Winter's Fuel

 As my contribution to the Handover's forthcoming Christmas issue, I have combined two old Christmas posts.

***

Fifteen on the Scale

It's Christmas eve. We get called to one of the local nursing homes for rib pain. The room number sounds familiar. As we wheel our stretcher through the lobby, "Good King Wencelous" plays through the speakers.

Gently shone the moon that night, thou the frost was cruel.
When a poor man came in sight, gathering winter's fuel.

In the East Wing, the nurse hands me the paperwork. "Mr. Ryder says he needs more Percocets. He's requesting transport."

Mr. Ryder is a tattooed biker, an emaciated COPDer with a long white beard. Almost sixty, he can't weigh more than a hundred pounds. He sits in his wheel chair, in his Rebels motorcycle jacket, wearing an oxygen cannula.

"I'm in real bad pain," he tells me in his whisper of a voice. "Fifteen on the scale." He nods as if to say it is the truth.

"Well, we'll check you out when we get you out in the ambulance," I say.

It seems he fell a couple weeks ago and cracked a rib.

I have taken him to the hospital at least ten times over the years. The night medics have taken him more. Nearly every time it is self-dispatched. He agitates the nurses until they call his doctor who after several calls relents and tells the nurses to go ahead and call an ambulance just to get him to stop pestering them. He gets pneumonia a lot and complains of the chest pain. It is always "real bad," he says. He goes to the hospital and gets sent back a couple hours later. He is rarely admitted, and in those cases it is usually for a COPD exacerbation.

While I don't like to categorize patients in this way, he does fall into the "pain in the ass" category. But a patient is a patient, and none of my paychecks has ever bounced, so I'm not really complaining. They'll be turkey with all its fixings on my feast table tomorrow. And besides, there is always something to be said for the familiar.

I see Jimmy nearly everytime we go into the nursing home. He is usually sitting out in his wheelchair in the main TV area. I say "Hey Jimmy! How'ya doing?" as I push the stretcher past going for someone else on the wing.

He lights up and says, "Not too bad, hanging in there."

That's the jist of our relationship.

Today in the ambulance, I have an EMT student do vitals as we start toward the hospital.

She chit chats with him.

"You've got all your Christmas shopping done?"

"Yeah, I just bought stuff for myself," he says. He tells her Dial-a-Ride took him to the Mall. His favorite store is Spensers where he gets a lot of novelty gag items.

"I buy presents for myself sometimes," she says. "How about you?" she asks me.

"I'm pretty much done."

"Well, unless you're going to the drug store when you get off, you're out of luck. Time's run out."

"I'm in good shape," I say. I think to myself if I get out in time, I'll probably make a quick stop at the liquor store where I'll buy myself some Christmas beer -- a case of Red Stripe. I always ask for a case of a specialty beer for Christmas. Last year it was Presidente from the Domminican. This year I want Red Stripe from Jamaica. My girlfriend was going to buy it for me, but she is still hung up at the hospital. I told her not to worry about it. I'd get it myself. There is a liquor store that doesn't close till eight on my way home. I'll drink the beer slowly over the course of the year, taking one out every now and then and drinking it slow. I'll buy other beer during the year, but this case -- my Christmas beer -- I'll stretch out.

The patient looks up at the EMT student and says, "This guy over here, me and him go back a long way."

"He's taken care of you before?" she says.

"Yeah." He nods at me and then says, "He's probably one of my best friends in the world."

I melt a little inside at his words. It also makes me terribly sad. I think of all his biker buddies -- Hoss and Snake and Big Steve -- and wonder if they are enjoying their winter's fuel at the Iron Hog without him tonight or if maybe they are all either in the cold ground or solitary in nursing homes themselves.

Jimmy looks up at me now, his eyes locking on mine. "I'm in real bad pain," he whispers urgently. "Fifteen on the scale."

-Christmas 2006-

***
Christmas

Last night I watched Scrooged, the Bill Murray version of "A Christmas Carrol," where Murray is the bah humbug head of a big TV network. Bill Murray is a very funny actor, and Scrooged always chokes me up at the end, when the little mute kid speaks for the first time and says "God Bless us Everyone." Then they all start singing "Put a Little Love in Your Heart" with Murray singing like his old Saturday Night Live lounge singer character.

Sometimes I feel like I am a Scrooge. I am always working on Christmas. My brother invited me to go to New Jersey and have Christmas with him and his family this year. Of course I couldn't go -- I had to work.

What kind of a bah humbug am I? Working on Christmas all the time. But working in EMS on Christmas is different than working a regular job on Christmas. I have always been proud that when my name is written in the book, I can be counted on to be there. It is not like we can just close up shop on Christmas. Christmas falls on my day to work, I work it. I like being reliable.

I read an interesting article -- "Will Words Fail Her?" -- about a young Chinese fiction writer, Yiyun Li, who wrote a great collection of short stories called A Thousand Years of Good Prayers. One of her teachers, James Alan McPherson, who was also a teacher of mine many years ago, was quoted in the article as saying in American fiction, we have lost the community voice. It is all about the self, but that community voice still exists in writers in Japan and China, writers like Li.

In this job over time you can lose yourself. You become a part of the community, the blanket of watchfulless over the cities and towns that you cover, and that becomes more important than who you are as an individual. People say it is bad to lose yourself in your job, and I don't disagree -- you need balance in your own life. But at the same time, I don't think it is neccessarily all bad.

In Scrooged, Murray's ex-boss, who comes back as the dead Jacob Marley, says his work, his life should have been that of mankind, not TV ratings. While I am not knocking the fact that today I am getting paid double time and a half holiday pay, I think you can make the arguement that our work in EMS is not the work of material advancement, but the work of mankind. There is a certain privledge in looking out over the community, in being its protector, particularly on Christmas Day.

There are some sacrifices in this job, and I am not advocating putting it before everything else in your life, but if you find meaning, even redemption in your work, that is no small thing.

-Christmas 2005

***

This year 2009, Christmas falls on Friday so I am off work. I will spend it gratefully with my family.

No Easy Trail

 Police cordon off the abandoned vehicle with yellow tape. It is an 86 Plymouth – an old man’s car.

“Am I going to need all my gear, or just the monitor?” I ask the officer.

“The monitor."

I look across the grass toward the tree line at the eastern end of the cemetery. I don’t want to have to get all the way in there and find out he’s workable. “He’s been there awhile?”

“Long enough. There won’t be an issue.”

I walk in alone. The leaves of late fall rest brittle on the ground. I have to watch my step on the uneven terrain. Bare branches pull at my pants and workshirt. There is no easy trail here. Still the air is fresh and it is good to be out of doors. No stale wheelchair lined hall this trek.

Fifteen minutes later, I reemerge with burrs on my clothes and blood on my hand from a thorn scratch. In my pocket I have a six second strip of asystole, a man’s name and date of birth on the back. 74 years old.

As I walk back across the grass, the late afternoon sun in the west makes me squint. I can hear the traffic from the main road that runs along the northern edge of the cemetery.

Indians lived here 300 years ago. When they grew old they too used to walk into the woods to die.

Ambassador of Love

 In emergency medicine, field and hospital come together when the EMT/paramedic hands over patient care to the nurse. This transfer is almost always professional and courteous. The good feelings demonstrated on the job between paramedic and nurse are not limited to working hours. After we punch out for the shift, we often meet in restaurants, bars and at parties large and small. Paramedics and emergency nurses love to eat, drink and be merry together. Many end up spending their lives with one another.

At one of the trauma centers in our city, a pretty young nurse chatted with four medics as we waited to get room assignments for our patients. We were discussing the routine “wait” of the triage line when the nurse smiled and said, “Well, at least the nurses at (our) hospital are the friendliest.” She was met with silence and bemused grins -- a reaction she clearly hadn’t expected. “We are the friendliest?...Aren’t we?”

While none of us would complain about the friendliness of the nurses at her hospital, the truth was all four of us were either married to or living with nurses at the other hospital in addition to being the fathers of their children.

My point is the much discussed conflict between nurses and paramedics is more often the exception that the rule. At work and at play, we love and respect each other. Still there is no hiding the fact that there can be conflicts. It usually arises when the nurse and EMT/paramedic are unfamiliar with each other. A rude or misunderstood remark takes on a larger significance. Instead of nurse and paramedic, it's Hatfields and McCoy’s.

Sly Hero

Each confrontation is retold and enhanced with the paramedic always being the sly hero and nurse being an archetype moron or villian. I wrote about this a couple years ago in Left Lateral Condoyle, Paramedic as Sly Hero and Stud or Idiot?

Dumb nurse and sly paramedic stories are quite common in EMS rooms or any place where ambulance crews gather to swap the day's tales. I suspect nurses may tell their own version of dumb paramedic and sly nurse stories when they are among their own kind in their own clubhouses.

Threat to Public Health?

Years ago I went before the legislature to testify about a bill enabling paramedics to give controlled substances on standing orders. (Connecticut had an antiquated law that required controlled substances be given only by “simultaneous communication” with an ED physician.) A few months before the state had passed a law changing paramedics from certified to licensed status, which meant instead of paying $35 every two years, medics now owed the state $75 every year. A certain interest group was concerned that giving license status to paramedics would enable them to work as paramedics in doctors' offices, walk-in clinics and nursing homes. So in response, they cajoled the legislature into writing a bill specifying that paramedics could only practice as paramedics within the confines of the emergency medical services system. This legal language change was lumped together with the proposal enabling us to use controlled substances on standing order.

My lowest day as a paramedic came from watching the representatives from the Nurse’s Association and the Emergency Nurses Association testify that it would be unsafe to have paramedics working in doctors' offices because paramedics were not as well trained as nurses and thus would be a danger to the public health, blah, blah, blah. A lone ER doc then got up and said completely without irony that in addition to being untrained, if we let paramedics work in doctor’s offices, there would be no one left to take care of the truly sick people in the field.

