Headline

 The headline in the paper catches me by surprise. “Iraq War Officially Ends.” With all the speculation leading up to the Invasion 10 years ago, the debate over weapons of mass destruction, then the shock and awe invasion, the fall of Bagdad, the Mission Accomplished banner, the resulting urban combat, the ICDs, flags flying at half mast. The Jessica Lynch story, the Iraqi prison scandal, the capture of Saddam, more urban combat and ICDs, more flags flying at half mast, it seems odd that the war is over just like that. There are no celebrations I know of, no couples kissing on Main Street, nothing seems to have changed. It is on the front page right there, but it has all the impact of a story buried deep in the paper. It is over? Was there a big battle we won or did we just decide enough is enough?

We get dispatched to the VA for a patient seeking detox. There are Christmas decorations in the lobby. A staff member wears a Santa hat. The doctor fills us in on our patient. The man admits to drinking a fifth of vodka a day. He apparently drinks nonstop. He is seeking detox. A nice man, the doctor says.

The patient, wearing brown fatigues, is sitting in a chair in the exam room. He is a giant – I’m guessing six six, two forty - but he struggles to get up from the chair. His body is stiff and his face contorts with pain as he moves. He hasn’t had a drink for three hours now, and already I can see the shakes in his big hands. We help him on the stretcher and try to get him comfortable. He says laying flat is best. He seems tense. I can see scars along his head and neck. He tells me has four purple hearts. He points out where shrapnel is still in his body. I ask him questions about the war. He was in both Afghanistan and Iraq. He was says he was part of an elite team that was there even before the invasion. He talks about dressing up like a sheik, wearing his beard long, gathering information. He tells funny stories about giving suitcases of heroin and bottles of Viagra to war lords for information. He had been in the army since he was he was 18. Almost twenty-five years.

For him he says it was all about his men. He has no interest in politics. Whether Washington or the chieftains he bribed for information and support, he says the nature of politicians is to change with circumstances to ensure their own survival. His loyalty was to his men, but with his injuries, he says he is of no use to them anymore. He is out now on 100% disability. “I haven’t been home but for two days since I got out,” he says. “I couldn’t stay there and let them see me like this. I live on the road now. I’ve got pain constantly and I can’t close my eyes without nightmares. I never drank till I got out. Now I can’t stop. I need help bad.”

I give him some fluid to ease the dehydration and 2 milligrams of Ativan to help with the withdrawal symptoms.

At the hospital, he thanks me, and I quickly thank him.

The paper can say what it wants. War doesn’t end.

Come on, People

 The young woman says her knee has given out. She thinks it is dislocated, but you can’t tell because you can’t even see the knee. She says she is five hundred pounds. She can’t get up on her own. One ambulance crew can’t do it. Try pulling her up by the arms and you will pull them right of their sockets. And if the sockets held, your backs wouldn’t. Also, we are on the third floor. No elevator. Tight corners in the apartment, lots of heavy furniture.

But then help is here. Now there are four of you. Throw in 10 mg of morphine and you have the start of a plan. The patient has said if you can just get her up to her feet, she may be able to hop down to the ambulance. Wishful thinking perhaps. Ever the optimist, I am. And if she can’t hobble, if you can get her to her feet, you can at least have her in a chair while you figure out your next move.

You go to old reliable to get her up. Get a board under her, strap her to the board. Sure she is hanging off both sides, but that’s what double belts are for. But first, you splint the knee. How do you splint a knee that wide. A KED -- wrap it around the knee like it is a torso. Now, its time to lift. Put one person on each side, one arm under the patients arm and the other holding a hole in the board. A third person at the feet to keep the person from sliding off the board as you lift it. And you, squatting down at the head end, and with a big grunt lifting, driving your legs up, as the two on each side, pull. Leverage. You have her standing in no time, and the four of you hold her up. My leg! My leg hurts! she says. So you quickly go to Plan B. The two chairs you have placed just to the side, and you quickly unstrap her and pivot her onto the chairs, where she now rests and lets out her breath. And then you turn and look behind you and see eight family members crowded into the room – every one of them holding a digital camera or video recorder, recording your every move.

You look at them and hold your hands up? You say nothing. You think what’s with the cameras, people, seriously? Is this to make fun of your sister? Is this to sue us? I admit that while I love my job and love the people of the great city where I work, in this moment, I am profoundly disappointed in these individuals.

