Methicillin-resistant Staphylococcus aureus (MRSA)
This happens all the time. You get called to the nursing home. There is a sign on the patient door that says "Contact Precautions." The staff tells you you have to wear a mask and a gown to enter, so you put it on. You are told the patient has MRSA in their sputum. They may also have C-Diff or other infectious problems. So you put the mask on and sometimes the gown, and you get the patient, who is often in respiratory distress, and you take them to the hospital and you enter the hospital still wearing the gown and mask, and the hospital staff laughs. And the triage nurse sans mask, talks to the patient, and the register, sans mask and gloves, talks to the patient, and puts on a wrist band, and then they tell you to put the patient in the crowded hallway outside room whatever. (This provides a good laugh as all the patients you pass in the hallway look at you in horror as you, gowned and gloved, wheel the patient past them. You squeeze the bed in between two other beds in the hallway after asking some visitors to get up from their chairs, and then you, gowned and gloved, leave the patient right next to them.
I wrote about a code we did a few weeks ago where we get all gowned up and sent into a room only to find the patient in cardiac arrest. We get the patient back enough to have to transport. We show up at the hospital -- all the EMTs who have showed up at our back ambulance doors to help us unload the patient, turn and flee when they see us in our gowns and masks. We go into the cardiac room, and no one on the ED staff wears anything more than gloves as they take over the code. And this is a patient with colostomy, foley, sores, and MRSA in sputum and C-Diff.
This also happens all the time -- MRSA-less people walk into the hospital for one problem and walk out with MRSA. A friend of mine's wife goes to the hospital for a knee operation, comes out (and soon has to go back to the hospital) with double pneumonia with MRSA.
I've put some links at the bottom of this post. An interesting one is the Yahoo answers where health care providers disagree with each other on what you need to do with a patient with respiratory MRSA.
For what it is worth, after browsing through the literature, this will be my policy:
If I am going to be within 3 feet of the patient and providing direct care that may contact body fluids such as sputum, I will wear a mask, gown and gloves.
***
CDC Multidrug Resistant Fact Sheet
Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings 2007
Does anyone know if MRSA in a persons sputum can infect people caring for the sick person?
Contact Precautions
MRSA Policy Introduction
MRSA Level III
Wednesday, January 30, 2008
Tuesday, January 22, 2008
Mobile
What I like about EMS is you never know where you are going to find yourself. Somedays are pretty boring and routine (nursing home calls and fender benders), but then the next moment, you find yourself in an upside down car, or diving head first through an open window of a locked house, or climbing a scaffold of a five story building. You could be in a penthouse suite overlooking the city or in the kitchen of McDonald’s, under a machine in a factory with loaves of freshly made bread whizzing over your head or even in the ring at Wrestlemania (Hartford 1995!).
Yesterday we got called to an elderly housing complex – a complex we go to all the time – for a fall outside from a motorized wheel chair. We find a woman lying on the ground in front of her wheelchair, covered with blankets – it’s quite cold out -- her face bloodied, but with no apparent injury other than a small cut by her eye. She doesn’t want to go to the hospital, but we insist on at least getting her on our stretcher and into the back of the ambulance where with the heat going we can warm her up and check her out more thoroughly. She is concerned about her wheelchair, but since we are right in front of the complex’s rec center, we say we’ll just wheel it in there in case we take her to the hospital. The chairs, which weigh over 250 pounds, are far too heavy obviously to transport in the ambulance.
Once we get her warm and cleaned up, the cut looks quite minor and we place a band-aid over it. No neck or back pain and no LOC, she does not wish to be transported, so we find out which building she lives in and tell her we will drive her over to it and take her in to her apartment on our stretcher. But what about the wheelchair? No problem, we say. I offer to wheel it over while my partners transport her.
Be careful she says the controls are very touchy. (It turns out the chair is a demo and she was out on her first ride. The touchy controls tripped her up.)
It takes me a little while to figure out how to turn the chair on, and then once it is on, I have a hard time making it go straight as I stand with one hand on the joy stick and one on the chair. An elderly woman bystander offers tips. “It’s easier if you sit in it,” she says.
And so I do. It takes me a little while to get the hang of it, but then I am off to the races. Feet up on the foot rests, arms on the arms rest, left hand on the joy stick I go motoring down the walkway. The speedometer reads 1.4 MPH. I put the hammer down and the speedometer hits 1.5.
What a beautiful day. I look at the trees, the leaves. I wave to a woman watching me from the balcony. She waves back. This is great! My destination is two buildings away. I wish it were four or five.
In my head, I hear The Who’s “Going Mobile.”