While the doctor was allowed to go on for 11 minutes, any paramedic that wished to speak was gaveled into silence after three. The one bright spot of the day was when a hospital clinical coordinator who was also a paramedic made the savvy point of speaking about first aid stations at a large area boat show that were manned by nurses. If a visitor needs an ice pack or a Band-Aid, he said, then the nurse takes care of them, but if they go into cardiac arrest, the nurse’s first action is to call for paramedics.

Mutual Respect

I do not hold the actions of the nursing organizations (that were successful in limiting our area of practice and who slandered our profession) against the ED nurses who take over care of the sick patients we bring in to the hospital or against the sweet ED nurse who gets up in the middle of the night to comfort my crying daughter, while I get up to warm a fresh bottle of milk. We have a mutual respect.

But still there are those rare, but telling moments when an unfamiliar nurse lets me know that SHE is a nurse and her actions imply I don’t know anything. This happened just the other day at one of the local nursing homes. A COPD patient, who I have been caring for for many, many years, was again having an exacerbation. While I questioned “Frank” about how he was feeling this time and assessed his lungs and breathing, the nurse tried to tell me how much oxygen to give and how to position the patient. Frankly, she was in my way.

I attempted to explain to her that I knew Frank well and had learned to trust him to tell me what he needed. Also, I told her we had capnography and could thus monitor his ventilatory status. She clearly didn’t want to listen nor do I think she had any idea what I was talking about. “I know what you can monitor,” she said, “but you can’t give him too much oxygen.”

I told her we had it in hand – a cue for her to leave. I wanted to say, not only have I been a paramedic for almost two decades, I am also a registered nurse, but I couldn’t say it because my nurse status was still listed as pending on the official state license verification site.

Paramedic, R.N.

That’s right.

For the last couple years I have (off and on) pursued a nursing degree, and I recently completed the final step of the process by successfully passing the NCLEX exam. Yesterday morning, I received an official letter from the state addressing me as Peter Canning, R.N. and including a copy of my new license. I am now a dual citizen.

In addition to pledgeing to uphold the fine and honored nurse traditions and standards of caring for my patients, I really want to meet Dixie McCall. I want her to teach me the nurses’s secret handshake and to formally invite me to the Nurses Annual Hotenanny at the local Moose Lodge.

Ambassador of Peace and Love

I will save a future post for a detailed look at how I got my nursing degree – what I think about the educational experience I had and what I plan to do with my nurse education (besides being an ambassador for peace and love among the clans).

I can say definitively, I have no intention of leaving the paramedic streets as long as I am healthy and able-bodied.

As far as credentials, I intend to be listed as Paramedic, R.N.

No Transport

In my state, "treat and release" is not in the paramedic scope of practice. While we regularly “treat and release,” this occurs only through the refusal process, after first offering/advising transport X 3 to the patient.

This morning I responded to a dispatch for “altered mental status” and on arrival, found a babbling middle-aged woman sitting on the toilet playing with her underwear. The first responders offered to get our stretcher for us (which we had left in the ambulance due to the pouring rain). Seeing my glucometer reading popping up at 34 after doing a finger stick, I told the responders to wait to see if we would be transporting or not.

An amp of D50 later, the woman was apologizing for bothering us, and refusing our advice of transport to the hospital. She forgot to eat last night, she said, after having spent the previous day hiking. She said she was back to normal now and did not want to go to the hospital. She promised to check her sugar regularly, and to follow up with her doctor. Her boyfriend was already cooking her toast, eggs and bacon. They both assured us they would call us back if there was any change in her condition.

Still we made the dutiful effort of offering transport X 3 before accepting her refusal, witnessed by her boyfriend and the police officer.

In the last week, these are some of the refusals I have taken:

A woman who called 911 because she thought the medicine the ED had just given her for her nausea was an "antipsychotic" instead of an "antiemetic." Somehow she had looked Prochloroperazine up on the internet and had determined it was the same as Thorazine, which quite upset her. Once I showed her prochloroperazine was, in fact, compazine, she said "never mind."

A woman whose lengthy oxygen cannula was tangled around her so badly that she could not walk without fear of tripping. She wasn't hurt, she just wanted to be untangled.

And two calls at the jail to check prisoners for scratches received during the altercations that led to their arrests.

On each of these calls, I dutifully offered transport at least three times. Each patient refused. I collected their signatures on the dotted line and thoroughly documented each encounter.

I feel rather silly sometims advising people to be seen at the ED when I didn't think they need to go.

Perhaps there is no more uncomfortable area for recommending transports than when we are called for the "prisoner evaluation." Aside from the scratches and bruises from fights, we often get called to the local jail on a Friday evening of a holiday weekend to evaluate a prisoner who says he is not feeling well -- a classic case of "jailitis." Again, while we are called to the jail for an "evaluation," since treat and release is not in our scope of practice, we have to evaluate and then recommend transport. Law enforcement, of course, often believes the patient is faking and they have no intention of sending the prisoner with the required officer/chaperone to the hospital. The cops look to us to tell them the patient is fine. They are covering themselves by passing the liability to us. We have a fine line to walk in dealing with these patients – hold true to our medical policies while not jamming up the police department unneccessarily.

Let me be clear, I am not talking about the prisoners who I believe actually do need to go to the hospital, and who I will fight vigorously to see get the care they need. I’m speaking of the malingerers.

Now certainly there is something called the art of the refusal. There is a way that your advice is prefaced and phrased that varies to the degree of the urgency of the patient.

I did not speak to the woman who had mistaken compazine for Thorazine in the same way that I would address a man with crushing chest pain and an ST elevation who is refusing to go to the hospital. Nor do I address the prisoner punched in the face without loss of consciousness or complaint in the same way I speak to the man who made a face impression in the windshield of his car at 55 miles an hour. Tone and body language certainly come into play. If they need to go, I am quite earnest and animated about it. If not, I simply cover the legal bases.

"If you are not transported, you might die."

versus

"You were punched in the face. There is nothing I can do to have you unpunched. I don't feel any broken bones. You did not lose conciousness. Your vitals are normal. You appear to have a completely intact and normal nuerological function. I am however, legally required (3 times!) to advise and offer you treatment and transport to the hospital. I cannot however take you against your will. If you do not wish to go, sign here (hand them pen and point to signature line), but you can always change your mind and call us back five minutes from now, an hour from now or whenever you feel there is a change in your condition, and we will be happy to return and take you to the hospital. It is your choice. (Again hand pen to patient if they have not already taken it)."

I write this because of the swine flu. I am hearing that some states are instituting measures whereby if an EMS crew arrives at a scene and finds an otherwise healthy person at home, feeling yucky with a fever and vomiting, the paramedic or EMT would call a medical hotline and speak with a nurse who, if she believes the patient merely has the flu, might tell the patient to stay hydrated and stay at home, and EMS would clear.

Should such a measure be implemented in our state, it would mark a change in the way we do business -- a welcome change in my opinion. Maybe such an experience with the swine flu could lead to a general purpose hotline with either a nurse or physician on the end of the line who could make some of these transport/no-transport necessary decisions, so we don't have to go through the recommend X 3 charade we do everyday. (Like some of my fellow bloggers lately, I do not advocate EMS making these decisions without at the minimum, a medical control consult.)

A problem with the nontransports is the ambulance companies don't get paid if they don't transport. Creating a reimbursement mechanism certainly involves a lot of work at a lot of levels.

Maybe the President's Health Reform can focus on this. I'm an optimist.

***

As an FYI, attached is our state's new policy on how EMS should deal with the many situations that arise when called to a jail or detention center:

EMS RESPONSE TO DETENTION/HOLDING FACILITIES

EMS providers are often called to detention or holding facilities to assess, treat and transport
detainees. It is important to keep in mind that detainees have the same rights to medical treatment as does the lay public.

Request for Evaluation Only

While it is beyond the practice for paramedics or EMTs to provide intentional treat and release
services, EMS responders often encounter situations where a patient (or law enforcement) desires evaluation, but does not want transportation. When in such a situation, EMS responders must treat the scenario the same as they would a patient in a home or at an accident scene who requests evaluation only. The EMS responder should follow good medical judgment in these situations, including doing a full history and assessment. Vitals signs should be assessed, including checking blood sugar if relevant.

Patient/detainee Refusal of Transport

If in the judgment of the EMS provider the patient/detainee should be medically evaluated at the hospital, every attempt should be made to convince the patient/detainee (and law enforcement) to allow ambulance transportation to a local medical facility. EMS responders should offer transportation several times; fully explain the potential medical consequences of refusing care to the patient/detainee and make every effort to ensure all parties understand the risks, and advise the patient/detainee to ask the law enforcement officer to recall 911
if necessary. Should the patient/detainee refuse this offer of transport, a full refusal PCR should be completed. The law officer should witness it. In the event the patient/detainee refuses care and refuses to sign the PCR, document this fact and have the law officer attest to the patient’s refusal to sign.

Police Officer Ordered Transport

In the event the patient/detainee refuses treatment and transportation, but law enforcement orders it, EMS should transport the patient/detainee and document all circumstances in the PCR. In all cases a law enforcement officer should accompany a detainee in the ambulance.

Law Enforcement Refused Transport

In the event the patient/detainee requests transport, but the law enforcement officer refuses to allow the patient/detainee to be transported, document this fact, including the name of the officer in your report. The officer can legally sign a refusal for a patient/detainee who requests transportation (however in practice this is not done – normally the patient/detainee will sign). Documentation should also include the EMS responder’s cautions to the law enforcement officer on the consequences of withholding necessary evaluation and or treatment. The EMS responder should request that the law enforcement officer sign under this documentation. Medical Direction must be contacted (see section below).