The other medic on the call speaks to them professionally and succinctly and they put the cameras away. I am still shaking my head.

Come on, people.

***

The bottom line on the call was an hour and a half scene time, and only with an assist from our first responder friends at the fire department (who had not been dispatched to this call) and a hunt for a Stokes basket large enough to fit her into and with much pushing and hauling and moving of furniture and turning tight corners and going down a narrow stairway with wobbly wooden stairs, did we finally make our way outside. The other medic ended up taking the patient in, while I attended to and transported an injured responder. I haven’t yet found out whether or not the patient’s knee was dislocated. And as far as I know, we haven’t turned up on You Tube.

Straight Blade

 We are called for the violent psych and told to stage for police. Years ago we would have just been called for the violent psych. Once we got there, if we needed the police we would call for them, or depending on how the call came in, they might already be there.

This morning the call is at a nursing home and when we get there the cops are not there yet. We wait a few minutes, and then just decide to go in. It is not like we are entering a house with a violent mental patient barricaded inside. At the desk, they tell us he is up on the 2nd floor. As we wait for the elevator, the policewoman walks in the door. She is a petite woman, unlikely to be able to wrestle a raging maniac, but she does have a gun and night stick.

On the 2nd floor, the nurse points out the patient, sitting in a wheel chair by the desk with his eyes closed. He is large and muscular—built like a bull – with a scar on his hard face. He looks likes the strong man in the movies who the hero punches, but the punch does not even make the man flinch. Still his body appears relaxed, and he looks up at us without menace.

I introduce myself and my partner to him, and he nods and says hello. As I help him onto the stretcher, my partner asks the nurse what happened. To get on the stretcher, the patient locks the wheels of his chair and then moves himself over with his muscular arms, as I hold the stretcher in place. I notice then his right leg is amputated above the knee.

“He threatened to kill one of the patients here,” the nurse says. “He said he was going to stab her with a knife.”

“No,” he says. “I said I would slit her throat from ear to ear with my straight razor if I had it, but I no longer carry a straight razor.”

“Say what?” the officer says, “You want to repeat that for me, honey?”

“I said I would slit her from ear to ear. The dirty bitch stole my shirt. Everyday she steals from me, and they do nothing about it.”

“Where’s your knife?” the officer says. “He has a knife?”

“No, I am without weapons. I said I no longer carry a straight razor, nor do I have a gun at my side. I gave up my violent trade. I was just saying if I had my straight razor, she would bleed for what she does to me. The dirty whore, stealing from me and they do nothing.”

“What hospital are we going to?” I ask the nurse, as the officer stands there still trying to understand if a true threat has been made.

“Hospital B,” the nurse says.

“B,” my partner says. “We almost always go to A from this facility.”

“Yes,” the nurse says, “But we have learned when we send patients to A, they send them right back. If we send them to B, we do not see them for awhile.”

“There you go,” my partner says, and the nurses all laugh.

“Did you really mean to do violence?” the officer asks the man.

“How can I slit her throat when I no longer carry my straight blade? But if I did carry it, it would always be near my hand, and she would feel its edge.” He says, “I do not like to be stolen from, to be made a fool.”

We get our paperwork and take him to hospital B. On the way out, he sees another nurse and says. “You call for them to take me to jail, you better come down and pay to get me out. I know you have money.”

The nurse just laughs and shakes her head at him.

At the hospital, the triage nurse also shakes her head at his story.

After we transfer him over to the hospital bed, we ask, as we always do if there is anything more we can do for him. “If I might have my mouth swabbed,” he says. “It has has been several days since I have had my teeth cleaned, and I do not wish my breath to be foul.”

A Warm Kitchen

 I watch as he slices a pear, an orange, and a banana and sets them next to the red grapes on the plate. He pours me a glass of orange juice and then lays out plates of sausage, low sodium bacon, honey glazed ham, and potatoes. From the oven he takes out French toast.

A month before a supervisor handed me an envelope at work when I came in off 12 hours on the road. I opened it up that night, and found a two page, single spaced typed letter from a patient I’d taken care of this summer asking me to call him. He said while he does not remember much about the call, a nurse had told him at the hospital that he needed to find me and thank me. He said he wanted to do it in person. He is a chef and wanted to cook for me.

