plants. I try the doors again. Locked. I stare at the front door. I take my wallet out and take out a credit card. Well actually my plastic Wampum card from the local casino. I try to credit card the door.

There is no deadlock and there is just a little give in the door. I have credit carded outside apartment doors before, but never a front door. As I sit there working the door, I feel sort of foolish like what kind of idiot am I banging up my wampum card trying to open an obviously locked door. The door opens.

Whoo-hoo! I walk right in, go down the stairs, into the garage, pick up the monitor and gear bag, go back up the stairs and out, locking the door behind me.

"You're lucky you have a resourceful preceptor," I tell me preceptee, as I hand him the monitor.

He looks enourmously relieved.

"How did you manage that?" my crew member asks.

I wave the wampum card. "Let's just say I am well read in many fields. Someday I'll teach you how to pick the lock on the narc box with the clothespons from the triangular bandage package."

I am very proud of myself obviously.

"Why don't you get in front and drive now. We've been here long enough," I say, then to my preceptee. "How's it going?"

He is dripping sweat. "I can't get an IV," he says. "If you can, I'll consider you a god."

Naturally I take him up on the challenge. As we hurtle to the hospital, I inspect her arms. "There's a little one right here," I say, pointing to her hand. "I think I can get a 22 in here."

Aside from my growing interest in cat burglary, my secret pride is my IV skills. I am a good paramedic -- not a neccessarily great one, but I am a great IV tech. My goal is to put an IV in a stone. But as I rub an alcohol wipe over the woman's hand, and look at the flimsy little vein, I am starting to doubt myself. But no, I think, I just credit carded a door. I can do no wrong.

Bottom line. You got it. I missed.

Not a god today.

"I feel better about missing now," my preceptee says.

"Just don't leave your gear behind again," I say.

Ruby

We're called for a fall at a private home. When we pull up my partner says he's been here before. He gets on the radio and cancels the district car.

"What if she's a big lady and we need a lift?"

"She's a little thing," he says.

We go to the front door. It's locked.

Darren swears. "She lives alone," he says, "its normally unlocked." He starts to radio for the cop to continue, but then I pull out my wallet and take out a credit card.

A minute later we're in.

Ruby is in bed. She is 89 years old and crazy as a bat. "What nice tall men," she says, "What are you doing in my house?"

"You called us? Is something the matter?"

She thinks a moment, then says, "Yes, I need help getting to the commode."

There is a portable comode by her bed.

"How do you normally get around?" I ask.

"Oh, I walk. I walk."

"Why do you need us to help you then?"

"Well, I hurt my foot. I can't stand."

I look at her ankle. It is swollen and deformed. I touch it, and she flinches.

"How did you do that?"

"I don't know. I don't recall."

"Did you fall?"

"Beats me. What tall good looking men you are."

"Thank you. We should probably take you to the hospital. You may have broken your ankle."

"Do you think?"

"You need an xray."

We are unable to get the stretcher into her bedroom due to the layout of the hallway and furniture, so I pick her up in my arms and carry her out to the living room where Darren has the stretcher set up.

"Oh, this is quite my day, isn't it. To be swept away. Where are you taking me?"

"To the hospital. You may have broken your foot."

"How did I do that?"

"Beats me," I say, "But its swollen."

Her name is Ruby and we talk as we drive her to the hospital.

"Are you the Ruby they wrote the song about?" I ask. I sing a few lines. "Ruby, Ruby, Ruby, Will you be mine?"

"No, no, I don't belive so," she says.

"Are you sure? I can imagine a young man singing that song to you once."

"Well, maybe. Where are we going?"

"The hospital. You may have broken your foot."

At the hospital, when I drop my paperwork off, she looks up at me like she has never seen me before in my life. "What nice handsome tall men. Where are all these good looking tall men coming from? They seem to be everywhere. Here comes another one."

A male nurse has entered the room. He looks at the paperwork. "Ruby," he says. "Are you the Ruby they wrote the song about?"

"Yes, yes, I believe I am," she says. "That's what they tell me."

Assault

We're called for a domestic in an apartment complex. Minor injuries. The police are already there.

They lead a man out of the front door. He is a big muscled man, six three at least with linebacker shoulders. Except he walks with a cane and I see a brace of his left foot.

"What happened?" I ask.

"She pushed me down," he says. "I had a stroke a year ago."

"Did you get knocked out?"