Medical Control

EMS responders are always encouraged to contact Medical Direction to allow the on-line physician to speak directly with the patient/detainee or law enforcement officer in an effort to convince them of the need for further medical evaluation. In all circumstances in which a patient/detainee is given an approved EMS medication such as a breathing treatment or dextrose, and then refuses transport or has transport denied by the law enforcement officer, the EMS responder must contact Medical Direction.

Scope of Practice

At no time should an EMS responder perform any treatments or evaluation methods beyond their scope of practice such as administering insulin, dispensing or verifying medications.

Transport Destination

The law enforcement officer may determine the hospital of choice unless it conflicts with
patient/detainee need as determined by regional guideline or state regulation. Medical Direction should be contacted with any questions.

Changes

I haven't been posting as much as I would like to. That should change soon. I just finished a major class I was taking (which I will write about shortly) so I will have more free time.

I also am making some changes to the blog. I have been invited to join the JEMS blog network, and am currently working on the look of the new blog, which will have a new address. People coming to this site will be redirected to the new blog site.

I have enjoyed being on Blogger, but felt it was time for a change.

I hope to be up and running on the site this week.

www.medicscribe.com

Running the Streets

I finished my half marathon on Saturday, limping across the finish line in 2:34:14. Part of the run went through streets and neighborhoods in Hartford where I have responded over the years to motor vehicles, drunks, cardiacs, asthmas, shootings, diabetics and general illness. When I started as a paramedic in Hartford, I did most of my calls within the city limits. I liked that. I felt I knew the streets, knew the people, many by my patients I knew by their first names. I felt a part of the neighborhoods. Hartford was "my town."

Over the years as ambulance companies consolidated, and territories changed, my response area became much larger, and fewer and fewer of my calls were in common neighborhoods. I also then became assigned to a contract town north of the city. Still until a year ago when I got my clinical coordinator job, I managed to worked 20-30 hours a week in “the city,” which basically now means a combination of towns as well as a fair number of transfers.

I’ve worked in the suburban town now for ten years or so. While I have been losing touch with my Hartford, the suburban town is now my true town. And one of the good things about this town is there are not as many carry downs as there are in the city, and that is my primary concern today as I head into work, stiff and sore from my race and barely able to lift my legs off the ground. No carry downs, please. I don’t even want to have to walk up a set of stairs as each step is a source of pain. Even worse, going down stairs. I am hoping for a quiet day, a day to rest my weary body. After checking my gear, I head to the bunkroom, where I am soon fast asleep, my cheek against the pillow.

Baaaaaaaehhh!

The tone sounds.

It turns out to be double good news. A first floor apartment and a patient who insists on going to the hospital in her daughter's car. The patient, who lives on the first floor, says she called 911 only because her she was unable to shout loud enough to wake her daughter, who was sleeping upstairs. She has a chronic illness, and apologizes for bothering us, and refuses our earnest offers of transport.

Our second call (after a nice two hour nap) is for a disoriented man with slurred speech found wandering along the road. The officer on scene is one of the newer recruits and he is concerned about the man's orientation and speech. The man is in his seventies, but impeccably dressed in his Sunday best. According to the officer the man claims he was walking to a church far on the other side of town -- well beyond his means to walk.

As I begin to question the man, something about him strikes me as familiar. I seem to recall him being in a minor motor vehicle accident and the officer at that scene, also concerned about the man’s speech, called us to access the man. The more I think the clearer it becomes. That call was outside a church, and some of the church members came out and said that he had had a stroke a year before and they vouched that this was indeed the man’s normal speech and behavior. That church was on the other side of town from where we are now. While the man denies ever being in our ambulance, he tells us the name of his church, and it is the one we responded to before. My partner speaks up then, and says he remembers that call as well.

We now do our run forms electronically and the laptop we carry has the ability for me to access any calls I have done. I enter the man’s name in the computer and it comes back with a hit. He is in fact the same man from that accident.

With that knowledge we are able to assure the officer that there is no medical issue here, just a man who likes to go to church on Sunday, and with the loss of his license following his inability to drive safely, it seems he still makes his effort to attend the Sunday service.

We get a refusal and the officer takes the man on to church.

After ten years in a town with a large elderly population it is quite common to have repeat customers. I like walking into a house or apartment and recognizing a familiar face and calling someone by their name without having to be introduced. I like that all the officers know me and that we have such a good working relationship. Community policing has been advocated as a solution to crime. I really believe in community EMS, and am glad that I can work in a town where that seems like it will always be possible. Patients in this town may have their own doctors and they largely have their own paramedics -- the four of us who cover the town between us 24/7. All four of us have been responding in this town for more than ten years.

There are no half marathons in the suburban town. If I do want to run these streets like I ran Hartford's, they do have an annual 5K road race. It, however, falls on Memorial Day – always a Monday, one of my regularly scheduled days. I could take off to run the streets of my now adopted town, and that would be great fun -- to run on sneakers instead of ambulance tires -- but that would mean losing my holiday pay. As much as I love running, I love triple time holiday pay more.

Here’s a link with an account of my run and some photos:

Hartford Half Marathon

Flu Shots

Flu season is rapidly upon us. I woke up this morning with a slight case of the sniffles that as the day has gone on has proved to be (hopefully) somewhat of a false alarm. I am hoping to get through the week unaffected as next Saturday I hope to run* in my first half-marathon. I have already paid the registration fee as well as completed my last long run -- a 10.5 mile trek a week ago. The race is 13.1 miles. After 10.5, I knew I could make 13.1 so I stopped to conserve my body and prevent overtraining, which can and has for me in the past led to a lowered immune system and consequently the flu, which wiped me out from participating last year, although I never went so far as to preregister as I have this year.

With flu season comes flu shots. Everyone Hospitals, medical offices, ambulance services, senior centers, and pharmacies are all giving them out. It is hard to avoid mention of them. There is a sign on our ambulance service’s bulletin board about where and when to go to get your flu shot.

I get my flu shot every year. I will get the swine flu shot too. I believe in science. I believe in benefit versus risk analysis. Sure I might die from the shot in a rare occurrence, but I am much more likely to avoid the flu or get it much less severely than I otherwise would have had I not gotten the shot. I hate getting the flu. I haven’t died from it, but sometimes I feel like I will never be well again, and I hate that. Not for me.

I know quite a number of health care workers who are refusing to get flu shots and/or swine flu shots. I recall seeing some controversy on TV where the health care workers were rallying and holding up signs and an off-camera hospital spokesman was saying they didn’t have to get flu shots as required by the hospital, but the hospital also didn’t have to keep them employed. Something to that effect.

One side is advancing the argument that health care workers need to get the shot so they won’t get sick from sick patients and then pass it along to other vulnerable patients who will get sicker. Makes sense to me.

The other side is advancing the we have a right to what goes in our bodies argument, which I generally believe in as a proponent of freedom and the American way.

When these two clash, it does raise interesting issues. Let me just answer it this way. If I have a choice of going to two hospitals -- one hospital where all the staff have gotten their shots and one where none of them have, I’ll go to the hospital where they have all gotten their shots.

The dear mother of my darling twenty-one-month-old also works in health care and she never gets the flu shot. She won't let them come near here with that needle even though she herself gives the same shot to others countless times. We don't even argue about it anymore. I'm not going to change her mind, she isn't going to change mine.

I had a patient this morning with some mild difficulty breathing on exertion. I asked him when it started. “Right after I got my flu shot on Monday,” he said. Similar words to what a patient told me yesterday, and similar words to what I have seen written on quite a number of run forms I have read in my job as a clinical coordinator. “Patient states it all started when they got their flu shot….”

Cause and effect. You get a shot, you get sick. It didn’t matter that this guy had a multiple pneumonia history, his blood sugar was 500 and he weighed 300 pounds and had four by-passes and for the last two years he has slept upright every night in a chair and his apartment smelled of cat urine. He’d be perfectly healthy if not for that flu shot. He even handed me the literature they gave him about the shot and all its possible side effects. I set it back on the table and asked again for his med list.

You get a shot, you get sick. Cause and effect. One of the patients on the run forms I read blamed his syncope on the flu shot. I saw his diagnosis -- AAA -- aortic abdominal aneurysm. If they are linked we are in more trouble than we thought.

You get a shot, bad things may happen. It is the way people think. But the shots don’t guarantee you won’t have to call 911 in the ensuing week. If they came with that guarantee, we’d go door to door inoculating everyone. Then we could close up shop for a week and all of us go to the upcoming EMS Expo in Atlanta. No need to cover the town.

Anyway, I can get my shot as early as this Thursday. But I think I am going to wait until next week. I don’t want to risk getting sick and missing my race.

Vaccine is on its way, but public still wary


***

*I am actually planning a 4-1 run/walk. I’ll run four minutes, walk one minute and then start running again, repeating until I cross the finish line. I have run as much as 7.5 miles without walking but by the end I am not running too fast. Running experts say at my age I will likely have a faster finishing time with the walk breaks. My goal is to complete the race not necessarily compete.

The Golden Hour

R. Adams Cowley, the founder of Maryland's well-known Shock Trauma hospital in downtown Baltimore, famously said:

"There is a golden hour between life and death. If you are critically injured you have less than 60 minutes to survive. You might not die right then; it may be three days or two weeks later -- but something has happened in your body that is irreparable."

The Merriam-Webster On-Line dictionary defines "golden hour" as "the hour immediately following traumatic injury in which medical treatment to prevent irreversible internal damage and optimize the chance of survival is most effective."

“Give us an hour…We will give you a lifetime” is the motto of Vanderbilt Life Flight, and perhaps, other helicopter services. Again from the Vanderbilt Life Flight web site: "Within one hour of the trauma, irreparable organ damage occurs but superior care before that one hour makes all the difference."