I'm going home
And when I want to go home, I'm going mobile
…Keep me moving
...Mobile, mobile, mobile, yeah
Yesterday we got called to an elderly housing complex – a complex we go to all the time – for a fall outside from a motorized wheel chair. We find a woman lying on the ground in front of her wheelchair, covered with blankets – it’s quite cold out -- her face bloodied, but with no apparent injury other than a small cut by her eye. She doesn’t want to go to the hospital, but we insist on at least getting her on our stretcher and into the back of the ambulance where with the heat going we can warm her up and check her out more thoroughly. She is concerned about her wheelchair, but since we are right in front of the complex’s rec center, we say we’ll just wheel it in there in case we take her to the hospital. The chairs, which weigh over 250 pounds, are far too heavy obviously to transport in the ambulance.
Once we get her warm and cleaned up, the cut looks quite minor and we place a band-aid over it. No neck or back pain and no LOC, she does not wish to be transported, so we find out which building she lives in and tell her we will drive her over to it and take her in to her apartment on our stretcher. But what about the wheelchair? No problem, we say. I offer to wheel it over while my partners transport her.
Be careful she says the controls are very touchy. (It turns out the chair is a demo and she was out on her first ride. The touchy controls tripped her up.)
It takes me a little while to figure out how to turn the chair on, and then once it is on, I have a hard time making it go straight as I stand with one hand on the joy stick and one on the chair. An elderly woman bystander offers tips. “It’s easier if you sit in it,” she says.
And so I do. It takes me a little while to get the hang of it, but then I am off to the races. Feet up on the foot rests, arms on the arms rest, left hand on the joy stick I go motoring down the walkway. The speedometer reads 1.4 MPH. I put the hammer down and the speedometer hits 1.5.
What a beautiful day. I look at the trees, the leaves. I wave to a woman watching me from the balcony. She waves back. This is great! My destination is two buildings away. I wish it were four or five.
In my head, I hear The Who’s “Going Mobile.”
I'm going home
And when I want to go home, I'm going mobile
…Keep me moving
...Mobile, mobile, mobile, yeah
Friday, January 18, 2008
On the Night You Were Born (an excerpt)
I stood by the hospital entrance I thought your mother would drive through so she would see me. It was dark and cold and I had to stomp my feet to keep warm. Then I saw her drive by. She didn’t see me, and as she continued toward the parking garage, I ran after her, a tall man in work boots chasing a black car.
On the labor and delivery ward, the nurses looked at me in my uniform and stethoscope around my neck and thought I was bringing in a patient, but I had to say, “I’m here as a father tonight.”
They attached your mom to a fetal monitor, which showed your heart rate as well as the strength of each contraction. Your heart was cruising at 140-150.
When the doctor broke the sac to speed the birth process, there was green in the fluid – meconium.
The contractions continued. Your mother got more dilated. Then during one contraction as the strength of the contraction went up 30, 34, 38, 41, 45, 50…I noticed your heart rate started to go down...134, 128, 122, 115, 108, 96, 88.
I wasn’t certain if it was a problem or just the position of the monitor. The doctor came back into the room. Your heart rate was back to normal. The doctor studied the strip a moment and then left the room.
I stood by your mother and watched the monitors. The rate would go down to 120, sometimes to a 100, and then go back up, as the contraction eased.
Your mom was almost fully dilated. The doctor tried to have her push, but you just wouldn’t come out. And then your heart rate started to drop again, back into the 80’s. Then back up. There was the possibility that your head was pressing on the chord.
Please let her be well. Let her be healthy and strong and have a good life. I will do anything, give everything.
They brought me blue scrubs to put on and I sat on a stool next to your mother. From where I sat I could look around the drape and watch as they cut a horizontal line across her abdomen. I held her hand and sometimes rubbed her shoulders.
When they reached in and pulled you out, they pulled just your head up first and there you were. Your head looked just like a big blue bulldog. You weren’t breathing, but I knew that was alright.
They took you over to the table and dried you off and cleared all the meconium away. I heard your first cry. I narrated everything to your mom. “She’s pink. She’s beautiful.”
They brought you over to me and then there you were in my arms, cradled against my chest, full head of hair, big brown eyes open, looking to me.
On the labor and delivery ward, the nurses looked at me in my uniform and stethoscope around my neck and thought I was bringing in a patient, but I had to say, “I’m here as a father tonight.”
They attached your mom to a fetal monitor, which showed your heart rate as well as the strength of each contraction. Your heart was cruising at 140-150.
When the doctor broke the sac to speed the birth process, there was green in the fluid – meconium.
The contractions continued. Your mother got more dilated. Then during one contraction as the strength of the contraction went up 30, 34, 38, 41, 45, 50…I noticed your heart rate started to go down...134, 128, 122, 115, 108, 96, 88.