"I hit my head. I saw stars."

I feel his head and neck. There are no bumps or bruises. His eyes are wet.

One of the cops rolls his eyes as if to say, "that's bullshit. Be a man."

"You want to go to the hospital?"

"Yes," he says.

I have my partner bring the stretcher over and we help the man on it. His huge feet hang out over the end.

He is forty-eight years old. High Blood pressure, high cholestrol and residual left sided weakness from his stroke. He hasn't worked for a year.

He sits on the stretcher looking forward, looking nowhere.

Cath Lab

A lot of EMS is bullshit. People using 911 for runny noses, sprained wrists, and stomach aches from eating too much greasy chicken. Then there are the legitimate calls like strokes and traumas, but too often in those calls there is really not much we can do to fix them. They are dead from getting into an accident at 60 MPH or they are stroked out so bad they are just going to stay that way. That calls that make the most difference I believe are the cardiacs -- the chest pains. The patient is pale, diaphoretic, with nausea and chest pressure. You take their vitals, do a quick 12-lead. It shows an inferior MI. You put the patient on a non-rebreather, give them some ASA, put in a couple large bore IVs and fly to the hospital. You call ahead, this patient is having an MI. They need to go to the cath lab.

When all goes well at the ER, the doctor meets you at the door, glances at your 12-lead, and then while you are unloading the patient, he is calling the cath lab, and before you have even sat down to write up your run form, they have heparin running and are wheeling the patient out of the ER and up to the cath lab.

The cath lab is where a cardiologist does angioplasty. They run a catheter in through the patients groin and up through his artery into his heart, where they blow up a balloon to clear the blockage in the heart that is causing the MI. Time from door to cath lab is critical. I've brought in patients with ST elevations--the hallmark of an acute MI -- and had them code on me in the ambulance. I've had them code in the ER, and I have heard about them coding in the cath lab. If they can make it there and get the plasty done, they are often up and walking around within days.

Recognizing an MI and getting the hospital to take it seriously is criticial. Sometimes, you have to go and find a doctor and say, Doc, my patient is having an MI. He needs to go to the cath lab. They are busy with other patients and you need to get their attention. No disrespect to the nurses, who are also busy, sometimes you just have to bypass them in the interest of time.

Trauma patients get the trauma room, but its hard to fix them. Cardiac patients can be fixed, but the system isn't really geared to them yet. Even the ER doc's have to call a cardiologist to get the cath lab open. In an ideal system, paramedics could call for the cath lab as they do for the trauma room.

Here's what happened today. We get called to a cardiologist's office for an Acute MI. I sign on with dispatch to get an EMD update. "They wouldn't give us a sex or age," the dispatcher says, "Its a cardiologist's office, they have an acute MI. Paramedic hot response."

A nurse meets us at the door. "What's going on?" I ask.

"He's having an acute MI. We're running in saline. He just walked in. The doctors are in with him."

I find the man in an exam room. He looks to be in his fifties, a healthy male with good complexion. Good color. He is attached to a three lead monitor that is not reading. They have a 250 bag of NS running wide open through a 22 in his right AC. I ask him how he is doing. He says okay.

The cardiologist comes in and briefs me. He tells me the man is having an acute inferiorposterior MI and I'm to take him right to the cath lab where the doctor will meet us. He is leaving for the hospital right now.

Okay, I say. We hurry him onto our stretcher and take off lights and sirens. I put him on a cannula, take a quick BP - 130/80. HR - 100, then notify the hospital. Coming from a cardiologists office going straight to the cath lab, can you have someone there to lead us straight up.

In ten years I've never taken anyone straight to the cath lab from a scene. I don't want to take a wrong turn in the maze of corridors.

I ask the man how he is. He says, fine, maybe a little nervous. I tell him not to worry he is getting the best care possible -- going straight to the cath lab. I put in a another IV -- a 20 in his hand that runs great. I tried an 16 in his AC, but blew it, my ego got the better of me. It was only an 18 size vein.

I put him on the monitor. It is my first look at his ECG. They never showed me one at the doctor's office. Normally I would ask, but here I would basically be giving a report back to the guy who gave me the report.

I'm looking at II, III, and AVF. Maybe a tiny slight elevation in III, nothing in II or AVF. I don't doubt the doctor at all. It just isn't screaming MI.