The 2nd edition of the Prehospital Trauma Life Support said "The critical trauma patient has only 60 minutes to reach definitive surgical care or the odds of a successful recovery diminish dramatically."

(It is my guess that this is no longer in the current edition.)

The following quotes are from a 2001 Academic Emergency Medicine journal article:

"The Golden Hour: Scientific Fact or Medical Urban Legend?"

“The golden hour justifies much of our current trauma system...scoop and run, aeromedical transport, and trauma center designations with trauma teams in place are, in part, predicated on the idea that time is a critical factor in the management of injured patients....While it seems intuitive that less time is better for trauma patients, there are risks and costs involved in attempting to deliver patients to trauma centers within an hour...These may be justified if there is a benefit, but may not be if there is no proven benefit or if the benefit applies only to certain circumstances.”

In the article they researched Cowley and any mention of the golden hour. What they found was articles referencing articles that referenced articles that had no reference.

A text on trauma edited by Cowley contains a chapter authored by Shakar, which discusses “Cowley’s Golden Hour,” referencing a 1976 Cowley article.

“The 1976 article …describes Maryland’s trauma system and states that the first 60 minutes after an injury determines a patient’s resulting mortality.” It references a Cowley paper of 1975.

“1975 Cowley article states ‘the first hour after injury will largely determine a critically-injured person’s chances for survival,’ but no data or reference is provided.”

They they looked at the scientific evidence about time and trauma. They found research studies both supporting a link and not supporting a link. As a rule the articles had poor quality, selection bias, small samples, and uncontrolled variables.

These were their conclusions:

“Our search into the background of this term yielded little scientific evidence to support it.”

“There are no large, well-controlled studies in the civilian population that either strongly support or refute the idea that faster is universally better in trauma care.”

“The intuitive nature of the concept and the prestige of those who originally expressed it resulted in its widespread application and acceptance.”

Which leads me back to a story I heard many years ago about the origins of the golden hour. Cowley, trying to win support for a the shock trauma hospital and what would become Maryland's elite helicopter program that would fly trauma victims from all over the state to the Baltimore hospital, determined with a helicopter any trauma victim in the state could reach the hospital in 60 minutes, thus "the Golden Hour."

Whether that story is true or not, I don't know. I do know there is nothing magic about 60 minutes. True some few may only have sixty minutes, but some have only forty, some five, and some none at all, while others may have two hours, two days or a lifetime.

Prehospital people need to look at each patient individually, weigh the risks (lights and sirens versus with traffic, helicopter versus ground), use their best judgment and common sense on a case by case basis. Err on the side of the patient. When in doubt contact medical control.

Clearly the more critical a patient the less time they have. Some patients truly need scoop and run. Ten minutes scene time won't cut it for them, many others may benefit by a slower, safer pace.

Promoting a definite time, not supported by evidence, serves no one.

***

Today as I was getting ready to post this, I came across the following "Article in Press" from the Annals of Emergency Medicine:

Emergency Medical Services Intervals and Survival in Trauma: Assessment of the "Golden Hour" in a North American Prospective Cohort.


Here's the conclusion:

"In this North American sample (Level I and Level II trauma centers in 10 cities, over 3500 patients among whom 20% died), there was no association between EMS intervals* and mortality among injured patients with physiologic abnormality in the field."

* Intervals include activation, response, scene-time, transport, or total EMS time.

The Editor's capsule summary offers the following: "This study suggests that in our current out-of-hospital and emergency care system time may be less crucial than once thought. Routine lights and sirens transport for trauma patients, with its inherent risks may not be warranted."

The article does state that their research adds further support to the concept that where a patient is transported is more important than how fast they are taken to the hospital.

Trauma

Tonight is the premiere of another new EMS oriented TV series -- Trauma -- which is on at 9:00 PM EST on NBC. At that hour I will likely be reading "Brown Bear, Brown Bear What do you See?" and "Good Night, Moon" to my twenty-month-old daughter in hopes that she will finally close her eyes and drift off to sleep so I too can finally lay my head on the pillow, stretch my tired body and get myself some sleep before the alarm goes off at five and I have to head back in to work for another 12-hour day.

Zoey made her own first trip to the ED yesterday after falling and cutting the inside of her lip. She was fine -- I think the trip was more for her mother (who works at the ED) to get some assurances that everything was going to be all right. (I sense my fearless daughter who has to do everything her older sisters do will be a frequent ED visitor in years to come as she learns to ride bikes and climb trees.) Before I could even get to the ED, I got a call that she was okay and headed home.

Earlier that day I took care of a little girl only a year older than Zoey who got her finger caught in a door and had her finger tip torn off. No bone, just the whole nail and half the tip -- a degloving I guess you'd call it. We packed the tip in ice and I gave her 2 mg of morphine IM for the pain and dutifully went a very easy lights and sirens to the hospital in hopes that they would be able to sew it back on.

I later did calls for an old man who was feeling dizzy because of some new medicine, yet he was zipping about his apartment with his walker on wheels when we arrived and then for a woman post car accident who the police officer thought might have a head injury. The accident was in the parking lot of a fast food restaurant. The woman was struck while backing out. Low speed impact, but enough to knock one side of her bumper off. She was 80-years-old and had had her seat belt on, but when she told the officer she was too shaken up to know what happened, he thought head injury and so called us for an evaluation. She didn't appear hurt, and said she didn't want to go to the hospital, but I couldn't quite get her to focus on the refusal discussion. She had a heavy Italian accent and her command of English was weak. She clearly said she did not want to go, but when I advised her to go to the hospital (we are required to advise everyone to go if we are called), she then felt she had to go and became quite upset about what she was going to do with her dog, a small terrier she held in her arms as she walked about outside the restaurant in the light drizzling rain. She kept asking me about what would happen to her car and explaining the accident and who was at fault and did not seem to understand that my role was that of a paramedic and not the police officer who was busy trying to get a tow truck for her car and writing up the paperwork seizing her driver's license. I tried several times to get a proper refusal, but she really wasn't focused or competent enough to understand. Long story short, we waited with her in the rain for a hour until her nephew finally came and confirmed what I had thought all along -- that this was indeed the woman's norm.

Not the most exciting day, but not necessarily atypical. I do some pretty good calls in the town I work, but I doubt many of the average ones will qualify for Trauma's TV script. It has been a year now since I worked in the city. I've done a dozen cardiac arrests, but of them only a handful weren't asystoles who we worked for 20 minutes and then called on scene. No shootings or gory stabbings (There was a big drive-by shooting last week near the city line with three victims -- but it wasn't on my shift).

I do respond to quite a number of traumas and hardly a day goes by that I don't give someone morphine. But my traumas are not helicopter or spectacular multi car crashes. I see hip fractures, broken shoulders, wrists, ankles and back pain from low falls. People getting old and tripping, losing their balance, etc.

Aside from the finger degloving, I don't think I've gone lights and sirens to the hospital in over a month (and even at that there seemed no urgency at the hospital to sew the finger tip back on). Our rules on lights and sirens are pretty clear these days -- only use lights and sirens if in the time you save going lights and sirens the hospital will be able to do something for the patient to make a difference in life or limb that you cannot do yourself.

My trips in are make them comfortable, pop in an IV, put them on the monitor, and chat while I enter their information and my assessment into the computer, making sure to apologize for the bumps in the road.

***

I plan a post this week about the "science" surrounding the Golden Hour and some new research about ambulance response times.

***
postscript:

After writing the draft of this this morning, I took a nap (I'm allowed to sleep from 600AM until 800 AM), then was awoken by the tones and I immediately cursed myself because I knew by writing how I so rarely go lights and sirens, I would get payback for it. Sure enough, a man with advanced COPD and extreme anxiety and claustrophobia -- a terrible combination. I used or tried to use the following airway devices -- cannula, nonrebreather (neb mask, neb mouthpiece, ETCO2 cannula, neb mouth piece minus the duo neb (the albuterol was making him more anxious he said so I just went with humidified water), CPAP. Everything met resistance from him. He said he was a mouth breather so a cannula wouldn't work. He refused to have a mask over his face. Everything was too much or too little oxygen. I started with a combivent, gave some Solumedrol and ended up having to call for orders to give Ativan to calm him down and lower his 02 demand as he was going so worked up he was desatting. Halfway there, I had my partner put on the lights and sirens. The Ativan didn't kick in until the ED, but even then they had to give him more Ativan and were even considering intubation as I was leaving because the patient was still getting so worked up. A real EMS call, but not one likely to be written into a TV script.

Elmo's Song

I’ve written recently above the new advances that have made our care and lives easier:

Stretchers going from two man to one man to now power-operated.

Airway adjuncts like bougies, LMAs, and of course capnography.

Life Pack 5s to Life Pack 10s to LifePack 12 with 12-leads.

EZ-IOs.

I discovered another one just the other day:

18 month old has just had a febrile seizure, and while alert, she is very cranky. We have a neat gadget called a Pedi-mate which is a rollup car seat, that straps onto the stretcher and then attaches the baby just like a car seat.



It’s great! But while her physical safety is now assured, we still have some emotional issues.

The child still would clearly rather be held in mama’s big warm arms. Little Kiesha is crying and throwning a general fit. Now, having my own twenty-month old daughter at home, I know the key to ending a tantrum is distraction. Kids that age take everything in and as soon as they lock on to something new, they go from crying to laughing in a moment.