I wasn’t certain if it was a problem or just the position of the monitor. The doctor came back into the room. Your heart rate was back to normal. The doctor studied the strip a moment and then left the room.
I stood by your mother and watched the monitors. The rate would go down to 120, sometimes to a 100, and then go back up, as the contraction eased.
Your mom was almost fully dilated. The doctor tried to have her push, but you just wouldn’t come out. And then your heart rate started to drop again, back into the 80’s. Then back up. There was the possibility that your head was pressing on the chord.
Please let her be well. Let her be healthy and strong and have a good life. I will do anything, give everything.
They brought me blue scrubs to put on and I sat on a stool next to your mother. From where I sat I could look around the drape and watch as they cut a horizontal line across her abdomen. I held her hand and sometimes rubbed her shoulders.
When they reached in and pulled you out, they pulled just your head up first and there you were. Your head looked just like a big blue bulldog. You weren’t breathing, but I knew that was alright.
They took you over to the table and dried you off and cleared all the meconium away. I heard your first cry. I narrated everything to your mom. “She’s pink. She’s beautiful.”
They brought you over to me and then there you were in my arms, cradled against my chest, full head of hair, big brown eyes open, looking to me.
Wednesday, January 16, 2008
ETCO2 with BVM
In my post of yesterday, I wrote the following:
While my preceptee prepared the tube, and our crew did CPR, as an experiment I applied a nasal capnography cannula to the patient to see how well we were ventilating with just CPR and bagging. I have heard it suggested that this is an excellent way to assess ventilation in cardiac arrest and or the need for intubation or the ability to delay it while concentrating on compressions or drug administration. The ETCO2 didn't even register, which was either due to poor bagging technique or just the plain difficulty of effectively ventilating someone in arrest by bagging. I would like to try this experiment again on a patient when we have more hands to help and a better seal with proper head positioning.
Later in the day we did a call to the local university hospital where while my preceptee wrote up the paperwork, I went down to the medical library to get copies of some articles from the latest issue of Prehospital Emergency Care, which comes out quarterly. The Jan-March issue features a section of "Abstracts for the 2008 NAEMSP Scientific Assembly," which includes almost 100 prehospital research abstracts. I was interested to find one titled "The use of End-tidal Carbon Dioxide Values Obtained During Bag-Valve-Mask Ventilation to Predict Post-Intubation Values."
Their conclusion "ETCO2 values obtained during BVM appear to accurately predict values following intubation. This is potentially useful to establish a baseline to improve the reliability of capnometry for ET confirmation and may allow for guidance of CPR and determination of futility...We believe ETCO2 sensors should be applied during BVM rather than waiting until after intubation."
The study was conducted in San Diego and involved over 221 patients, including 90% in cardiac arrest.
I will definitely try this experiment again.
***
Note: In a comment New Medic suggests there is an adaptor that connects the sensor to the bag mask -- that the nasal cannuala is not used in this study. This makes more sense now as to why we had no reading at all. I will post more on further investigation.
While my preceptee prepared the tube, and our crew did CPR, as an experiment I applied a nasal capnography cannula to the patient to see how well we were ventilating with just CPR and bagging. I have heard it suggested that this is an excellent way to assess ventilation in cardiac arrest and or the need for intubation or the ability to delay it while concentrating on compressions or drug administration. The ETCO2 didn't even register, which was either due to poor bagging technique or just the plain difficulty of effectively ventilating someone in arrest by bagging. I would like to try this experiment again on a patient when we have more hands to help and a better seal with proper head positioning.
Later in the day we did a call to the local university hospital where while my preceptee wrote up the paperwork, I went down to the medical library to get copies of some articles from the latest issue of Prehospital Emergency Care, which comes out quarterly. The Jan-March issue features a section of "Abstracts for the 2008 NAEMSP Scientific Assembly," which includes almost 100 prehospital research abstracts. I was interested to find one titled "The use of End-tidal Carbon Dioxide Values Obtained During Bag-Valve-Mask Ventilation to Predict Post-Intubation Values."
Their conclusion "ETCO2 values obtained during BVM appear to accurately predict values following intubation. This is potentially useful to establish a baseline to improve the reliability of capnometry for ET confirmation and may allow for guidance of CPR and determination of futility...We believe ETCO2 sensors should be applied during BVM rather than waiting until after intubation."
The study was conducted in San Diego and involved over 221 patients, including 90% in cardiac arrest.
I will definitely try this experiment again.
***
Note: In a comment New Medic suggests there is an adaptor that connects the sensor to the bag mask -- that the nasal cannuala is not used in this study. This makes more sense now as to why we had no reading at all. I will post more on further investigation.