I want to do a full 12 lead for my own edification, but the man has a shag carpet on his chest, and I can't get the leads to stick.

"You can shave me," he says.

"We're going over the Delmar Street Bridge," I say. "That's not a good idea." the Delmar Street bridge has been under construction for two years and is nothing but potholes and uneven bumps. "You'll end up in the trauma room instead of the cath lab. Besides we're just about out."

At the hospital, the tech leads us right up to the cath lab, where the doctor meets us, and we bring him right in and get him on the table.

I can't tell you how many times I have struggled to get patients up to the cath lab. Called ahead, said, this is an acute MI, I've got tombstone ST elevations. I've run through the ER showing doctors my 12 lead, screaming MI. But they have their procedure they have to go through in the ER, register the patient, assign a room, have the nurse assess the patient, do a 12-lead, get the doctor over, the doctor questions the patient, then he orders heparin, and calls a cardiologist and discusses the case. Sure, sometimes its quick. 20 minutes. Sometimes its an hour.

This guy was lucky to get such service.

You know what the deal was?

He was a golfing buddy.

I'm not saying I don't help my friends out. If I was the heart doctor and that was my buddy, I would have done the same thing. All I'm saying is if we can get a doctor up there at the snap of the fingers we ought to be able to get other people up there that quick. Cath's can save lives.

David

I got an email titled “Sad news.”

It is from my friend Tom.

"Hate to break this to you in an e-mail, but David died yesterday. He was found in his home when he did not report to work, dead of an apparent heart attack. I will forward funeral information in case you can attend. "

David and I worked together twenty years ago before my life as a medic. There were four of us. David, Tom, Rusty and me. We called ourselves “The Road Show” as our job was to drive our boss all over the state. Tom was the advance man, David and I the camper drivers, and Rusty the backup driver.

David’s parents were very wealthy, but he’d worked for awhile as a doorman at a ritzy hotel in Washington. He was good at taking care of details, making people feel important. He'd get up at five in the morning drive twenty miles to a small drug store newsstand that carried the boss's favorite juice, a concoction called Park Avenue Punch, so when the boss was thirsty, David would reach into the cooler and produce it for him. The camper was always immaculate, gassed, washed, and vacuumed. Even the shit tank dumped.

He was a good hearted, crazy guy. When he went out on dates, sometimes he'd rent a limo and take his date to the McDonald's drive through. He used to like to go into strip clubs, walk up to the dancer, hand her a ten, turn around with a spin, drop down and do a split, then walk out. He once innocently offered the boss's busty daughter five dollars if she would just show him her breasts. He went on a vacation at Hedonism, and came back with pictures of himself standing bare-assed on the beach with some women he’d met. His favorite movie was “Fast Times at Ridgemont High.” He could do dead on impersonation of Sean Penn as Spicoli. He also liked “Ferris Buelher's Day Off.” After we’d drop the boss off at night, he’d pop The Who's “Teenage Wasteland” into the tape deck, and he'd play a perfect Keith Moon air drums as he drove.

Some nights when we'd been on the road late and were scheduled for an early start the next morning, I'd crash at his parent's place. He'd stay up watching TV, a tequila bottle on the table next to him. I think he had insomnia.

In later years, he went to law school, and got a job in his father’s firm, but he had problems with drugs and alcohol. He quit and the last I had heard was working as a pool boy at a fancy country club. But Tom, when I spoke to him on the phone, said David had cleaned up and was working again as a lawyer and doing well for himself. He'd been living down in Florida.

I had completely lost touch with him.

How many times have I gone into a house and seen a cold stiff body on the floor?

I run the six second strip of asystole and note the time.

Precepting

I'm assigned a paramedic student. And while I love students, I’m not too happy to be precepting this one. She is as close to clueless as you can get and still be allowed to ride.

I precepted her a couple weeks ago. She talked a good game so I figured it would be an easy day. We did a call for a violent psych. We get there and find four mental health workers holding down a screaming fifteen year old, one adult on each junior, though muscled limb. I call and get orders for ativan and benadryl. I draw up the ativan and hand it to her, then turn my back to draw up the benadryl. When I turn back, there is blood all over the place. I look at the patient’s AC, and see that is where the blood is coming from. She gave her an IM shot in the AC. The other medic, who was at the call, watching, says he was going to say something, but thought maybe they were teaching a new technique in school these days.