We have Tough Book computers for our electronic run forms. My service also has an internet aircard so our computer has access to the web. I have a new little notebook computer I use at home I bought so I could watch my daughter in the living room, while still staying connected – I can follow the Red Sox or check my email. I made the mistake of one night showing her U-tube so now whenever I open up the notebook, she comes over and says, “E-I-E-I-O,” which is her way of saying, “Play that Old McDonald had a Farm video for me, Dad.” Or she’ll say “row, row, row” for the Row, Row, Row, Your Boat video.

Back to the crying 18-month old. I realize I have on the bench seat next to me -- my Tough Book computer -- a compter with access to you-tube. The light-bulb goes on.

A few taps of the computer screen with the stylus and some quick typing and there we are:

On the screen, Elmo, the red furry little red monster from Sesame Street, is tickling the ivories and singing to his buddy Big Bird, “La-la-la-la, la-la-la-laa, Elmo’s song!”, and over the course of our transport a host of speciaal friends drop by --, Elmo, Barney, Dora and Diego, and others -- and Mom, me and Little Kiesha are all E-I-E-I-Oing and doing the itsy bitsy spider going up the water spout.

La-la-la-laa. La-la-la-laa. No more tears.

***

Postscript. Don’t have a service issued computer with internet access? Check with your partner, who may have a Blackberry or I-phone. They work well too.

Elmo's Song
Old MCDonald Had a Farm
Row Row Row Your Boat
Itsy Bitsy Spider

Thank You

Thanks to everyone who read my novel over the last several months and for all the generous comments.

I will be back to regular posting soon.

Afterward

Capitol Ambulance was sold to a national corporation. Shortly after the state made them give up the South side of the city to Champion Ambulance in a deal brokered by politicians. The fire department has started going to all EMS calls as first responders, and may eventually go paramedic themselves.

Helen Seurat now runs Champion Ambulance, and continues to be active in the community. Her company has trained over fifteen Hartford residents to become EMTs, four are now paramedics. She remains close with the Ruiz family. Hector’s youngest boy is a top student in one of the public school system’s magnet schools.

Kim and I were married that fall. She works as a nurse now. I am still out in the street, though not working nearly as much as I used too. Last summer we went up to Maine and I showed her the town where I grew up. I was surprised people still remembered me. In the town square thirty years after his death, they had erected a small monument to the town’s sons who died in the war. I ran my fingers over Billy’s name and as I wept I felt I could again see his face and hear his words as we laughed and imagined about all the great things we would do.

Two months after Hector’s funeral, Troy Johnson was critically injured in a car accident. He spent the next ten years in a convalescent home by the Connecticut River. Linda Sullivan used to visit twice a week until she married and moved to California. I visited him once a year. The last time I saw him he sat erect in his wheelchair. His eyes gazed hard at me, but I never knew if he recognized me or even knew I was there or what I was saying. I told him that Linda had written to say his son had hit a home run in his first Little League game. She said he won a track race at his school, beating even the fifth and six graders, and that though he struggled at times with his studies, the girls seemed to all adore him. A picture of the boy was taped to his mirror. Troy Patrick Johnson Sullivan. He had his father’s mischievous sparkle.

Troy died last year. His father and I took his ashes and spread some of them over the playing fields at Thorton High and then took the rest up to Zion Hill and let the wind carry them out over the city of Hartford. He and Pat are together again – I like to think of them looking out for the people of the city, and looking out for the rest of us who still work the streets. It may not have been where they dreamed of ending up as boys, but it is who they became. It was their place in the world.

On Friday nights we still raise a beer at the mention of their names.

-the end-

Chapter 48

Troy’s pickup wasn’t in the parking lot the next day when I got to work.

“Your partner booked,” Brian Sajack told me when I checked in to get the vehicle keys and radios.

“Is he okay?”

“Hmm. How to answer? Let’s say this, after he told me he wasn’t coming in, Linda comes on the same phone and says she’s booking off too. I’d say he’s doing okay. I didn’t write a reason down on the book off form. Don’s in a stew this morning.”

Just then Don Seurat walked in. “You know where Troy is?” he demanded of me.

I shook my head. “I heard he called in sick.”

“Did he say anything to you about booking today?”

“Last I knew he was coming in.”

“How about Linda?”

“Didn’t talk to her.”

He said to the supervisor. “How are the order-in’s going?”

“I’ve got Melnick coming in to work with Lee and Jen Dumont and Jared Goldberg are coming in. Scott Thompson and Ron Talit said they’d come in when they get off at the fire house.”

“Keep working the phones. And don’t accept any more book-offs.”

“What’s up with all that?” I asked when Seurat had left.

“You mean aside from Troy and Linda? We’ve got Senator Shrieb coming in to town to announce his candidacy and the Hector Ruiz funeral, which the words from the cops is might be a bigger parade than New York last gave the Yankees. We had to call Ben in on his wife’s birthday to replace Linda on the Shrieb standby. He’s on his way to the airport. Now Shrieb’s a presidential candidate, the little man’s getting secret service and the works.”


Melnick and I were told to station ourselves down by the funeral service in case there was any violence or anyone got sick. In the event anything happened we needed our response to be quick.

It was cloudy with an imminent threat of rain. The air was damp and the wind picked up occasionally and brought an unseasonable chill. The procession began at the funeral home on Wethersfield Avenue, turned left at Park Street and went all the way to Pope Park where an open air service was to be held. Shops closed down. People lined the streets. Many ran out into the road and laid flowers and offerings on the small flatbed truck that carried Hector’s casket, guarded by six mourning friends who wore dark suits. Hector’s family and friends rode behind. Many of the on-lookers joined in as the parade went past.

Marchers carried photos of Hector, other held signs. End the Violence. No to Drugs. Save our Streets. Some carried the flag of Puerto Rico, others the American Flag.

“I don’t get it,” Melnick said. “What’s the big deal? This guy was a hoodlum? How does he rate a funeral procession?”

“He’s a symbol,” I said.

“A symbol?”

“They aren’t mourning him,” I said. “They’re mourning what’s happening in their community, and mourning they can’t figure out how to stop the violence.”

“Put away the guns and pick up the books,” he said. “Get a job.”

I handed him the ambulance’s PA mike.

He shook his head. “I don’t think so. I’m not wearing a vest.”


There were over two thousand spectators in the park. On the stage community leaders, ministers and people who knew Hector addressed the crowd. His grade school teacher read a poem he had written. His minister told of his struggles with faith.
Think what you want about Hector, about the gang-bangers and the violence, being there listening to the voices from Park Street, hearing their stories and their pleas, you couldn’t help but feel the pain of their struggle. These were people like anyone else. People who just wanted their children to grow up with a chance for a good life. One by one they spoke of their hopes, their dreams for a real world where they could just be left alone to live their lives.

Helen Seurat stood on the stage next to Papi Ruiz, and other members of Hector’s family. She spoke only briefly. “Hector adore su familia,” she said in a slow steady Spanish. “Pero de este amor, su famila vino a saber solamente dolor.”

Even Melnick listened.

“El era un hombre,” she said, “que perdio su camino.” He was a man who lost his way.


When the service was over, they carried Hector’s casket up the hill to the cemetery. They buried him and adorned his grave with flowers.

Chapter 47

Troy was a half hour late the next morning. I had already checked out the ambulance, including all of his ALS gear. I was gassing up the truck when he finally showed up. “I was worried about you,” I said.

He had deep bags under his eyes. “I stopped and saw Pat’s father.” His hands shook as he drank from his bottle of Coca-cola.

“How’s he doing?”

“Okay, he’s all right.”

“How are you?”

“Okay,” he said.

“Did you get some sleep?”

“A little.”

He still looked awfully pale.

“You sure you don’t want to just go home?”

He shook his head.

“This is where I belong.”

“You need something to eat?”

“I’ve got a sandwich.”

I didn’t question him further. I noticed he had a small ceramic box with him that he set on the console.


Our first call was for an elderly woman with a fever, who’d spent the night vomiting. The visiting nurse said, “I’ve already called in the report. They know all about her at Saint Francis. I promised her you wouldn’t try to stick her with any needles. You’d leave that to the nurses in the ER.”

I was putting the sheet across the stretcher when she said that. I turned to look at Troy. I awaited his explosion. “Thank you for your report,” he said instead, without sarcasm. He knelt down by the patient’s side and took her wrinkled hand. “Hello. My name is Troy. I understand you’re not feeling very well.”

His voice sounded a little mechanical, but not insincere.

“I’ve been a bit queasy,” the woman said.

Troy patted her hand. “Well, we’re going to do our best to see that you have a comfortable ride in to the hospital. I’m going to do a couple things on the way there. I’m going to take your blood pressure, listen to your lung sounds, put you on our heart monitor, and ask you some questions I know the nice woman here has already asked you. They’ll ask you the same questions at the hospital, but we’re doing it just to make sure you get the very best care. We want to get you healthy and get you back here to your lovely home as soon as you are well enough.”
“Thank you,” she said. “I hate to bother you.”

“It’s no bother at all. It’s our job, our pleasure.”

When we got to the hospital, Troy had an IV in her arm, running in normal saline to hydrate her. She was smiling like a schoolgirl. “Light as a ballerina,” he said as we moved her across to the hospital bed on the sheet. He said to the nurse “Mrs. Greenspan’s son is an internist in New York, and her grandson’s following in his footsteps in medical school.” He went on to describe why we had brought her in and his physical findings, and then he patted her shoulder. “I wish you good health. You’re in good hands here.” She looked up at him with a light that must have been similar to the one she shone on her grandson.


“What’s going on with you this morning?” I asked as we walked back down the hall.

“Just trying to be a good paramedic,” he said.

“Well, you reminded me of one.”


Around ten thirty, we were sent for an unresponsive at the funeral home on Wethersfield Avenue.

Cars were double parked on both sides of the Avenue. “Hector R.I.P.” was white-washed on their rear windows of several of the cars. Police patrolled the grounds of the funeral home. A line of mourners stretched out the door and around the block. Many wore tee-shirts with Hector’s picture them.