When he met me at his door, I told him he looked good, and he does. He says he has lost forty pounds, has a new medicine regime, goes to cardiac rehab, and now he has a defibrillator in his chest. He says he is grateful for each day.

We sit and eat and talk about our lives in the kitchen of his home. Like me he has a young daughter born later in his life. She calls while we are eating and asks him to find a folder she forgot to bring to school. Both of us talk about how having a child has changed our lives.

I don’t know why it took me almost three weeks to call him. But I am glad I did. In our line of work, we separate ourselves from our patients. We become a tribe unto ourselves. Here this morning, as the two of us talk about growing up in the area and raising families while doing the things we love, I feel like I am part of something larger – a part of the community. We rise in the darkness, go out into the world, and at the end of the working day, come home to our families. We are surrounded by others, grocers, bankers, electricians, teachers, factory workers. I am a paramedic and he is a chef.

He tells me how the French toast is made out of artisan bread. He sliced the bread into cubes and mixed the cubes with chunks of apple, then piled them on top of uncut slices of bread and baked them with just a touch of cinnamon. The toast is rich and delicious; the kitchen warm. We talk like old friends.

A Younger Man

The snow started in the afternoon earlier and harder than expected. I got the kids inside with some DVD’s and pizza. I cracked the thermostats up to give us some heat in the event we lost power that evening, which was the worry with the autumn trees still being so full of leaves and the snow predicted to be wet and heavy. The kids didn’t get halfway through RIO before the lights went out. They were impatient for it to come back on, but with daylight still present, and a quick call to Grandma confirming she had power, I packed them up with a couple days clothes and some food and drove through the storm. Once I had them safe, I headed back home to wait the storm out. Getting home was crazy. Power lines and trees down, streets blocked. I was happy to make it back to my driveway unscathed. All that night you could hear the trees cracking and the wind whistling. Occasionally the sky light up green as transformers blew. Instead of four inches, we’d gotten 12.

When the storm was over 800,000 plus in the state were out of power. Many of the towns like my own were 100% out. The devastation was rare to our area, which at worse gets a blizzard or a weakened hurricane. Many roads were impassable. Trees were down in nearly every yard.

I slept at night in long johns and under every blanket in the house. On the fifth night the temperature in the house dipped down to 48, and the cold took root in my bones. I came home the next afternoon to find the power finally on, although still no phone or cable service. I was lucky as many of my neighbors were still and are still in the dark. The utility company said everyone would have their power restored by midnight of the eight night, but it hasn’t happened.

This morning we responded to a fall. The house a nicely kept middle class home, not far from a commercial center, was dark and cold when we walked in. No power here. In the bedroom we found a 89 year old man in bed, skin pale and cool and dry, shivering under a mound of blankets, wearing a winter jacket and a baseball cap that said 101st Airbourne. A first responder told me the man’s legs had given out and he’d fallen against a table and bruised his chest. It was 42 degrees in the house, and now he couldn’t stop shaking.

“He was at the Siege of Bastonge,” the responder said.

There are place names that invoke awe. Bastonge is one of them. Late in World War II, the Germans mounted a massive surprise attack against the Allied lines in Belgium under the cover of severe weather. The 101st airborne were surrounded in the Ardennes forest near the town of Bastogne. Unable to be reinforced, they dug in in foxholes, fighting subzero temperatures, while being blasted by artillery. They were critically short on food, medicine and ammo, but they repeatedly refused entreaties to surrender. Some of them froze to death. Still they held the Nazis off for a week until General Patton’s tanks could come to their rescue. More commonly known as the Battle of the Bulge (the Bulge signifying the near break in the Allied lines), it was a key turning point in the war that devastated the Germans’ hopes to hold off the Allied advance.

“If you haven’t heard it enough, thank you.” I said to the old man, and then added, “I guess this cold now must all be like a summer day to you.”

“I was a younger man then,” he said, quietly. 