Today she blows an IV on a chest pain, blows it bad enough that I switch places and do the IV myself instead of giving her a second shot. I run off the 12-lead and ask her what she thinks. She looks at me for an answer. I show her the inverted T's in the anteroseptal leads.

"Reciprocal changes," she says.

I shake my head and show her there are no elevations in the any of the other leads.

"Should we do a right-sided ECG?" she asks.

I shake my head again.

At triage she tells the nurse there are reciprocal changes.

We go over it after the call. She looks at me, almost coldly like she is pissed that I am semi-scolding her. I’m not scolding. I am just telling her some of the basics of cardiology.

Her assessments are poor, her IV skills are terrible. We do a shooting, 18 year old shot in both arms in a drive by. Right elbow, left proximal humerous. He's alert, warm and dry. Good pulse. We get him in back. I tell my partner to drive. The student is already trying for an IV.

"How about a blood pressure?" I ask.

After she gets that, she goes right back to the IV. She uses a 16, and gouges a hole in the kid's AC, and grinds it so hard, the kid who's right elbow is completely shattered, shouts at her to stop.

I switch places again and pop an IV in.

In the trauma room, I am showing the trauma doctor, the bullet holes. Right elbow, left proximal humerous.

"What about there?" the doctor says pointing to the left AC. "There's a third."

"No, no, no," I say. "That's an IV attempt."I

t’s almost time to head in for the day. The student reluctantly hands me her evaluation papers, then we get a call for an unknown, not far from the hospital.

We show up and see the telltale relatives standing outside, urging us frantically to hurry. The fire department has arrived just before us.

"Step it up," a fire fighter says.

We charge in through the old house. I can hear people yelling and crying. When I get in the room, I see a man doing mouth to mouth on a woman who looks to be in her thirties. She has a dialysis port coming out of her naked chest. The fire guys are putting the defibrillator on. Shock advised. Shock.

I hand the rider our monitor and tell her to attach it. I tell the fire guys to start CPR, as we ease the family member out of the way, and I get out an ambu bag.The woman is in V-fib.

"Go ahead and shock," I tell the student.

I get out the intubation kit, lay the laryngoscope to the side of the woman's head, then stick a stylet in a tube and attach a syringe, as the student shocks again.

"Ready to tube," I ask her.

She looks surprised like she didn’t think after how the day had gone I was going to let her tube."

Go for it," I say.

She scoots to the head, and sticks the blade in her mouth. She seems to struggle with it.

"You've got it?" I ask. I'm not giving her a second change if she can't pass it.

"Yeah, yeah, I do."

And I see her pass the tube. I hand her the ambu-bag and it looks good. Check the lung sounds and they are present and equal.

“Good job,” I say.

We work the lady hard. She's got no IV access, and its dark in the room, so we move her out to the ambulance, where I put in an EJ, and we slam some IV drugs. She's still in and out of v-fib, and then settles into ventricular asystole. They work her for a little while at the hospital.

The student is ecstatic. She is wired, running around the ER like she just scored the winning basket in the NCAA championships, telling everyone about it in detail.

I see the family coming down the hall. They look distraught. I ease the student outside where she can do her funky chicken dance out of the family’s sight.

The truth is I am happy for her. She had a shitty day, then she got her code, got her first field tube. I remember when I got mine. I was just as excited.

I've been doing this for twelve years. The truth is I was clueless once too.

In the Dark

We're called for a stabbing.

Its dark and when we pull up on scene, we can see officers with guns drawn. We stage and wait the word to go in.

It's hard to tell what's going on, then another cop comes running out into the street right for us. We step out. "You're going to need your stretcher," he shouts, "and, and disinfectant, lots of it. Give me the strongest stuff you got. I got blood on me. He got HIV and he bleeding all over the place." The officer is hopping up and down and moving his hands like he's got posion ivy, but can't itch himself.

I grab a couple trauma dresssings and a box of vionex, which I hand to the officer.

We go down the hill behind the house and find six cops standing in the dark. They attack the box of vionex, shining their flashlights on each other as they scrub their hands.

I look around and see a body lying face down on the ground, handcuffed. "Can I get a light over here?" I ask. "Is this guy alive?"

"He's fine," an officer says. They are scrubbing each other like surgeons.

I shine my tiny pen light on the man. His eyes are closed, but I can see a little chest movement. He's got some lacerations about his head. His hair is matted with blood. Smells like etoh. He's got a nice steady pulse in his neck. Rate of 80. "You okay, buddy?" I ask.