Monday, January 14, 2008
Thoughts on CPR, Compressions, ETCO2 and Codes
I came back from a week off the other day and was greeted with a cardiac arrest on my first call and then another arrest the next day. Both codes were asystole, although we managed to get pulses back briefly on the second one. I had my preceptee with me on both calls. He got some good experience, including getting a successful intubation, and did a fine job orchestrating the second call.
On the first code we had excellent capnography (30-40) with CPR, but could never get any kind of rhythm going. The patient was last seen breathing an hour before. The initial capnography on intubation was 64, but it went down to the 30s as soon as the excess carbon dioxide was ventilated off. The high reading indicated a likely respiratory cause of arrest as the still beating heart carried CO2 to the lungs where it could not be ventilated off. After some ventilation, the excess removed, the number dropped.
Three years ago I wrote a post called Compressions about an new EMT doing his first code. That same EMT was on this call with us, and, now a seasoned EMT (and notorious "shit magnet") he did an awesome job on the compressions -- so much so I thought the patient was in VT, although as soon as he stopped compressions, the lines went flat again. He also did a fine job in instructing our newest EMT in the proper method of compression.
Here's the difference between the two compressions:
Beginner CPR
Good CPR
We worked the patient for 30 minutes, but with no change from flatline, we called it.
As an experiment, once we stopped working the patient, I had the crew stop CPR first and I kept bagging for a minute to see the effect on the end tidal. As we stopped CPR, the ETCO2 dropped precipitously. 35, 29, 15, 9, 3. No cardiac output, no ETCO2.
The second code was at a nursing home, a patient with a significant medical history (IDDM, HTN, MI, cancer, amputee, respiratory failure) complete with foley, colostomy, huge freshly zipped scar running vertically up his chest and of course a full code. I figured he would also be a 20 minute ACLS and out. While my preceptee prepared the tube, and our crew did CPR, as an experiment I applied a nasal capnography cannula to the patient to see how well we were ventilating with just CPR and bagging. I have heard it suggested that this is an excellent way to assess ventilation in cardiac arrest and or the need for intubation or the ability to delay it while concentrating on compressions or drug administration. The ETCO2 didn't even register, which was either due to poor bagging technique or just the plain difficulty of effectively ventilating someone in arrest by bagging. I would like to try this experiment again on a patient when we have more hands to help and a better seal with proper head positioning.
My preceptee sunk the tube quickly. The ETCO2 was an unpromising 8. We had brought in our new EZ-IO and one look at this guy showed no quick IV access, so I grabbed the EZ-IO and elbows up, told my preceptee, "Me first!" Having never done an EZ-IO, I felt I was entitled. It truly is as advertised -- an easy IO. Pop the needle on the drill, press against the skin and squeeze the drill. Brrrrup. Instant access. I have to say this, along with CPAP, are two of the most amazing innovations I have seen in all my years in EMS.
We gave some epi and atropine and my other partner and I switched off between bagging and doing CPR. I was really pounding the CPR, but couldn't get it above 8. I noticed my partner would get it to 10 when he did it. We switched back and forth a couple times and he was consistently a few points higher than I was. I was going much faster than he was, but maybe not as deep. The next switch, I slowed down and went much deeper and concentrated on full recoil of the chest and slowly the ETCO2 started to rise and it just kept going. I got it up into the high 30's.
Some more epis and atropines and we had a wide complex rhythm and even pulses and a blood pressure back a couple times, but we had trouble maintaining it. Almost every time when we stopped compressions, the ETCO2 dropped. It was probably just the epi talking. We ended up transporting and the patient was called dead at the hospital. All told we had worked him almost an hour. We all had sore backs. I don't do CPR that often, p[articuarly not in a moving ambulance or going down the hall in the hospital -- I am usually managing the airway, but since on this day it was my preceptee's job, I did the compressing. With the new CPR, it is vitually impossible to do it properly in a moving vehicle or even going down the hallway. The old I'm just doing compressions and we all know they don't work method just doesn't cut it anymore, particularly when the capnography shows an instant drop off in compression effectiveness.
It was a good precepting call and a good educational call all around. I love the ETCO2 as an indicator of how well CPR is being done, and as instant feedback to your technique. Now I know sometimes it is hard to know whether to credit the rise to the technique or maybe the effects of the drugs finally working, but it is certainly something to consider.