“Look,” I said. “Why don’t I call in that our engine died and they’ll send someone else? I don’t think it’s a good idea going in there.”

Troy shook his head. “It’s our call, it’ll be all right.” He got out of the ambulance, took the monitor and blue bag out of the side door, and then laid them on the stretcher that I had pulled out.

We moved in through the crowd which slowly made way for us. People were dressed in black, many weeping. There were more flowers than I had seen in one place before.
Troy wore his Yankees hat. I kept vigilant.

We were led through a hallway into the receiving room. Hector lay in an open casket. Papa Ruiz sat slumped in a wheel chair. People gathered around him.
“What’s going on?” Troy said.

Helen Seurat was there. She nodded to Troy. “He’s the father of the deceased. He is not responding to anyone. I told the family I thought it was emotional, but they are worried maybe he had a seizure.”

I saw Hector’s wife holding Hector’s son, standing with the other family members, all watching Troy.

Troy nodded. “Did he fall over or have seizure activity? Bite his tongue? Wet himself?”

“No,” she said. “He just lay his head forward and hasn’t moved since.”

The family pressed around, looking at us. There were several small children.
Troy looked down at the man whose eyes stared nowhere. Troy touched his forehead. “Warm,” he said. He touched a finger to his eyelids, which twitched. Troy looked at me.

I shook my head. Don’t do it, I thought. Show some respect.

Troy knelt beside the man, felt his pulse. But he wasn’t looking at his watch. He watched the man for signs of movement.

“Blood pressure cuff,” he said. He held out his hand.

I gave it to him. He wrapped the cuff around the old man’s arm, pumped it up, and then slowly letting the air out, took his reading.

“How is it?” a woman asked.

“130/70.” Troy said, “That’s good.”

“What is the matter with him? Did he have a stroke?”

“No, I don’t think so.”

“What is wrong?”

I watched him look around at the faces of the others in the room. He took his cap off. He hesitated a moment.

“Take him to the hospital. He could be dying,” a man said.

Troy shook his head.

“Look at him. He’s having a stroke. He needs to go to the hospital.”

Troy gestured to a little girl, who stood behind a woman’s leg. “Come here.”

The girl went to Troy. He nudged her toward the old man. He beckoned to a woman, who held a baby.

She approached.

He held his arms out for her to hand him the child.

He took the baby, and set it in on Papi’s chest, and moved the old man’s arms until he was holding the child. Papi held the child close to his heart.

Troy said to the others, “He doesn’t need to go to the hospital. He needs to be here with his family.”

Troy stepped back.

While everyone watched the old man, Troy picked up his gear and walked out.


That afternoon we sat at Kenney Park.

“So what do you think of me?” Troy said, finally.

I looked at his dark eyes. “We all do things we regret,” I said. “It’s how you deal with the aftermath that matters.”

He looked out at the park now, at the tree limbs swaying in the light breeze, the children playing down by the pond. I don’t know where his mind was.


At dusk we drove up to Zion Hill. He took the box off the console, and we walked up the incline. “Pat’s Dad gave me some of Pat’s ashes. I’m supposed to disburse him where I remembered him best. Allison spread hers at Kent Falls where they had their first date. His mother spread hers at the playground she used to take him to when he was little. His father spread his over the high school football field. I think they wanted me to spread them out in the woods or at the next Super Bowl. I’m going to spread them here. Those were all places he played. Here is where he lived. You can say none of this makes a difference, but it’s got to count for something.”

On the radio dispatch sent out calls. “463 to Main and Tower for an MVA. 451 take Ashley Street for the asthma.”

Troy opened the jar and held it aloft to the wind that swirled down and took the ashes and whirled them out over the city. “Look out for us, old friend,” Troy said. “We need it. Even Lee, here.”

After I punched out, I saw Troy talking to Linda in the parking lot. It was unusual for her to be there that late, but they’d needed her to fill the shift of a sick employee.

Troy and Linda got into separate cars, but drove out together. Instead of turning down toward New Britain Avenue, Troy followed her car out South Street toward Newington where she lived.

And as for me, that night I did not drive home. I went to Kim’s. I sat at the curb for awhile, and then shut off the engine and walked toward the front door. With a rising in my heart, I knocked.

The light came on. She peered out through the curtain, and then opened the door. I believe she saw in my face then what she had been looking for, what I had kept hidden even from my own heart. She took my hand and led me inside.

Chapter 46

Troy looked terrible the next morning. I had to buy him some Scope so he could get the stench of alcohol off his breath. His eyes avoided mine. His face was pale grey.

Around noon, a sixty-two year old man dropped on a city bus. We were there in three minutes. He was in v-fib on the monitor. Troy shocked him at 200. He went flat line. I started CPR while Troy intubated him. I noticed the bag wasn’t reinflating quickly. Troy looked confused. Melnick and his partner had arrived to back us up. Melnick listened to the man’s chest as Troy squeezed the bag. He switched his stethoscope to the belly. “You’re in the stomach,” he said.

“What?” Troy said.

“Listen for yourself, or look at his belly. It’s getting bigger. You’re in the esophagus, you have to take it out.”

Troy tried twice more, but couldn’t get it in. I’d never seen Troy have such trouble. He’d never missed a tube before. Andrew had to push him out of the way and take over. Despite Andrew getting the intubation on his first attempt, the man remained asystole, and was pronounced dead at the hospital.

“What’s up with Troy?” Andrew asked in the EMS room afterwards.

“Nothing,” I said. “Everyone’s entitled to a bad day.” I walked away.


“Troy looks terrible,” Linda said that afternoon when we’d stopped back at the office to resupply and wash the vomit out of the rig. “I just asked him how he was. He completely blew me off.”

“He’s in a funk.”

“Did something happen?”

“He just missed a tube.”

“You’re kidding? Troy?”

“Yeah, he’s in a deep funk.”

“Do you think there’s anything I can do?”

“Call dispatch and ask them to go easy on us. Try to keep it BLS.”

“I can do that.”

“If we can get him through the day, maybe he’ll be better tomorrow.”


They posted us at Capitol and Broad next to 462. When a call came in they gave it to 62, then sent another car down to sit with us. The next call went to the other car. It went on like that for three hours. Troy didn’t even notice. When we were sitting there, Annie Moore came up and gave Troy her big smile. “Hey, handsome, I’ve feeling real lucky. I know today I’ll be a winner.”

He took out his wallet, handed her a twenty, and before she could say anything, used the automatic button to roll up the window.

“What’s up with him?” she said to me after she came had back around the corner from the liquor store as I was on my way in for a coffee.

“He’s moody,” I said.

“He’s gonna make me sad, but as long as he keeps giving me twenties, he’ll never break my heart.” She smiled at me as she stuffed the change in her pocket.


“I think you ought to take some time off,” I finally said to Troy. “Maybe take a whole month. You need to get out of here, clear your head of everything that has happened. People won’t think it’s strange.”

He didn’t say anything.

“You’re not doing anyone any favors coming to work like this. Did you even sleep last night?”

He looked straight ahead. He looked like a man condemned.

Chapter 45

It was a cool evening after a day of late autumn rain. I was outside Hartford Hospital. I remade the stretcher and slid two long boards in the empty slots under the bench. We’d just brought in two patients from a minor motor vehicle accident, both claiming neck pain after being tapped by a Lincoln Continental. I was rolling up a nine foot strap by the supply closet when Troy came out, and said, “Let’s go. We need to go back to the office to change our 02.”

“I changed it this morning,” I said. “We have 1500 in the main. We didn’t even use any on that call.”

“Just head back there,” Troy said.

I got in the ambulance, turned the headlights on, and drove out the back way onto Retreat Avenue. Troy was silent as I turned left onto Washington, then took a right onto New Britain and followed that through traffic all the way to the office.

When we got back to the parking lot, Troy had me stop by his grey Chevy pickup. He took a duffle bag out of the passenger side door.

“What’s that for?”

“You can tell dispatch we’re clear,” he said.

Around ten-thirty, we swung by Capitol and Broad. Troy looked around, but not seeming to find what he was looking for, told me to circle the neighborhood. When he spotted Annie Moore standing in the doorway a few blocks up the street, he told me to pull over. Troy called to her.

“Tonight my lucky night?” she said. “You got five bucks for a girl on her birthday?”
“Your birthday was last month. Get in back.”

“I’m not done drinking,” she said. She showed her forty that had at least ten left in it.

Troy reached into his duffle bag and pulled out a fifth of Southern Comfort which he showed her. “Present from Sidney. Now get in back,” he said.

“This a trick?”

Troy stepped out of the car, and walked around to the back. He opened the door for her. “Sit on the bench. Go on.” He helped her up.

“Head over by the cemetery,” he said to me.

“You’re not going to rape and kill me are you?” Annie called from the back.

“No,” Troy said distractedly.

We drove into the cemetery. Troy helped Annie out, then gave her a blanket, the bottle of Southern Comfort and some crackers. “Go up and keep Sidney company for a couple hours and we’ll be back for you.”

“Oh, I’ll be good company,” she said, quickly taking possession of the bottle.

“You’re still here in a couple hours, I’ll give you fifty bucks.”

“It is my lucky night.”

“Just be here.”

“What are you up too?”

“Just taking care of business,” he said without looking at me.


At eleven thirty, as soon as we’d dropped off a psychiatric patient at Hartford, he told me to drive back to the cemetery. On the way, Troy checked his sugar, and then carefully ate a peanut butter sandwich. At the cemetery, Annie lay not ten yards from where we left her. Troy shined the ambulance spotlight on her. She was out cold, resting against a tombstone. He stepped out of the ambulance then, took off his uniform shirt and handed it to me. He reached in for his backpack, and then threw the backpack over his shoulder.