EMS Towns

 Many years ago, I was a taxi cab driver. Us cabbies used to talk about cab towns. What was a good cab town and what was a bad cab town? A good cab town was always hopping. People used cabs instead of cars. There were no traffic jams. The rides were of conversation distance. You wanted at least a $7 dollar fare. You hated the take me three blocks calls. In a good cab town, cops couldn’t be bothered to hassle cabbies. And in a good town, people knew how to tip proper. At least ten percent of the fare and lots of keep the change, buddys. You could make a living in a good cab town without having to hustle all the time, and if you did hustle all the time, which is what we did, you could make a fine living. A bad cab town, on the other hand, had short rides, dime tips, parking lot traffic, cops who like to bust on cabbies and a safe and functional bus system.

Having worked in more than a few towns in EMS, I can tell you there are good EMS towns and bad EMS towns. A good EMS town has single floor homes, not too many nursing homes, a populace educated enough not to call 911 for a genital wart, and enough highways, industrial buildings and driveways that need shoveling to ensure that when EMS is called, the people likely really do need a paramedic. A bad EMS town has three and four floor walkups, apartment buildings with broken elevators, nursing homes as a their cottage industry, a populace without cars and a dsyfunctional transportation system. A bad EMS town isn’t necessarily a poor city. Sometimes architecture alone can be a drawback. Some of these nice two story homes in upper class towns are such that the patient is always bedbound up on the second floor and there is little room to maneuver at the top of the stairs, and the staircases are narrow and steep, and there is artwork on the stairwell walls, and antiques on the landings. In bad EMS towns, they don't like bad weather boots on their carpets. I will take a town of humble single story homes any day over most anything.

It is hard to find a town with all the elements of a good EMS town. And of course, it varies with what you like to respond to. Don’t like trauma? You don’t want an interstate or windy back roads in your town, nor do you want hip hop clubs and crack houses. Don’t like sick old vomiting people? You don’t want an elderly population. If you like crazy people, the city is for you. If you don't like crazy people, I have news for you, crazy people are in every town! Tired of taking people two blocks to the hospital for a finger lac? Find a town without a hospital in it.

Me, I like variety, which I get now. I respond in several different towns during the day depending where system status management has me posted. Variety is good, but I also like decent calls. By decent I mean if someone is going to call 911; I like them to really need us. I like to have my skills and knowledge challenged. Although sometimes, I am content to not have to do more than be a taxi driver again. I don’t get tips anymore, but my paycheck has always been good at the bank.

Moment of Truth

 Your patient is unresponsive. They are also cool, and diaphoretic. You are thinking they are diabetic. You have pricked their finger to get a capillary blood glucose. This is the moment of truth. You are actually hoping for the reading to come back LO or at least less than 50. If it does, you relax, you believe the issue is simply low blood sugar and some IV dextrose will have the person back to normal and maybe even signing a refusal in no time. But if the blood glucose comes back normal, that’s bad. That means something else is causing the patient to be unresponsive and cool and clammy, something far more sinister and less responsive to treatment than hypoglycemia. You wait as the meter counts down. 5, 4, 3, 2, 1.

If it is LO – You give IV Dextrose. If it is normal – you start thinking maybe this is a stroke or cardiac (what does the monitor say?) or it is hypovolemia (You would likely already know this by an absent or weak thready pulse).

If they are hypoglycemic, there can be a second moment of truth. In most cases, they respond and wake up and swear that they knew they should have eaten and damn, where are they? And no, absolutely, no, they don’t want to go to the hospital. But sometimes, they don’t respond and you check the sugar again, and it is now normal or even high, and they are just like they were – cool, clammy, unresponsive. The low blood sugar either wasn’t the cause of this episode and is just a symptom of it, or they have been with low blood sugar so long some damage has been done.

I have had several patients over the years who I encountered with low blood sugar, who ended up going into cardiac arrest on me. One was a man with very poor IV access. I couldn’t get a line, so I took out the glucagon. Unfortunately, I dropped one of the vials, and had to get down on all fours and reach under the stretcher for it. When I finally reached it and came back up, now eye level to eye level with the supine patient, he looked different to me. Different like his eyes were open and lifeless and he was not breathing. I know one medic who encountered a patient with low blood sugar, loaded him into the back of his ambulance, told the family their loved one would be fine, and when they met him again at the hospital, the ambulance doors open, the embarrassed medic was doing CPR.