Where I continue to have some confusion is when the ETCO2 rises into the 30's and 40's and maintains it there at least temporarily without compressions, but you still cannot find a pulse. I have been told by experts and have told others that it is impossible to maintain an ETCO2 in the 30s and 40's without cardiac output, and I agree with that. But the question is just how effective is that output? Is this PEA or just a really low pressure? Does it represent a pressure of say, 40 or 50, and wouldn't it be better to just do CPR? (much in the way we do CPR on infants with low heart rates). My final answer is you just have to judge on a patient by patient basis. I would say if you have what looks to be a perfusing rhythm with a good ETCO2, and the patient is pinking up, but no palpable pulses (sometimes I can't palpate pulses on a talking person), then maybe hold back on the CPR, try to get a pressure either manually or with the automatic cuff. Maybe try some dopamine if you can't. But if you don't have a rhythm you believe capable of perfusing and or the patient does not look as if there is life, there, then by all means, keep pounding away. This is really inadequately chartered territory. I have witnessed the sudden rise in ETCO2 attributed to return of spontaneous circulation and felt pulses and I have seen rises without being able to feel pulses. Some patients I have been comfortable witholding CPR on (and the ED BP machine has validated my decision with solid pressures) and others, no way. And forget trying to explain to an ED doctor why you are not doing compressions because of a non compression assisted capnography reading in the 30's or above. It is, at least for now, (unless you have an exceptional and I would say narrow complex rhythm)a tenuous limb. Until the ED docs (and the literature) are more on board, it is a little risky.
Capnography for Paramedics
On the first code we had excellent capnography (30-40) with CPR, but could never get any kind of rhythm going. The patient was last seen breathing an hour before. The initial capnography on intubation was 64, but it went down to the 30s as soon as the excess carbon dioxide was ventilated off. The high reading indicated a likely respiratory cause of arrest as the still beating heart carried CO2 to the lungs where it could not be ventilated off. After some ventilation, the excess removed, the number dropped.
Three years ago I wrote a post called Compressions about an new EMT doing his first code. That same EMT was on this call with us, and, now a seasoned EMT (and notorious "shit magnet") he did an awesome job on the compressions -- so much so I thought the patient was in VT, although as soon as he stopped compressions, the lines went flat again. He also did a fine job in instructing our newest EMT in the proper method of compression.
Here's the difference between the two compressions:
Beginner CPR
Good CPR
We worked the patient for 30 minutes, but with no change from flatline, we called it.
As an experiment, once we stopped working the patient, I had the crew stop CPR first and I kept bagging for a minute to see the effect on the end tidal. As we stopped CPR, the ETCO2 dropped precipitously. 35, 29, 15, 9, 3. No cardiac output, no ETCO2.
The second code was at a nursing home, a patient with a significant medical history (IDDM, HTN, MI, cancer, amputee, respiratory failure) complete with foley, colostomy, huge freshly zipped scar running vertically up his chest and of course a full code. I figured he would also be a 20 minute ACLS and out. While my preceptee prepared the tube, and our crew did CPR, as an experiment I applied a nasal capnography cannula to the patient to see how well we were ventilating with just CPR and bagging. I have heard it suggested that this is an excellent way to assess ventilation in cardiac arrest and or the need for intubation or the ability to delay it while concentrating on compressions or drug administration. The ETCO2 didn't even register, which was either due to poor bagging technique or just the plain difficulty of effectively ventilating someone in arrest by bagging. I would like to try this experiment again on a patient when we have more hands to help and a better seal with proper head positioning.
My preceptee sunk the tube quickly. The ETCO2 was an unpromising 8. We had brought in our new EZ-IO and one look at this guy showed no quick IV access, so I grabbed the EZ-IO and elbows up, told my preceptee, "Me first!" Having never done an EZ-IO, I felt I was entitled. It truly is as advertised -- an easy IO. Pop the needle on the drill, press against the skin and squeeze the drill. Brrrrup. Instant access. I have to say this, along with CPAP, are two of the most amazing innovations I have seen in all my years in EMS.
We gave some epi and atropine and my other partner and I switched off between bagging and doing CPR. I was really pounding the CPR, but couldn't get it above 8. I noticed my partner would get it to 10 when he did it. We switched back and forth a couple times and he was consistently a few points higher than I was. I was going much faster than he was, but maybe not as deep. The next switch, I slowed down and went much deeper and concentrated on full recoil of the chest and slowly the ETCO2 started to rise and it just kept going. I got it up into the high 30's.
Some more epis and atropines and we had a wide complex rhythm and even pulses and a blood pressure back a couple times, but we had trouble maintaining it. Almost every time when we stopped compressions, the ETCO2 dropped. It was probably just the epi talking. We ended up transporting and the patient was called dead at the hospital. All told we had worked him almost an hour. We all had sore backs. I don't do CPR that often, p[articuarly not in a moving ambulance or going down the hall in the hospital -- I am usually managing the airway, but since on this day it was my preceptee's job, I did the compressing. With the new CPR, it is vitually impossible to do it properly in a moving vehicle or even going down the hallway. The old I'm just doing compressions and we all know they don't work method just doesn't cut it anymore, particularly when the capnography shows an instant drop off in compression effectiveness.
