QUEAS-E

I had a routine call with my preceptee today -- an obese patient with sudden onset of reproducible chest pain. Lots of cardiac risk factors, but also a history of recent bronchitis. 12-lead looked good. Stable vitals. Some response to nitro. What was really going on with the patient? What was the real source of the chest pain? Who knows? We discussed what a medic should put down for their "clinical impression" in such cases.

Now as far as "clinical impression" goes, I used to love filling out this box, so I could declare what I thought was going on. Nowadays I like the box less because I really can't say I know what is going on. All I can do is treat the patient appropriately by the protocols mixed with common sense, be nice to them and get them to the hospital safely, both from the perspective of a safe ride and by not doing harm with my medicine.

In this case, my preceptee wanted to write ACS (Acute Coronary Syndrome). I questioned it because I thought it was likely more a muscle skeletal or pleuritic problem, but I admitted I didn't know for sure. I told him unless I had a STEMI or at least a far better cardiac story, I usually either wrote "?cardiac/?muscleskeletal" or just wrote simply "chest pain" as my "field impression."

Afterwards, back at the base I was trying to look up the study I had read about where it was shown nitro (because it is a muscle relaxant)works as well at alleviating non-cardiac chest pain as it does cardiac chest pain, meaning you cannot use nitro as a diagnostic to determine what is causing the pain.

One of the sites I found on my search turned out to be a newsletter called the QUEAS-E Update, which is a newsletter from the Wesley Medical Center in Wichita, Kansas written by a Dr. Mark Mosley. What a treasure trove of information and thought! QUEAS-E by the way stands for (Quality, Uniformity, Education, Attitude and Service in Emergencies.)

I found confirmation of the nitro study I had read about as well as some other interesting "cardiac myths." Best of all was the suggestion to write "chest pain indeterminate" when you don't what is causing the pain. Problem solved.

In addition to finding this information, in this and other issues I looked up, there was much fascinating content, including a provocative discourse on the cost to the health care system of mandatory CPR training(and retraining), lessons after spending a night in a hospital unit as a patient, and a plea for EMS to think of themselves as "emergency treaters" as opposed to "emergency responders" when dealing with patients in pain when there is a short transport time to the hospital.

Myths About Chest Pain

QUEASE-E Newsletter July 2008 (CPR is a Waste of Resources)

Pain Management Issue

I am bookmarking the QUEAS-E Update and will make it regular reading.

Archive on On-line Issues

Overtime

When I started working as a precepting medic in 1995, I was making (I believe) $12 an hour, which may have gone up to $14 when I was cut loose six weeks later. I worked three 12's and was often held after crew change, but never to the point of going over 40 hours for the week. Once in awhile an overtime possibility came up, but you had to really fight to get it. The owner of the company did not like to pay overtime. Also back then medics picked their partners and partners were very faithful to each other. People rarely called in sick because calling in sick meant your partner got jammed with someone they might not want to work with.

After the owner died, his son-in-law took over and overtime rules were eased a little bit. There was an overtime list you signed up for and if you were first on the list, you had a better chance obviously of getting overtime than if you were last. They posted the overtime sign-up sheet at seven in the morning. One of the suburban towns had an open shift every Sunday, so if you were first on the list, it was yours for the whole following month. One guy used to get there at an absurd time -- like four in the morning so he could be first on the list. He drove a Cammaro with the license plate OT, or maybe he just called the car - OT. The years play with my memory. Anyway, I coveted the same OT so one night I got there at one in the morning like I was camping out for a concert or World Series tickets. He came in at four and was shocked to see three of us there already. "You all are sick," he said.

When our company was sold, that's when overtime really opened up. Instead of three 12's with the partner of your choosing, most people worked four or five days a week in shifts ranging from 8 to 10 to 12 hours with a largely random partner and every six months the shifts were bid again. The economy was booming then, too, so the average working man or woman had plenty of opportunity to work other jobs. We pretty much had unlimited overtime. From empty spots in the schedule to people booking off, it was easy pickins. Make your own schedule. You could work seven days a week if you wanted and not have to commit to working a shift until the day of when they were frantically paging for people to come in and work. The bitch wasn't lack of overtime, it was getting ordered in to work.