The other day I had a woman found unresponsive in a car and vomiting. She was cool and diaphoretic. Her husband said she was a diabetic. Something didn’t strike me right about the call. As the first medic there checked the sugar, the number came back – 129. Normal. All right, let’s get moving, we both agreed. The woman was hypotensive. BP of 80/40, then 70/36. The heart rate was 60. We didn’t have knowledge of her meds other than she took insulin. The woman groaned and was alert enough now to complain of severe abdominal pain, as well as pain in the back. We popped in two IVs and called in a medical alert. Her belly was hard and distended. We were both thinking maybe a GI bleed or a AAA. The 12-lead was normal – no STEMI. The lady was so clammy and hypotensive, I thought she was going to code on us.

They met us at the hospital with a full team. They did an emergency ultrasound that was inconclusive. When I checked back on the patient later, she was looking much better. Still in her ED room – not in the OR or up in ICU. Her skin warm and dry, her BP in 118/78. Pulse of 60. Sat – 98% on a cannula. Yesterday, I saw a nurse who take of her and asked for the bottom line. Likely constipation. It seems the patient hadn’t had a bowel movement in 5 days. Maybe she vagaled, the nurse said. She was disimpacted and went home that night.

Twenty years of this, and you never really know what you have. Diabetic, Triple AAA, GI bleed, or a vagaled constipation?

5,4,3,2,1…the answer isn’t always the answer.

Sept 11

 September 11, 2011

It’s a beautiful day, just like ten years ago. We just drove through a town center and there was a small gathering by the war memorial. People held up signs “We Will Always Remember” and applauded as we drove by. Shortly after in the Dunkin’ Dougnuts, a woman walked up to me and thanked me for what I do.

I admit to being somewhat uncomfortable for this type of recognition. I didn’t walk up the stairs into a burning tower or ram a food cart into a cockpit door to take a down a plane headed for the US Capitol. I don’t wear camouflage and body armour, and carry out dangerous midnight raids. Like anyone, I go to work and try to help people. Some days I do it better than others. I try to always be careful. I get paid every week. I go home to my family at night.

Sitting on post, we talked about how crazy life was like in the aftermath 10 years ago. We thought there were thousands of sleeper cells ready to wreak their evil havoc on us. One of my partners was certain the Arab American who ran her corner grocery was a terrorist. She talked about how she always saw him in the back room, talking with his other buddies – they had to be plotting. My partner today just told me about a friend of his family’s who was a pilot, and while a regular American, he had a Muslin name. When he announced his name to his passengers the day air flights resumed over the country, half of them stood and walked off the plane.

Not long after September 11, I was on duty, handling a school bus accident when over the radio, I heard a call go out for an explosion at the Civic Center with reports of thick black smoke in the air. On the radio, I heard the first responding unit, put out and promise a quick casualty update. The local TV channels went to live coverage, but it soon turned out the explosion and smoke were from a transformer that blew up. The terrorists hadn’t chosen our civic enter as their next target.

Will they attack again? Perhaps today on this 10th Anniversary? It’s hard to believe this beautiful still morning could be transformed into chaos. But someday it likely will happen again.

And we’ll find out once more of what we are made.

Storm Watch

 A month ago, I swapped out of my Sunday shift for Saturday. Of course I had no idea then that a hurricane would be forecast to strike our state on Sunday. (My reason for swapping was so I could enter a mile open water swim in Boston Harbor called “Sharkfest.”) I will admit like most in EMS to being somewhat of an action junkie, but instead of being upset that I might be missing out on the hurricane action, now that I am older and have a family to protect, I was quite glad that I could spend the day at home instead of out on the road battling the elements. (Sharkfest was cancelled).

The weather media machine was in full hype for storm Irene, and having witnessed first-hand the damage done by Hurricane Katrina, I have learned to respect weather, regardless of the possibility of any storm turning out to be less than advertised. I dutifully joined others in the grocery stores, buying bottled water, canned goods, charcoal for the grille, and other provisions to tide us over through what we were warned was the possibility of being without power for up to a week. On Friday (while at work on the ambulance) the day before the storm, I even managed to secure batteries, a flashlight, candles, a lighter, and a precious manual can opener – all items I had either forgotten to get or that were sold out from the larger Home Depot stores. Through searching all the little gas station convenience stores, I managed to get what I needed. I then bought 2 bags of ice at the 7-11 right before we were sent in for the day, and thus had my emergency provision list fully completed.