It was a good precepting call and a good educational call all around. I love the ETCO2 as an indicator of how well CPR is being done, and as instant feedback to your technique. Now I know sometimes it is hard to know whether to credit the rise to the technique or maybe the effects of the drugs finally working, but it is certainly something to consider.
Where I continue to have some confusion is when the ETCO2 rises into the 30's and 40's and maintains it there at least temporarily without compressions, but you still cannot find a pulse. I have been told by experts and have told others that it is impossible to maintain an ETCO2 in the 30s and 40's without cardiac output, and I agree with that. But the question is just how effective is that output? Is this PEA or just a really low pressure? Does it represent a pressure of say, 40 or 50, and wouldn't it be better to just do CPR? (much in the way we do CPR on infants with low heart rates). My final answer is you just have to judge on a patient by patient basis. I would say if you have what looks to be a perfusing rhythm with a good ETCO2, and the patient is pinking up, but no palpable pulses (sometimes I can't palpate pulses on a talking person), then maybe hold back on the CPR, try to get a pressure either manually or with the automatic cuff. Maybe try some dopamine if you can't. But if you don't have a rhythm you believe capable of perfusing and or the patient does not look as if there is life, there, then by all means, keep pounding away. This is really inadequately chartered territory. I have witnessed the sudden rise in ETCO2 attributed to return of spontaneous circulation and felt pulses and I have seen rises without being able to feel pulses. Some patients I have been comfortable witholding CPR on (and the ED BP machine has validated my decision with solid pressures) and others, no way. And forget trying to explain to an ED doctor why you are not doing compressions because of a non compression assisted capnography reading in the 30's or above. It is, at least for now, (unless you have an exceptional and I would say narrow complex rhythm)a tenuous limb. Until the ED docs (and the literature) are more on board, it is a little risky.
Capnography for Paramedics
Tuesday, January 01, 2008
Life
Clearing out my garage a few months ago, I came across a fifteen year old notebook in which I wrote down my monthly goals.
Be a good man.
Read 5 books.
Work out regularly.
Do 30 pushups in a row.
Be a good EMT
Get 2 Ivs.
It was from a different time, a different life. I lived with my friend Barbara and her son in a rented two bedroom condo in a small town where I volunteered one night a week as a new EMT-I on the local ambulance while during the day I worked for the state government.
I had a radio that I kept by my bedside. Some nights the tones went off and I would dress quickly, run out to my car and with green light whirling drive to the scene where another EMT would arrive with the ambulance. Sometimes the next day, I would close my office door and lay my head on my desk and take a short nap. Some days driving home, I’d have the radio on in hopes of hearing another call I could respond to, and maybe get another chance to get an IV. I wasn’t very good at it, and once in failing to properly tamponade a vein when taking the needle out and attaching the IV line, blood flowed all over my suit pants. Getting an IV was a mark of achievement for me then. It somehow meant I was more than just an EMT. I was this semi-superman character underneath my suit and tie, yes, governor routine.
Part of my job was helping oversee the EMS system. As the executive assistant to the health commissioner (appointed by the Governor) I was charged with orchestrating the effort to hire a new EMS Director. It was a difficult time for EMS in the state. Budget cuts targeted at the regional EMS offices had created a huge rift between the state office and the regional staff between those who wanted a more centralized EMS system and those who wanted to keep things the way they were. People were afraid of who the new person would be, someone from their side or someone from the other view. One top doctor in the state suggested I take the job myself as I seemed to be fair and reasonable. I dismissed it the possibility. I probably could have used my political connections to the governor to get the job, but in addition to not being particularly qualified, I saw clearly that it was a miserable job then -- that the EMS system in the state was a quagmire and my life would be one unsolvable problem after the other, with every person I made happy, there would be another who I would upset, and besides, there would be no true power to change things, that the politics was rigged for stalemate. I could go out on a limb to create a new, better system, but that limb would surely be cut off. And meetings, god, I would be in meetings all day long. It wasn’t for me.
A few weeks ago, driving back from a transport to a distant hospital, I took a short detour and drove by where we used to live. I have always found it hard to believe that you cannot walk through a door that is still there and not find your old life behind it just like it used to be. A smiling face, glad to see me, cold beers in the fridge for a Friday night, music on the stereo (Springsteen, Otis Redding, Marshall Tucker, Conway Twitty), steaks ready to hit the grille out back, lively conversation.
Much has changed in the years since. People go their different ways. I left government, became a full-time paramedic, met a new friend, wrote a book, then another, bought a house, got married, stayed a paramedic, got divorced, kept working as a medic, met another friend, and today find myself still a paramedic, with a wonderful young family of my own.