“Where are you going? What are you doing?”

“We get a call,” he said. “Tell them we just got flagged down for Annie.”

I looked at him closely. He didn’t avoid my eyes.

We stared at each other.

I offered him the radio.

He shook his head.

“I’ll be back after midnight.”

I watched him walk up the hill, and disappear in the darkness.


It was quiet in the city. 473 did an asthma on Westland Street. 456 a chest pain out in Newington. A police siren passed nearby, and then it was quiet. I couldn’t see anything up the hill. Mist rose off the pavement. A dog barked in the distance.

A shape emerged from the night. Troy was back. He wore a Yankee hat. I saw a welt under his eye. We stared at each other. He looked tired, but defiant.

He took off his muddy boots and stowed them in his sack, from which he’d removed another pair. He put his paramedic shirt back on, and then quickly ate a sandwich and drank it down with apple juice. “Let’s get out of here,” he said.

“We have to get Annie?”

“All right.”

“482,” I said into the radio. “We’re getting flagged down for a drunk here. Looks like Annie.”

“Okay 82, I’ve got you out.”


Jean Rushen, the triage nurse at Hartford, asked Troy about his eye.

“She clocked him,” I said.

“But she’s out cold.”

“With a bottle in her hand, she’s never out cold.”

“You should get that looked at,” Jean said to Troy.

He didn’t answer.


At four, right before we were supposed to get off, we were sent back to the cemetery. “Possible 78,” dispatch said. “See the PD on scene. Priority Two.”

There were five police cars there when we arrived. One officer told us, “It’s just a presumption.”

Troy slung the monitor over his shoulder and we walked up the hill to where we could make out the flashlights.

Hector Ruiz lay before a grave, his neck twisted at a horrible angle. I looked at the gravestone. Maria Ruiz.

“There was quite a scuffle here,” Denny Creer was saying. He shone his light on footprints. “They fought. The killer chased him around the grave three times, must have caught him, snapped his neck. Stabbed him in the gut. Left the knife in him. I doubt there’s prints on it. Somebody wanted him dead.” He looked at Troy. “You didn’t do it, did you?"

Troy looked at Creer with his dark eyes. I thought for a moment he might answer.
“We were on another call,” I said quickly.

“I was just joking,” Denny said. “Had to be gang-related. They’ve had a hit out on him. Pretty smart, I’d say. They knew he’d be coming here to see his sister. It’s the anniversary of her death. Can’t say as it’s a great loss. It’s a shame though. It’s just going to open up the OK Corral. Wild West time again. Keeps us all employed anyway.”

Troy wrote his name, date of birth and unit number on a piece of paper along with the time of presumption. He handed Denny the paper. Creer thanked him, and then turned to talk to his sergeant. I saw Troy carefully fold the six-second asystole strip he’d recorded and put it in his pocket. Troy looked down at the body. He spat on Hector’s face.

Chapter 44

Not a day went by that Troy didn’t drive by the abandoned building on Lawrence Street where Pat had been killed. Sometimes Troy had me park at the curb. He’d just sit there and stare at the place. I wondered what he was thinking. Maybe he was replaying in his mind what might have been had he been there. I don’t know whether he saw himself taking the bullet for Pat or maybe sensing something not right, hearing a creaking board in the dark house, in his mind he pushed Pat aside, dove to his right, then came running up the stairs, pursuing his fleeing assailant, tackling him, and then punching him senseless. Or maybe finding Pat shot, he put his finger in the hole in his heart, plugging the dike, and carried him out in his powerful arms, working his magic, getting him to the hospital where a surgeon could have time to work his craft.

We spent a lot of time driving slowly through the neighborhood. Troy would watch the street, eyeing the residents, the passersby, the hangers on. It was as if he were looking for a sign, a clue, something to make sense of who would do this deed.
One afternoon we went into the El Mercado on Park Street for an early lunch. El Mercado was a Spanish marketplace that included a supermarket specializing in Hispanic foods and produce, small merchants who sold beepers, Spanish musical tapes, and trinkets, a bakery, and several cafeteria style food vendors. I had just gotten my order of arroz con pollo, and Troy was ordering kingfish, when I noticed a man in a New York Yankees hat getting a box of pastries at the bakery stall. It was Hector Ruiz.

Troy saw the look on my face. He turned and saw Hector, who was walking toward us on his way to the back door.

Hector stopped stared at each other like they were both seeing something that had troubled them, but they weren’t yet certain what it was.

“Where’d you get that hat?” Troy demanded.

“Are you asking me?” Hector said.

“Yeah, I’m asking you. Where’d you get that hat?”

I glanced toward the market entrance. Denny Creer and another cop had walked in.
Slowly recognition crossed Hector’s face. “I know who you are now,” Hector said.
Now it was Troy who looked confused. I had a horrible recognition, but I dismissed it just as quickly.

“Who am I?” Troy said. “What are you talking about?”

The cops were walking towards us.

Hector stepped back, and retreated toward the back door.

“Hey, what’s good to eat here?” the other cop said.

“Try the chicken,” Denny said. “It’s Troy and Lee. What’s up guys?”

Troy was still watching Hector. He looked troubled like he was trying to figure out a calculus problem.

“You know who that is, right?” Denny said.

“I’m not sure,” Troy said.

“Hector Ruiz,” Denny said. “I’m surprised to see him in public. We just heard there’s a contract out on him.”

Troy’s eyes narrowed like it was all coming clear in his brain now. He nodded, but said nothing more.


“I think he’s the bastard who shot Pat,” Troy said when we got back in the ambulance. “He thought he was shooting me.”

“Why would you say that?”

“I was going to testify.”

“I don’t know. I think that’s a reach.”

But I could see he was convinced.

That afternoon when we stopped at Capitol and Broad, Troy went over to the pay phone and called Victor. He turned his back on me and spoke in a hushed tone.

Chapter 43

We responded for an unknown on Manchester Street in the Blue Hills neighborhood. “He was just right here talking, then he fell out,” the woman said.

The man wearing a grease stained mechanics uniform looked to be in his late sixties. He sat on the steel garbage can by the side of a one car garage as the woman and her husband held him up. He was unconscious. His breathing was irregular, his entire left side limp.

Troy looked at his pupils. “Right pupil’s dilated.” To the people, “What kind of medical history does he have?”

“He just a friend. He was in the hospital a year ago I know.”

“What’s he normally like? How did he get here?”

“He drove that car.” She pointed to an old Pontiac at the curb.

“Let’s get him to Saint Fran,” Troy said to me.

We rushed him to the hospital. Troy had me patch in a stroke alert. As I drove I watched him work with a flurry in the rear view mirror. He nasally intubated the man and put in two IVs. But as we neared the hospital, I could hear Troy talking to the man. When I came around back to pull the stretcher I saw Troy extubating him. The man coughed, and then Troy pulled the tube. The man looked at me and smiled.

“He’s healed,” Troy said.

His grip strengths were equal, his pupils back to normal. He’d had a massive TIA, a transient ischemic attack – a stroke that resolves itself. It wasn’t impossible, but I had never seen such a quick recovery from such total unconsciousness. I know it was crazy, but I had to believe it was Troy’s touch. While he had always been an exceptional paramedic, since he had come back, it was like he could do no wrong. In a space of a week we had three cardiac arrest saves. He had an aura about him now that made me feel he could save anyone by will alone.


Then we had a two-week lull like one no one had ever seen. There were no car wrecks, no shootings, and no cardiac arrests, at least none when Troy was on the clock. In those two weeks Troy delivered five babies -- four Patricks and one Patricia. The day the baby girl was born he bought a box of cigars and passed them out to all the crews on the road. He even passed out a box to the drunks in front of the Laundromat on Vine Street.

But Troy, who seemed to be trying almost too hard to make up for Pat’s loss, occasionally suffered from unpredictable mood swings that bordered on manic. I didn’t know if it was just stress from all that had happened or if he was on the verge of a true crisis. I watched him carefully.

He was pale, his eyes dark. He seemed very irritable. People would just ask him questions like how about the game last night and he’d snap at them in a tone that said leave me alone. I don’t care to be talked to by you. “What’s eating him?” they’d ask me. I’d just shrug, and say “That’s Troy these days.”


The morning was one where fender benders were breaking out all over town. We’d pull up, and people would be sitting there slumped in their seats, trying to look like they were in pain, while the other driver – of a Cadillac or a Volvo -- paced about, talking on his cell phone telling work he’d been in an accident and would be late. We’d walk about checking the cars for damage, not seeing any. “Guy’s got neck pain, wants to go to the hospital,” the cop said.

I felt the tension building in Troy all day. We were called to the home of a double amputee, who was running a fever and the visiting nurse said he needed to be evaluated at the hospital. “He just needs a ride to the hospital,” the nurse said. “I’ve called ahead, they’re expecting him.”

“You called 911 because he has a fever?” Troy said.

“Yes. Is that a problem?”

“You’re dam right it is. We came here lights and sirens for difficulty breathing.”

“I’m sorry,” she said. “I told them he was stable.”

I interjected then. “It’s not your fault. The problem is with dispatch. Generally though, if it’s not an emergency, call this number.” I wrote the non-emergency down on a paper I handed her. “You’ll get an ambulance promptly. It just won’t come lights and sirens.”

Troy was still stewing as we left for the hospital.

“Since we got called,” he said to the man. “I’m going to have to put in an IV.”

“Let them do it at the hospital. I’d rather you didn’t,” the man said.

“Look,” Troy said. “We’re a 911 ambulance. I’m a paramedic. This is my job. You don’t want anyone to take care of you, call a taxi next time.”

“But I have no legs,” the man said.

Troy looked even more annoyed that the man had zinged him so innocently.