EMTs were making up to $60,000 a year, counting overtime. Medics could make $80,000 in their sleep, several topped $100,000. A senior medic by now was making $25-$26 or more an hour. That put overtime pay at $39-$40 an hour. I took great advantage of this. I benefited by working 2-12s and 1-16 in a suburban town, so I had four days a week to pick up overtime and wasn't beat down on my regular days from the ravages of system-status-management where it seemed some days you spent your whole shift driving from post to post with knees pressed against the dashboard. I could take a few days of that but not all week. With three days on the suburban couch, I could do another three sitting scrunched in the ambulance. No way could I ever handle six like that.

Back when I started I was single, living in a $500 a month including utilities one bedroom apartment with a free health club on the premises. I was driving an old Ford and gas was $1.10 a gallon. I told myself then I would never get myself in a position where I had to work overtime to live. Making as much money as I did over the years in OT, I often faced the choice of moving up in the work ladder, but making less money for more work. Why be a supervisor for $50,000 when I could make twice that wearing a blue shirt? Why go to law school when I'd be tens of thousands in debt and making less money? I loved my job, and I was rolling in cash. I could have four days off a week or I could work seven days and make huge money doing what I loved. A great life.

While there have been periods over the years when overtime has dried up, it has only been temporary. Students come back from school and want to make some cash, but then end up blowing off work to go to the beach. The company puts through a new class of hires -- only a few of whom stay around long.

See where I'm going with this.

Things have changed. It's been getting harder and harder to get overtime. Some blame it on the scheduler. Playing favorites. Who knows? That may have something to do with it. Then there seems to be a shift in company policy. It seemed like it used to be the policy to let the full-timers do the overtime so the company didn't have to hire more people, train them and pay benefits to where maybe the company realized they were spending too much on overtime. So maybe they decided let's just hire a lot of part-timers. I mean a lot of part-timers. And let's keep hiring them. And hiring them.

Everyday I see new faces, more and more of them, and not just our company, other companies, too. There doesn't seem to be a shortage of people with EMT cards these days. Some would say there doesn't seem to be a shortage of people with pulses, but I won't go that far. You take the class, you pass, you get your card, you put on a uniform and answer a call, you have my respect.

The thing of it is -- the economy isn't so good these days. People are happy to take on part-time jobs. And people who might have left for greener pastures are sticking around. With gas costing over $4 a gallon and everything else going up, people are taking part-time jobs not as a lark, but because they need the extra income just to pay their bills. And the full-timers, their bills are going up to, so there are alot of people competing for fewer and fewer open shifts.

I have a house and a mortgage now, and a family to take care. If I don't work overtime, I have a serious negative cash flow. Most of us do.

So I've taken on a part-time job. I'm excited about it -- it is EMS-related, but it is not on the street. I'll still be working 40 street hours a week, doing calls, but I won't be doing sixty or seventy street hours. Not any more. The part-time job will be my overtime.

Maybe it was time for me to cut back. I'll be fifty before thirty days are out. The street wears a person down. I'm lucky to have this opportunity. And I'm sure whoever picks up the 8 or on a good week 16 hours extra OT I had been fighting for and getting lately (I've been fighting for more, but getting less) will be happy to see their name in the shift book instead of mine.

Day-to-Day EMS

You punch in. You check your equipment. You get your calls. You respond. 83-year-old female fell, head lac. 6-year-old boy, history of seizures, had a seizure. 63-year-old man with abdominal pain. 74-year old with fever. 59-year old man with syncope. 23-year-old driver with neck pain from rear-end MVA. You do your assessments, get your histories, give the routine treatments, take your patients to the hospital, write your reports. Go back on-line. Do another call. End of the day, you make certain the ambulance is restocked. You punch out.

Day-to-day EMS.

"What's going on?"

"The usual."

This past week someone else has been saying, "Hey, I had an interesting call."

Maybe tomorrow it will be me doing the telling.

When Are You a Competent Medic?

I recently received the following question in the comment section:

At 10:31 PM, DavisEmt said...
This is going to sound stupid:
But I don't really have anyone I trust to ask.

How do you know when you are a competent medic, because I know every call isn't going to run perfect, but I've been a medic a year (only 3 months for a busy service) and it just feels like the mistakes are never ending. I haven't hurt anyone, but I definitely don't feel I've helped anyone either.
Is there a way to know when you're just not cut out for this job, I just don't want to hang on in denial until I actually do cause damage.

Any input would be great, and well today was a bad day.....

Here's my take:

Competency comes in small steps.

I think most medics when they are first starting question their own competency. This is because no amount of schooling, ride time or precepting can prepare you for everything you will have to deal with. Also, I think beginning medics may think they need to be perfect, when the longer you do this, the more you recognize there is simply no perfection in this business. (Being perfect is different from trying to be perfect, which we should all attempt.)