I look in the mirror. I’m forty-nine years old, and although I am in the best shape of my life, I am no longer a young man. The mirror shows the years. Creases in my forehead, gray at the temples. Hair growing out of my ears.
A few months back, I received a call from Barbara’s son, telling me she had passed. I knew she was sick. I had gone out and visited her and her son’s family in New Mexico last year. We listened to music, drank beers and talked about sports and politics and literature and writing like we used to. She had cancer, and was preparing for treatment that at least initially looked like it might be successful. The last time I talked to her, we quarreled and then didn’t speak for awhile. A discussed visit was never finalized. I was going to call and see how she was and now I can’t. I think when we last spoke she knew she was dying and didn’t want me to see her in a feeble state. Her son told me she shut most of her friends out in the last month. He said she kept going to work, tried to keep herself busy right up until the end when she could no longer hide that she really was dying. They got her hospice care for the final few days to help her with the pain.
Last month I drove up to Boston for the fiftieth birthday party for my lifelong friend Brad. On the way up I decided to make certain to enjoy the event as if it were the last time I was seeing him. I thought of our history together from high school to living and working in Washington together. On Friday nights we used to drive to Georgetown –the nightclub district, buy a case of beer and sit under a bridge and drink and get a good buzz on before hitting the bars (thus saving a great amount of money). We spent some weekends at the beach, staying up almost until dawn, and then setting our sleeping bags on the beach and waking up at noon to find wall to wall bathers around us. Later we spent a summer driving around the country together, logging 14,000 miles on his old Oldsmobile, going to Statesboro, Georgia, Navarre Beach, Florida, Juarez, Mexico, Silver City, New Mexico, San Diego, Coos Bay Oregon, Deseret, Utah, Lander, Wyoming, Courdelene, Idaho, and a host of other places, having crazy adventures and ending with a tour or every brewery in Milwaukee, Wisconsin. He went on to law school, and on to a law career and a large family. In 1994, I to a leave of absence from my government job to help him run for Congress. Every summer we still meet at the Boston Beerworks outside Fenway Park to catch up and drink a few, three, four beers before going into the Park to see the Red Sox play.
At the 50th birthday party I talked with many of his friends, some from the old days, many from his current life and it occurred to me how much a part of our friends we become – we are a collection of our friends and our experiences. I remembered how at Brad’s wedding twenty-five years ago his sister, on meeting me for the first time, said she was struck by how much of Brad she saw in me, and how much of me she saw in Brad. When at this 50th birthday party, it came time for me to give my toast, I talked briefly about the death of my friend Barbara and how sad I was that she was gone, but that now I was coming to understand that people don’t really die – they live not just in memories, but in other people in how they shaped their lives . And how, if you want, you can simply, by closing your eyes, walk back through those doors and remember life and people how they were.
I don’t want to rush through the day, I want to remember and carry every moment with me. At almost fifty, for all the aches and pains, I have at least, learned to sit back and appreciate what it is we all have.
In Shakespeare’s Julius Caesar, a man says to his comrades on the night before battle, “if we meet again, we will meet by light of day, but if not, why then this parting was well made.”
I don’t keep a notebook with my monthly goals anymore, but if I did, it would say this:
Be a good man
Work out regularly
Be a good paramedic
Take no day for granted.
And when I look into the eyes of the sick and dying, I need to remember that no one who has ever lived life is feeble.
Be a good man.
Read 5 books.
Work out regularly.
Do 30 pushups in a row.
Be a good EMT
Get 2 Ivs.
It was from a different time, a different life. I lived with my friend Barbara and her son in a rented two bedroom condo in a small town where I volunteered one night a week as a new EMT-I on the local ambulance while during the day I worked for the state government.
I had a radio that I kept by my bedside. Some nights the tones went off and I would dress quickly, run out to my car and with green light whirling drive to the scene where another EMT would arrive with the ambulance. Sometimes the next day, I would close my office door and lay my head on my desk and take a short nap. Some days driving home, I’d have the radio on in hopes of hearing another call I could respond to, and maybe get another chance to get an IV. I wasn’t very good at it, and once in failing to properly tamponade a vein when taking the needle out and attaching the IV line, blood flowed all over my suit pants. Getting an IV was a mark of achievement for me then. It somehow meant I was more than just an EMT. I was this semi-superman character underneath my suit and tie, yes, governor routine.