“Get a handicapped van to take you,” Troy snapped back.


“Can I get you a candy bar? I said afterwards.

He took out his glucometer and had me watch as he pricked his finger. The result came up 160.

He walked away.


That night Kim and I were in front of the fire at my place. We’d had a few beers, and while in the past we would have fallen into the bed, tonight we were both heavy in our thoughts of our world in Hartford, and how it seemed like Troy and maybe all of us, might be coming apart.

“You need to talk to him,” Kim said. “He looks up to you. You might be able to get through to him.”

“He isn’t open to anything right now. The very thought that people are thinking about what he’s feeling is driving him away from them.”

“Linda says he won’t even talk to her.”

“Sometimes men hold things inside. It’s our way.”

“It doesn’t have to be.”

“I know that.”

I put my arm around her and squeezed her.

“I love you,” she said.

I held her there in front of the fire and stared into the blazing wood.

Chapter 42

Troy worked like a whirlwind, seven days a week, no rest. I used to always beat him into work. Now I always saw his grey pickup in the lot when I drove in. I’d find him sitting in the passenger seat in 482, reading the sports page, the engine running, the car gassed and washed.

“You check out the gear?”

“ALS and BLS lists,” he’d answer. “O2’s good, we’ve got two boards and plenty of clean laundry. I’m just waiting for your tired ass to get behind the wheel so we can go out and do some good.”

We were supposed to get off at two, but Troy volunteered us to stay till four every night. I was getting so run down, after midnight I’d climb in the back and nap between calls.

One night I was vaguely aware of Troy driving while I slept. When I finally awoke, Troy said, “You owe me twelve bucks.”

“Twelve bucks?”

When I still looked puzzled, he handed me a completed run form. Capitol and Broad to ADRC for detox. “For doing your job,” he said.

I checked the date and times. The call had been done in the last hour. “You did this while I was sleeping?”

“Yeah, I thought you needed your beddy time. I had the guy ride in the front.”

“You amaze me. How about I just get you a cup of coffee?”

“You can drink mine. You’re such an old man these days.”


“How’s his sugar?” Ben asked when he and Linda saw me changing the O2 M tank in the garage, while Troy had gone into the stock room to resupply after we’d run through the drug box on a v-fib cardiac arrest.

“He’s all right,” I said. “He’s keeping it higher than he used to. No problems.” He was eating more than normal. When he checked his sugar, I saw his numbers were up. 120-160, 180. He was giving himself a buffer.

People watched him, waiting for something to give.

“He’s all right?” Linda asked. Her eyes fixed on me like a wife waiting to hear about a sick husband.

“Yeah, he’s holding up all right. We’ve had no problems.”

“You’d tell us?”

“He’s keeping it higher. It’s not going to happen.”

“Keep us informed,” Ben said. “It won’t go anywhere else.”

“I will,” I said.


One rainy morning on the way into work, I saw Allison at Marty’s Mobil in Bloomfield. She was buying a coffee when I went in to pay for my gas. She’d cut her hair short. I almost didn’t recognize her. The luster was gone from her smile. I could see the lines in her forehead and the corners of her eyes. She’d left the ED and was working now as a nurse in a doctor’s office down the street on Cottage Grove Road. “How’s Troy?” she asked. “I heard he was back to work.”

“He’s losing himself in his work,” I said. “I think he’s trying to do the job of two people.”

Her eyes watered. “Tell him, I said, hi,” she said.

“Take care of yourself,” I said.

She nodded and gave me a forced smile before she headed back out into the grey day.

Chapter 41

It was a Tuesday afternoon at three minutes past one. We were standing outside Hartford Hospital when we heard an explosion that sounded like a B52 dropping a five-hundred pound bomb. It rocked us where we stood.

“What the f—was that?” Melnick said.

Already black smoke was rising to the north. It came from downtown.
We swore in unison, and then jumped in our truck and started in that direction.
It was the Civic Center. The explosion had ripped through its south side. The force of the blast shattered glass and overturned cars. Melnick and I were the second car on the scene. The smoke was thick and black. Stunned bleeding and burned people stumbled onto the glass-strewn street. Flames leapt through the smoke.

“Medic! Medic! We need a medic!” A man, his clothes torn, bleeding from the head, helped another half naked man along who was burned, his skin peeling off his arms and chest.

“Get the stretcher!” Andrew shouted at me. “Get me a burn sheet.”

“Help, can’t you please help? He’s not breathing.” A woman knelt over an obese man who lay on the sidewalk. A hunk of concrete lay across his legs.

Andrew grabbed the blue bag and ran to his side. I watched as he took out his intubation kit.

“Do CPR!” he shouted at me.

A huge cloud of black smoke blew at us. I lost sight of him for a moment. People running from the building jostled me.

Andrew and I coughed heavily. He had the laryngoscope in his hands. I looked closer at the man.

“He’s dead, Andrew. Leave him.”

He looked up at me, his hands shaking.

There was another explosion. A car burst into flames. I felt the heat on my back.
“Over here, over here.”

A mother carried her daughter in her arms. Their faces were blackened with soot. The girl’s leg dangled at a grotesque angle.

“Everyone back!” a police officer shouted, while another cop grabbed my arm and tried to pull me forward. “There’s a guy over here who’s hurt real bad.”

The smoke cloud again obscured our view.

More units arrived, but we were lost. No one was in charge. There were patients all around us. Someone said it was a bomb, another said a transformer had blown, another a gas line. Voices shouted over each other on the radio. Andrew stood there dazed.
I heard a shout. I turned and looked up the street and saw him. Troy – in full paramedic uniform . A car fire blazed behind him.

“Tercelli, get these people out of here. Melnick, set up triage in the Laz E Boy lot. Nelson, find the fire commander and tell him what we’re doing. Lee come with me.” Troy barked orders into the radio, talking to dispatch, to Ben Seurat and to the C-MED dispatcher.

A fireman came out of the building carrying a motionless bloodied girl.

Troy took her in his arms. He gave her two breaths and handed her to me. “Keep breathing for her and get her up there. You can do it.”

I put my mouth on hers and breathed. My god, I thought, I can feel her move. She was moving.

Troy nodded. “Get her up there and come on back. I’ll need you here with me.”

I walked fast with the girl in my arms, holding her up to my mouth, breathing for her. With each breath, I felt more movement. Com’on, little girl. Com’on, little sweetheart.

I followed the flow of people down Asylum Street. People made way for us as if I were carrying the Olympic Torch. They steered me into the Laz-Boy Lot where Andrew had already set up a small station.

As I held the girl, Kim Dylan put an oxygen mask on her face, and listened to her lungs. Her partner brought over their stretcher.

“You all right?” I asked.

She nodded. “Stay safe,” she said.

“You too.”

They loaded the girl and headed off to Saint Francis.

Ambulances lined up on the far side of the lot. Andrew radioed for them to come over one at a time. Patients sat on the ground or leaned against cars in the lot. I saw other medics checking them out, sorting them into groups by urgency of their injuries.

I turned and headed back up the street.

Troy, his face now covered with soot, leaned over a motionless fire fighter, surrounded by three of his fellows. Troy raised his fist up and smacked the firefighter in the chest.

The man coughed and began to breathe. He said “Huh?”

The other firefighters looked to Troy, but he was already leaving. The firefighter wanted to get up and get his hose.

“No, he’s got to come with me,” I said. “He has to go to the hospital.”

“No way. I’m fine.”

“You have to understand,” I said.

“Com’on Frankie,” his fellows said. “Listen to the man. I saw it. He’s telling the truth. You scared the shit out of me. You weren’t breathing.”

They helped me load him on the stretcher, and take him down to the triage area.
Kim who was already back from Saint Francis after taking the girl, who she said was doing much better, took the firefighter. I manned a stretcher and headed back toward the smoke where Troy and others raged against the chaos.

By three o’clock we had treated over two hundred patients. The day went by in a blur. There were fourteen fatalities. Seven criticals. There could well have been more but for the efforts of the firemen and police and EMS.


Later, I saw Troy at the hospital. He sat on the bench in the back of his ambulance. His pale face was still covered with soot.

We hadn’t had time to talk. “Howdy, stranger,” I said. “You came back.”

“Yeah, I was bored.” He rechecked a laryngoscope blade.

“You were the best out there.”

“Thanks.”

“You look wiped out.”

His eyes were drawn, his hands shook slightly.

“I’m okay.” He started to speak, but had no words.

We took stock of each other.

“Let me get you an orange juice,” I said. “I’m buying.”

“Okay.”

When I got back with the orange juice he was out cold. I thought about trying to find a medic, but I didn’t. On this night, after all he had done, I didn’t want anyone to see that he was mortal. I closed the doors, strapped the tourniquet on his arm. I was about to stick the catheter in his vein when Ben opened the side door.

“He’s out,” I said.

Ben nodded. He reached over and felt Troy’s cold, wet forehead. “Give me that,” he said.

I handed him the catheter. He hit Troy’s vein, and attached the IV line. I handed him the D50. He screwed the amp into the Bristo Jet, pushed out the air, and then stopped. Maybe it was because of all that happened with Pat, or what had happened that day or maybe it was just that he realized that what mattered was not all the bullshit, but actually doing the job – whatever – he clearly had a change of heart. He handed the D50 back to me. “Go ahead, you know what to do.”

I nodded my thanks. I know Troy wouldn’t have wanted to awaken with Ben standing over him.

Just as he was about to go out the door, I said, “One thing?”

“What?”

“How’d he get back to work?”

“He showed up with his note.”

“Marcus Welby?”

He smiled. “Who am I to say he’s not a real doctor somewhere? Now all I have to do is tell my brother about it.” He looked at Troy a long moment. “When he comes to, get him something to eat.”