I think it took me about a year before I started feeling competent. This came from starting to handle the routine calls ( the 02/NTG/ASA chest pain, the breathing treatment dyspnea, the D50 hypoglycemia) well as I developed a rhythm and system that seemed to work. But then every now and then a call (asthmatic arrest, pedi struck by car) would come along and kick my ass, and I would go through the whole "Am I fraud?" "Am I going to kill someone?" agonizing, which I think all medics go through.

As the years have gone by, I have gone through a series of plateaus. I'd pound out the calls, feeling like I was not progressing, and then all of a sudden I'd do a call(a flash pulmonary edema -- and the guy whose head was purple and who looked like he was going to die would get better), and I'd think, hey, I am actually getting good at this, and I'd find myself suddenly bumped up a level, and then I'd stay there for awhile, until the next breakthrough call. In time, many of the calls that I had thought were challenging (cardiac arrests, multisystem traumas) become more routine. And those calls that kicked my ass, well, I still had calls (admittedly fewer) that kicked my ass, but maybe my expectations were lower. I don't expect to save everyone. I am no longer a "paragod," I simply try to do the best I can with what I have to deal with.

There is a knowledge curve in EMS. You start out at knowing nothing, go to knowing something, progress to knowing alot, maybe come close to thinking you know everything, and then slowly start to slide down as you realize more and more you know less and less of what you thought you knew. And that is probably the place you want to end up. You need to have respect for the unknown. That doesn't mean I don't try to learn it, it's that I recognize that knowledge is not finite, it is infinite. I just try to learn as much as I can and do the best I can. My youthful pride has been replaced with middle-age humility.

I still always evaluate each call I do for how I could do it better. I recently had a tough multi-patient critical call that I think went very well, and I was proud of how I handled it, but if I had to do it all over, I would do it much differently.

I guess today I don't beat myself up as much for not being perfect. I do the best I can. I try to learn from the lessons each call gives me.

And when I don't know what to do, I remember the wisdom of my first EMT teacher, Judy Moore: "If you can't remember or don't know what to do, remember to at least put the patient on the stretcher and take them to the hospital."

***

In the previous comments Rogue Medic offered DavisEMT some excellent advice:

At 5:56 AM, Rogue Medic said...
DavisEmt,

Keep working at improving. Keep asking yourself what you could do better on every call. Keep asking others for advice, especially the doctors and nurses at the hospital when you bring in patients. Bug people, but learn. Think about ways you can apply what you have learned.

Review calls in your head. How could you have done things differently? Would it have made a significant difference?

Get a set of questions that you ask everyone, so you have both a starting point for questions and something to return to so you can cover the important stuff.

I ask everyone about chest discomfort, difficulty breathing, weakness, dizziness, nausea, vomiting, diarrhea, fever, head ache, visual disturbances, changes in things - medications, appetite, urination, BMs, . . . . Anything answered with a positive, even if only tangentially related, gets investigated - when did this begin, PQRST, SOAP, whatever works for you. Once you have a set of questions, and you feel that it is in an order that helps you to remember, but also helps you get to the important stuff first, just keep using it, modify it as needed for your style, keep returning to where you left off asking questions once you follow one line of questioning. You may still be asking questions when you arrive at the ED - that's OK. Stick around and listen to the questions the nurse asks, the doctor, too.

Dim Bulb

What do you do when your laryngyoscope bulb is either not lit or too dim to see anything?

I know you are supposed to check your scope every morning. I do. My preceptee does when I am precepting a new medic. Maybe I should check it too. You snap the blade in and it comes on. But is it really bright or is it just lit?

I’ve had dim bulbs before, but with a little tightening they have lit up fine. I’ve also had no bulbs before and often wondered where the bulb went. Did the night crew intubate someone and lose the bulb down that person’s gullet?

So anyway, we’re doing a code and my preceptee says he can’t see anything. I tell him to reposition. No, no, he says, he can’t see, it’s too dim.

I tell him to tighten the bulb. He does. The light is still weak. I finally go in and it is dim. I can see the epiglottis, but underneath is just darkness. My other partner hands me his penlight, and pen light in mouth (yuk) I am able to see the chords and get the tube.

But say you don’t have a pen light or your partner’s pen light is just too yucky, what do you do?