Part of my job was helping oversee the EMS system. As the executive assistant to the health commissioner (appointed by the Governor) I was charged with orchestrating the effort to hire a new EMS Director. It was a difficult time for EMS in the state. Budget cuts targeted at the regional EMS offices had created a huge rift between the state office and the regional staff between those who wanted a more centralized EMS system and those who wanted to keep things the way they were. People were afraid of who the new person would be, someone from their side or someone from the other view. One top doctor in the state suggested I take the job myself as I seemed to be fair and reasonable. I dismissed it the possibility. I probably could have used my political connections to the governor to get the job, but in addition to not being particularly qualified, I saw clearly that it was a miserable job then -- that the EMS system in the state was a quagmire and my life would be one unsolvable problem after the other, with every person I made happy, there would be another who I would upset, and besides, there would be no true power to change things, that the politics was rigged for stalemate. I could go out on a limb to create a new, better system, but that limb would surely be cut off. And meetings, god, I would be in meetings all day long. It wasn’t for me.
A few weeks ago, driving back from a transport to a distant hospital, I took a short detour and drove by where we used to live. I have always found it hard to believe that you cannot walk through a door that is still there and not find your old life behind it just like it used to be. A smiling face, glad to see me, cold beers in the fridge for a Friday night, music on the stereo (Springsteen, Otis Redding, Marshall Tucker, Conway Twitty), steaks ready to hit the grille out back, lively conversation.
Much has changed in the years since. People go their different ways. I left government, became a full-time paramedic, met a new friend, wrote a book, then another, bought a house, got married, stayed a paramedic, got divorced, kept working as a medic, met another friend, and today find myself still a paramedic, with a wonderful young family of my own.
I look in the mirror. I’m forty-nine years old, and although I am in the best shape of my life, I am no longer a young man. The mirror shows the years. Creases in my forehead, gray at the temples. Hair growing out of my ears.
A few months back, I received a call from Barbara’s son, telling me she had passed. I knew she was sick. I had gone out and visited her and her son’s family in New Mexico last year. We listened to music, drank beers and talked about sports and politics and literature and writing like we used to. She had cancer, and was preparing for treatment that at least initially looked like it might be successful. The last time I talked to her, we quarreled and then didn’t speak for awhile. A discussed visit was never finalized. I was going to call and see how she was and now I can’t. I think when we last spoke she knew she was dying and didn’t want me to see her in a feeble state. Her son told me she shut most of her friends out in the last month. He said she kept going to work, tried to keep herself busy right up until the end when she could no longer hide that she really was dying. They got her hospice care for the final few days to help her with the pain.
Last month I drove up to Boston for the fiftieth birthday party for my lifelong friend Brad. On the way up I decided to make certain to enjoy the event as if it were the last time I was seeing him. I thought of our history together from high school to living and working in Washington together. On Friday nights we used to drive to Georgetown –the nightclub district, buy a case of beer and sit under a bridge and drink and get a good buzz on before hitting the bars (thus saving a great amount of money). We spent some weekends at the beach, staying up almost until dawn, and then setting our sleeping bags on the beach and waking up at noon to find wall to wall bathers around us. Later we spent a summer driving around the country together, logging 14,000 miles on his old Oldsmobile, going to Statesboro, Georgia, Navarre Beach, Florida, Juarez, Mexico, Silver City, New Mexico, San Diego, Coos Bay Oregon, Deseret, Utah, Lander, Wyoming, Courdelene, Idaho, and a host of other places, having crazy adventures and ending with a tour or every brewery in Milwaukee, Wisconsin. He went on to law school, and on to a law career and a large family. In 1994, I to a leave of absence from my government job to help him run for Congress. Every summer we still meet at the Boston Beerworks outside Fenway Park to catch up and drink a few, three, four beers before going into the Park to see the Red Sox play.
At the 50th birthday party I talked with many of his friends, some from the old days, many from his current life and it occurred to me how much a part of our friends we become – we are a collection of our friends and our experiences. I remembered how at Brad’s wedding twenty-five years ago his sister, on meeting me for the first time, said she was struck by how much of Brad she saw in me, and how much of me she saw in Brad. When at this 50th birthday party, it came time for me to give my toast, I talked briefly about the death of my friend Barbara and how sad I was that she was gone, but that now I was coming to understand that people don’t really die – they live not just in memories, but in other people in how they shaped their lives . And how, if you want, you can simply, by closing your eyes, walk back through those doors and remember life and people how they were.
I don’t want to rush through the day, I want to remember and carry every moment with me. At almost fifty, for all the aches and pains, I have at least, learned to sit back and appreciate what it is we all have.
In Shakespeare’s Julius Caesar, a man says to his comrades on the night before battle, “if we meet again, we will meet by light of day, but if not, why then this parting was well made.”
I don’t keep a notebook with my monthly goals anymore, but if I did, it would say this:
Be a good man
Work out regularly
Be a good paramedic
Take no day for granted.
And when I look into the eyes of the sick and dying, I need to remember that no one who has ever lived life is feeble.
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