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.