Well, first off, when you check your equipment in the morning, make certain the bulb is not just lit, but bright. (Maybe you should if you use the same gear all the time, make it a habit to replace the batteries on a regular schedule. When we opened up the scope, the batteries were starting to corrode). Carry a second handle. We do have a second handle in our pedi kit, which I would have remembered, I think.

You can also do a blind intubation either digital, bougie, or a blind capnography intubation.

To do a blind capnography intubation, attach the capnography filter to the end of the ET tube, insert the stylet – it will fit as long as it is the thin kind -- hook up the capnography to the machine, turn it on, and then go in for the tube. Once you think you are in, glance at the monitor. You either have a wave form or you don't. You're either in or you are out. In a breathing patient, make certain you have at least four good wave forms, and then pull the stylet and proceed with your routine checks.



For apneic patients with a pulse, you just have to have your partner ready to attach the ambu bag when you ask. No more looking around for the capnography filter -- it is already in place. Keep in mind as always for pulseless patients you will need a little CPR to get your wave form reading.

The following are typical ETCO2 strips on intubation. The tiny bumps are CPR, each compression creates a small tidal volume that releases CO2, ventilating the body by compression only. The large wave is from the first ambu-bag ventilation on the just placed ET tube.





Make certain you have an extra capnography filter available as backup because if by chance you miss your tube and gastric contents come up, they will contaminate your filter in addition to your tube.

But most of all check your equipment. When we did put new batteries in the scope, the difference between the light with the new batteries and the light from our backup scope was immense, even though the backup scope was acceptable.

For more on capnography, check out Capnography for Paramedics.

The Grapes of Wrath

We hear the cops go out for a minor motor vehicle up on the mountain, and then twenty minutes later we get called up there for neck and back pain.

The accident doesn’t look like much as we get there. One vehicle rear-ended the other, but I start to get a little nervous when I count the people standing by the side of the road. There are two adults outside one car, and there are two adults outside the other, but there are also four children, including one in a baby car seat, and another pushing an empty stroller. A muscled tattooed man is also taking stuff out of the car and piling it on the grass – bags of groceries, plastic bags full of clothes, a cooler, two jugs of water, a folded up play pen.

One of my partners checks out the adults in the first car – they both refuse. The adult female in the second car says she has lateral neck pain, but says she is most concerned about her two oldest children – they both have neck and back pain. I approach them – a seven and ten-year-old. Yes, they say, their necks hurt – right in the center. I have my partners get to work c-spining them while I check the woman over. Her neck pain seems muscular and is only on the left side. No pain along the spine. No numbness, tingling, weakness, etc. No pain or limit to range of motion. My plan is to put the two children on boards, one on the bench seat and one on the stretcher and have the mother go as a patient in the captain’s chair.

But then she says, “What about my other children?”

I say, “What about them?”

“I can’t leave them.”

“They can’t come in the ambulance. They’re going to have to stay with your friend.”

“Can’t you call another ambulance? And what about our stuff?”

“We can’t call an ambulance for people who aren’t hurt. And we can’t take all your stuff.”

“What am I supposed to do?”

“Can’t someone come pick them up?”

“No, we don’t have a ride.”

“Hold on,” I say, and then walk over to the police officer, who is writing them tickets and summonses for an unregistered vehicle and failing to properly secure all the children.

I explain the situation to the officer. They don’t have a ride and we can’t fit them all in the ambulance. “They can walk back to the city,” she says. “They can leave their stuff in the bushes and come back for it later.”

From where I stand, I can look down the mountain and see the city in the distance. It looks as far away as the Land of Oz. I look over at the baby sucking her pacifier in the car seat and the four-year old pushing the stroller around in circles, and then at the tattooed man taking more groceries out of the car.

I know it has been a particuarly busy day for police, EMS and fire. Calls are going out all over town.

I walk over to the man. “You can’t get a ride from someone?”

“No.”

“How ‘bout we’ll get you a cab.”

“I got twenty dollars to my name.”

“And you can’t get anyone to pick you up?”

“I don’t have a phone.”

I take my cell phone out and hand it to him. “Start calling.”

While he and the woman pass the phone back and forth calling people – they are having no luck getting anyone -- a tow truck arrives to cart their car off. I keep looking at the children and at the far off city rising out of the valley below.

“Look,” I say to the mother now. “Here’s what we may be able to do. If you don’t want to be transported as a patient – you can still be seen at the hospital -- I can put you in the front seat. I can put the baby in the captain’s chair in her car seat, and I can put the four year old in another seat. I might be able to get some of your stuff in the ambulance. And then if he still can’t get someone to pick him up, then only he will have to walk back.”