He opens one eye, looks at me like he's bored, then closes it.

I look back at the officers. "You missed a spot," one says, shining his big mag light on the other's hands. "Right there."

Behind Every Door

I'm standing in triage with my patient when I find myself looking at a man standing unsteadily by the entrance to the ER. A security guard has his hand on the man's upper arm, both holding him up and keeping him from walking away. The guard tells the nurse. "I found him outside. What room does he belong in?"

"I put him in the East Wing about an hour ago," the nurse says.

I am staring at the man wondering where I know him from. I can't place him, but I know I know him.

By the computer there is a list of the demographics of recently placed patients. I see a name I recognize and it comes to me. My God. Its Dave Thomas. I grew up with him. He lived just down the street. I played little League baseball with him. Neighborhood basketball. I ran his campaign for student council president.

I watch as the guard leads him back to his room.

I ask the nurse who is taking care of him, what's his story.

"Him -- He's in here all the time." She makes a motion of a man downing a bottle.

Every now in this job there is a reality check, and this is one of them. Dave Thomas -- what happened? All that promise? What tragedy caused his life to unravel? Or was it preprogrammed in his genes?

You deal with drunks all the time. Each one of them was someone's child friend, someone who was looked up to, someone with promise.

You just don't think about that.

***

I get a letter from my college girlfriend and we take up a correspondence. I learn that her husband died of brain cancer five years before. She tells me about the hospital trips, the feeding tubes, and cleaning. It is hard to imagine something like that happening to her, of her having to go through with all the pain and hardship.

I wheel my stretcher down the hall of a hospital floor. In each open door, I see a family member watching a sick relative, a room of balloons and flowers and heartache.

Now she is behind every door.

The Stink

About Tuesday I noticed a foul smell in the ambulance -- a smell like someone had left a meat sandwich under the seat or a mouse had died somewhere in the woodwork. We left the ambulance outside with the doors open for two hours, but it didn't help. It was a nasty smell, sometimes it was so bad, when I was sitting on the bench taking care of a patient, I wanted to apologize to them. I also wanted to think it wasn't me, because it smelled as bad as the worst patients I've had -- not the really worst -- the ones with anaerobic bacteria rotting flesh -- but pretty damn close -- the I haven't bathed in five months nasty.

The Tuesday night medic said he'd noticed the night before and thought it was just the musty smell when the front carpeting gets wet. Dude, you have to go to the nose doctor if that is all you smell. The Wednesday night medic told me he had his crew empty out the entire ambulance and hose everything down, then spray it with cleaner. Still the stink remained.

Thursday I'm sitting there and it is overcoming me. I've got one crew member in the back along with my patient -- an eleven year old mentally retarded girl with cerebral palsy who'd had a seizure, and her aide. I apologize to the aide for the smell. I tell her we have looked all over and can't figure it out. It has to be a dead mouse or something. She says, it smells like it is coming from over there. She is pointing at me. I start sniffing. I sniff to the right, then sniff to the left.
I learn over the sharps box my curiosity peaked. I inhale.

Picture this. CSI. The poor victim inhales. A vortex of green flourescent microbes shoots up his nostrils like dual cruise missles. The deadly spores travel throughout the body finding purchase deep in the tissues. Three days later, he's on the slab at the morgue and everyone is wearing white space suits.

I don't know what was in there. Whether some diabetic lost their gangrenous toe in the back of the ambulance and someone picked it up and plopped it in the sharps box, or some alien puked their vile spooge in there, but it was nasty. I was instantly nauseous, my head spinning, my eyes seeing black spots. I fought back the puke that no doubt would have infected everyone in the back and maybe even killed the driver, causing her to go off the road, taking out a few more cars, pedestrians, maybe sprawling across the railroad tracks and derailing a train carrying nuclear waste. We are talking major disater here, affecting the weather patterns, and ultimately ending up in the destruction of earth. A future extraterrestial explorer lands on the devestarted earth years from now, and picks up the bug and carries the Andromeda strain back to its interplanetary galaxy, and we're talking the end of everything here.

Oh Lord, I don't want to die this way. At least I saw the Red Sox win the World Series.

Daily Special

We get called for a fall at the local fast food chicken restaurant.

Back in the kitchen, the woman is laying on the ground between the fryers and the food prep table. She's maybe twenty-two, but a big woman -- looks like she's been dining on the fast food fare most of her life. I'm guessing she's two-ninety. She says she slipped on the grease on the floor, wacked her head on the table, and now her neck and knee hurt. She's got ketchup and flour and bread crumbs on her uniform shirt.

My partner almost wipes out on top of her when he comes back with the c-spine bag. I'm thinking this place is nasty. Food sitting out unrefrigerated. Crusted mashed potatoes on the counter. Grease everywhere. Flies on the biscuits.

The woman hangs over both sides of the board. We have to reach down under her to get the straps fixed. We slide her on the floor, around several corners. There was no way to get the stretcher in the tight quarters. A police officer and I lift her up on the board, bending our knees and driving up. We set her on the counter. My partner is on the other side -- the customer side. We slide her right across, past the cash register, right onto our waiting stretcher.

A toothless customer, watching with big eyes, remarks, "Daily Special. I'll take an order of that."

The Stretcher

Arthur is making up the stretcher by the linen cart just inside the ER doors. "I'm going down to the cafeteria to get a sandwich," he says, as he tightens the last strap. "You want anything?"

"No, I'm good. I just have to get times and drop off my report."

I end up getting in a conversation with a doctor, and so its a good ten minutes later when I come back down the hall. I pass a stretcher and the linen cart on my way out to the ambulance, where I find Arthur eating the last of his sandwich.

"Get enough to eat?"

"Yes, thank you," he says. "Not a bad sandwich for $2.25. Ready to clear?"

"All set."

He clears us on the radio and they post us at the hospital

We stay put. Arthur does the crossword puzzle, while I read my book.

About fifteen minutes later, we get a call. "857. Main and Pershing for the MVA. Priority One."

Arthur repeats the address, hits the lights on and we roll.

The Fire Department arrives just ahead of us. We get out to inspect the two cars and their occupants. Its a legitamite accident, nothing dramatic, but enough of an impact to take any complaint seriously. One man is up and walking about. He says his shoulder hurts. There is another man behind the steering wheel, who is claiming neck pain. The driver of the other car says he is all right.

"I'll get the stretcher," I say to Arthur.

I walk around to the back of the ambulance and open up the doors. I stare in the back. There is no stretcher.

Maybe the fire guys pulled it, I think. They do that sometimes.

I walk back to the cars. I see Arthur and four fire guys standing around. No one has the stretcher.

"Come with me," I say to the guy with shoulder pain. I walk him around to the back of the ambulance and help him in. I have him sit in the captain's chair. "I'll be right back."

I get a board, collar, headbed and straps and walk them over to Arthur. "Board and collar this guy," I say, "and then carry him around to the back of the ambulance."

"Where's the stretcher?"

I stare at him a moment. "Don't ask."

I see the glint of recognition that comes into his eyes then.

"Just board him and bring him around. He's not too big."

I'm in the back with the other patient when a few minutes later, Arthur and the fire guys carry the now boarded patient around to the back. I take the head end as they hand the patient in, and we lay the boarded patient up on the bench seat.

The four fire guys are standing looking in at the back of the ambulance. They look perplexed.

"Thanks guys," I say, and shut the doors. "Let's get out of here," I call to Arthur.

When we get to the hospital, Arthur goes in and comes back out with the stretcher. We load it in the back, transfer the patient on the bench seat onto the stretcher, then pull him out. I get a wheel chair for the guy with shoulder pain. We wheel them both in.

***

"Sorry," Arthur says later. "I must be getting old."

"Happens to the best of us."

"We'll keep this between ourselves?"

"We will never speak of it again," I say.

Coming and Going

We're sent on a priority to for the unresponsive, but when the cops get there they slow us down. It's a 10- a dead body.

We go in and walk down into the basement where we find the cops standing around the body.

A man in his forties is sitting on a couch, his head face down on a table covering a girlie magazine. On the right side of his head is a crack pipe, on the left a open can of Budweiser beer. His pants are around his ankles, and his right hand is riggored stiff clutching himself.

"How about that," my partner says. "Died coming and going at the same time."

The Man Who Wouldn't Die

We're called for a person not feeling well in an elderly housing hi-rise not far from the hospital. The man is an emaciated AIDS patient, who is laying naked on the couch in his dark apartment. he has a colostomy bag. His girlfriend says they were at the emergency department for seven hours today, then left.