So I get the children in all safely secured. I explain to my crew that three of us will have to either sit on the floor or stand holding onto to the top bar. Then I go out and try to help the mother with the possessions. I ask her to point out which is most important. Stroller, play pen, groceries, clothes. What comes with us? What goes in the bushes?

Guess what?

The stroller goes in the side compartment next to the main oxygen tank. The bags of groceries and clothes go stuffed in the stair chair compartment and in the compartment with the flares and hard hats, and in the compartment with the collars and head-beds and straps. The play pen we put between the front seats and the back. We pack every open space we can find. I mean, how can you leave any of this stuff? A baby has to have a play pen. The squirrels and raccoons will get the groceries if we leave them. The kids have to eat, don’t they? The hospital isn’t going to give them but one meal at the best.

The man is talking with someone in very heated Spanish, and then closes the phone in disgust. I tell him we’ll be taking his girl and the kids and the stuff.

He nods and after the cop gives him his summons, he starts walking down the mountain, while we swing, a slow wide u-turn and head back to the city ourselves, four EMTs, one mother, four children, and a family’s food and possessions.

Advice to a New Preceptee

A year ago I wrote a post called Letter to a New Preceptee, offering reassurance to a new paramedic. Today I am supplementing that with "Advice to a New Preceptee."

Note: This letter is not directed to anyone in particular, but rather meant for preceptees in general.

***

Dear Preceptee,

I have been precepting new paramedics for over ten years now. While I recognize that every preceptor has different standards, different pet peeves, and different personalities, here’s what you can do to get on my good side, which I try to show to everyone.

1. Don’t be late to work. Even better, be at work before I get there. I am usually always fifteen minutes early. I can understand an occasional car problem or alarm malfunction, but if you are habitually late, I will think less of you.

2. Check your gear out first thing. I used to trip up my preceptees by removing strategic items from the gear -- stylets, Lasix, pedi defib pads -- to see how thorough they were at checking or if they would lie to me when I asked them if they checked the spare kit. I don’t do that anymore. You are either checking your gear or you aren’t. If you are not, it will come to light, and you’ll learn your lesson the hard way. And don’t blame me if, after two weeks, you can’t find something in your gear or in the truck. It’s your job now to know where everything is.

3. Don’t spend the shift sleeping – either in the bunk room, on the couch, or in the back of the ambulance. Again I can understand if you are not feeling well or had a hard night, and you need some rest. A time or two I will let it slide, but don’t make it a habit.

4. Dress and groom yourself as a professional. I am not the picture of fashion. My shirts are a little rumpled, and sometimes in the early morning my shave is a little uneven, and when I stretch, sometimes my shirt tail gets pulled out, but I tuck it back in. Shower and use soap.

5. Treat your patients and fellow responders with respect.

6. Don’t gossip. Don’t trash talk.

7. Bring your books to work so you can look stuff up after your calls. It’s your choice – you can play video games after a call or you can read your books. I’m not saying there is anything wrong with video games, but if you are not doing great and you’re not asking specific questions about calls, and all you are doing is watching TV or playing video games, it starts to become a problem.

8. Ask specific questions that require some thought, not just general questions. If we have just done a patient with CHF, ask a question about CHF. Don’t expect me to teach you everything you weren’t paying attention to in paramedic class. Do expect me to help explain what you are not clear about.

9. And while I want you to take as much time as you need to write a full run form, don’t take an hour at the hospital every time. We have an obligation to write a timely (and accurate) run form and be available for the next call.

10. Help clean and restock if it needs to be done. Don’t punch out and split at the end of the shift if I am carrying bags of saline out of the supply room.

11. Don’t buy me coffee and doughnuts. (True I don’t drink coffee or eat doughnuts. I’m a Diet Coke and wheat bread man). Don’t buy me anything. I do recognize that many preceptors appreciate coffee and doughnuts, and I do not judge them for that. My initial preceptor wouldn’t let me buy him a coffee or a Coke for the length of our preceptorship. And I won’t take it from you.

Final thought: Preceptees worry about their IV skills, their scene handling abilities, their drug knowledge. These are things that you can learn and get better at, and I will work with you on. The things that will fail you are laziness, poor ethics, and disrespect for your patients and profession.

Maybe I am getting crotchety as I approach 50, but that’s where I stand.