"What did the doctors say was wrong?"

"Nothing. We were in the waiting room."

The fire fighter first responder says he can't feel a pulse, but the man is talking and alert. Its not unusual to have a difficulty feeling a pulse on some AIDS patients who are often baseline hypotensive. Since it is so dark in the apartment, I just say put him on the stretcher, give him some 02 and we'll work him in the ambulance.

Downstairs in the ambulance, I try for a blood pressure and can't hear anything. His nail beds are white. I put in an IV while my partner puts him on the monitor.

"Why are you grimacing?" my partner asks.

The man is suddenly writhing.

"My chest hurts," he says.

I look at the monitor. He's in V-tack.

I slam some lidocaine in the IV line and tell my partner to drive to the hospital. We are only a coupld blocks away.

I put the pads on the man's chest. "This is going to hurt," I say.

Before I hit the shock button, I pull out my intubation kit and have it ready.

I shock him.

He screams.

Still v-tack.

"Sorry, I have to do it again."

I shock him. He's out.

I grab and tube and using a device called a bougie, slide the bougie between the vocal chords, then slide the tube over it. I'm in in like twenty seconds. I do some compressions, venilate through the tube, grab some epi and slam it in the line, and just like that we are out at the hospital.

Another EMT comes around and helps us unload the patient. When we wheel him into the cardiac room, the doctor takes one look at his emaciated body and says, "He's asystole, he's dead."

"But he just coded like two minutes ago," I say.

"Look at him, he's terminal."

The doctor is right. He looks like a Biafrian.

"He was v-tack. I shocked him twice. He was here for seven hours today in the waiting room."

The doctor ponders a moment, looks at the ECG, says, "11:34," and leaves the room.

The nurse takes the rest of my report, then writes in the time, then goes over to prepare the body.

The man takes a breath, a deep gasp.

She jumps. "Oh, my god."

He gasps again, and with each gasp, his breathing becomes more regular. She hooks him up to the monitor. He has a rythmn.

"I guess I better get the doctor."

She comes back with the doctor just in time to see the man take his last gasp. The monitor goes back to straight line.

The doctor shakes his head. "He's dead," he says.

"You don't want to give him some epi?"

"No."

He turns to leave the room. The man takes another deep gasp.

The doctor turns and glares at him as if to command him to cut it out. He's still breathing.

The doctor approaches, lays his hand on the man. He stops breathing.

"I'm giving him epi," the nurse says.

"Fine," the doctor says. He glares at me. "Thanks again," he says.

I have been bringing him a number of codes lately. "My pleasure," I say.

I leave to write my run form. When I come back fifteen minutes later there is a sheet over the man. The nurse stands across the room watching him.

"He's really dead now?" I ask.

She gives me a sarcastic smile as she accepts my run form, then returns her gaze to the body on the ER table.

Death in a Nursing Home

We're called for a child not breathing. The address is a convalescent home. It makes no sense.

Then we pull up. There is a car parked askance by the entrance, two front doors and a back door open. The engine still running.

In the front lobby two nurses and a police officer kneel over a small body-- a boy of maybe six years. One nurse does chest compressions, while the other holds the bag valve mask over the boys face and tries to breath for him. The police officer attaches a defibrillator.

I kneel down by the head. The robotic voice from the defibrillator says, "No shock advised. Check pulse. If no pulse, continue CPR."

The boy is lifeless. I feel for a pulse. None.

My partner Annie attaches the cardiac monitor to the patient while I take out my airway kit.

I slip the tube into his throat. I glance up at the monitor. Asystole. Flat line.

I look at his arms for a vein. I see nothing, so I take out an IO bone needle. I pull back his pant leg, swab his tibia, then twist the needle down hard like a screw. It pops as it goes through the bone.

I push epi and atropine. No response.

What happened? I ask now.

His parents were driving by, a nurse says. They brought him in, he wasn't breathing. They said he wasn't feeling well today. We started coding him right away.

I look up at a woman sitting in a chair, looking glazed. A man stands behind her, no hand on her shoulder. Then I notice a silent row of residents in their wheelchairs in a semicircle around us.

I see in my head this scene from above. Us kneeling around a lifeless child, trying to make his heart beat and to fill his lungs with air. The honor guard of the aged around us. The scene gets smaller and smaller as the camera view goes up through the roof, through the night clouds and up into the stars.