Trauma Room: The Sequel

When recently (seven weeks ago) we saw certain of our heroes, the trauma team, in the Trauma Room, I had just unveiled an item of interest for them:

"I give my report in the trauma room. I feel bad to say so but I feel almost like a celebrity chef unveiling a master dish when I finally unveil the man's grotesquely deformed limb. "Open tib-fib fracture," I say with a flourish.

Here is my own description of the injury at the crash scene:

"I look down at his legs. I see jagged bone ends. His right foot is upside down next to his considerably shortened right leg, hanging by a thin margin of skin and muscle."

***

In EMS there is a certain lack of sequel. This can be good -- you do your call and your work is done. But it can also be frustrating -- you do your call, but you never hear the resolution.

Every now and then, you hear the rest of the story.

***

We are sent to a local convalescent home for dsypnea. The medical dispatch tells us an x-ray shows an infiltrate. Big deal, I am thinking. I am precepting a new medic and this call does not promise to be anything more than another routine ALS call, which seems to be all we are getting this week.

The patient, a large man lies in bed, with an oxygen cannula on. I notice the steel halo contraption on his right leg, but think nothing of it. I am thinking look at those scars. I wonder what happened to this guy as I vaguely listen to the nurse give my preceptee the report about his low grade fever and increasing dsypnea today.

"Were you in a car accident a number of weeks back?" my partner asks.

The man grunts.

"Was it a car into a tree?"

The man grunts again.

"Mountain Road?"

He nods.

"We took care of you! That was quite a crash!"

The man's wife gives a reserved smile, but then says, "The accident is still a sore point with him."

"I have to tell you," my partner says. "You're husband's legs look a lot better now than they did that day."

I'm thinking the same thing.

"I'm amazed you still have them." He runs his fingers along the man's leg. "I thought you'd lost this one for sure. It was just dangling there by a strand. The other one wasn't too much prettier."

The man does not look happy to be reminded.

But my partner is beaming. "They did good work on these!"

"They want him up and trying to walk in a couple weeks," his wife says.

I keep staring at the legs myself. All back together. Able to wiggle his toes. Wow.

You know for all the times I get annoyed by the trauma team or think they are chaotic or rude, I have to say, they did a hell of a job here.

Kudos.

We gently move the man over onto our stretcher, careful not to bang the leg -- we treat it like a work of art, like a fragile sculpture by Michelangelo.

"Thank you," the wife whispers to us as we wheel the patient out the door.

"You Know You're a Paramedic When..."

The topic of the week at the Normal Sinus collective blog is “You know you’re a paramedic when..."

Contributor's posts should be up later this afternoon.

Here's my take:

***

You Know You're a Paramedic When...

At the movies you find yourself noticing the veins in movie stars arms as much as their looks.

At youth sporting events you are the only person who does not rise from his seat when a youngster bangs his knee and falls to the ground crying. Yet you still applaud heartily when the youth finally gets to his feet and runs off field.*

In a crowded restaurant you are the first person to notice a person turning blue is actually choking.

You ask the phlebotomist at the doctor’s office if you can stick yourself (after she has already missed twice).

You can sleep soundly in an ambulance and only wake up when your ambulance number is called.

You are as a nimble at dodging vomit as an Olympic slalom skier is at dodging gates.

You can get off the scene of a bad trauma before the news crews arrive.

Every now and then you still pop the tops off the epi and bristojet at the same time for old times sake.

You either have a second job or you make almost as much in overtime as you do in regular pay.

You would rather not think about what you will have to do for work on the day you are too old or beat up to work as a paramedic.

You think they don’t make medics like they used to.

You would rather have someone put a bullet in your brain than put you in a nursing home.

***

* Years ago we had a company softball team that played in a regular competitive softball league. I remember one day, the opposing team's catcher took a throw from the outfield that skipped off the ground and then hit him right in the mouth. He sat on his knees spitting out blood and teeth, and the other team was all gathered around him, and talking about calling an ambulance, and we, a bunch of paramedics and EMTs, were sitting on our bench, chewing sunflower seeds and saying, "He's alert, he's breathing. Be a man and get up."

We played another team where one of their players slide into second base and then lay there writhing in apparent agony. His teammates picked him up and carried him back to the bench. Their next player hit a double and the same thing happened. He slid into second and then lay there writhing on the ground. Again, his teammates ran out and picked him up and carried him off the field. One of the playerss carrying him was the guy who had been "injured" on the previous play.