That night I gave the three girls the game plan for the storm. Eat the perishable food first, don’t use the flashlights unless necessary, etc. I had them help me finish the laundry and get all the dishes done so we would be in a good state of preparedness. Their mom was working late that night and since she had to work again the next morning, she had plans if the storm was bad enough to stay at the hospital. Little Zoey got in bed with me and I gave her a heart to heart about what the storm might bring. The howling wind, driving rain, sound of trees crashing. I told her not to be afraid, that I would protect her.

“Daddy, I’m scared,” she said.

“Don’t be, it’ll be all right.”

“I think I’m going to sleep with my sisters.”

So with that, she got up and scurried down the hall.

“You can come back if the storm gets too bad,” I called after her.

I slept through the night, rising with the first sunlight. It was raining hard, but nothing truly torrential. The power was still on. I saw no damage in the yard, no water in our basement, which is usually dry after storms. I had my Diet Coke and watched some of the news. The full brunt of the storm hadn’t quite reached New York yet, still to our south. The next six hours were forecast to be our worst. I was glad to be on guard at home. I didn’t even think how if I hadn’t switched, I’d be out there in the rain, battling to get to patients through flooded streets and downed limbs.

Zoey and I made pancakes and read books while watching the news in the background. There were the traditional shots of weathermen standing in knee deep water with trying to keep their rain hoods on as the wind buffeted them.

By two in the afternoon the rain had stopped and the now Tropical Storm had passed. I put Zoey in the running stroller and Lauren rode her bike alongside us as we ran throughout our local neighborhoods, inspecting the damage. A lot of leaves and small branches down. A low-laying bridge on the golf course over a stream was now underwater. No big deal at all.

For dinner we made meat balls and spaghetti, adding our secret ingredient – whipped cream – to the meat balls. We watched the nightly news and saw all the storms highlights, washed out roads in North Carolina, demolished houses along the Connecticut shore, torrential flooding in Vermont. We also learned scattered lives had been lost and millions were without power. We were grateful we had been spared the worst of it. Zoey fell asleep watching her favorite TV show – King of the Hill (I think this is why she often greets me "Hey Dude!" -- and I carried her to her room and set her head on the pillow, and pulled up the covers.

This morning I got up, showered and dressed, turned on my pager and saw the previous night's pages asking for additional crews to come in and help out a division of ours on the shoreline and later a page for crews to help evacuate a hospital whose generators had failed. Finally there was a page thanking everyone for working so hard during the storm. Making us all proud.

My family still asleep, I walked out the front door into a beautiful late August morning. The air was fresh with ozone. I drove in for my scheduled 12-hour shift.

Doctor's Offices

Doing calls in doctor’s offices can be tricky. “Do you start working the patient in the office or wait till you get out to the ambulance?”

Here are the assumptions. You are a transport medic so you have the stretcher with you. The patient is not in cardiac arrest or so sick that they will crash if you don’t do something right away. At the same time, they are sick enough that you will likely have to give them an IV and medicine once you get into the ambulance. Here is a scenario I have had three times -- a patient with an PSVT in the 180-220 range who has come to the doctor's office for an emergency visit because he is feeling uncomfortable. Here is how it played out each time.

1. I am a relatively new medic. After getting a report from the doctor, I say, “Do you want me to give him some adenosine?” He says “No, wait for the ED staff to do it.” Deflated, I wait for the ED staff and the ED Doc gets mad at me for not having given it.

2. I am a more experienced medic, I keep my mouth quiet. I nod, put the patient on the stretcher, get them down in the ambulance, where I do my thing, give them the adenosine -- the rhythm breaks and converts to a sinus in the 80 range, the patient feels much better, and all is good.

3. Just recently, the doctor tells me the patient is in an SVT. He already has an IV line, and has done a 12-lead. This time, it is a little different. The doctor asks “Do you have adenosine?” I say, “I do. I can give it here or out in the ambulance.” “Your choice,” he says. I think a moment, and then say, “Let’s do it here.” I give it, and it all works out great.

Let’s analyze all three situations.

Situation 1. You have a doctor who doesn’t appreciate EMS. The problem with these doctors is if you ask them in front of their patient about treatment, you run the risk of a clash of wishes. I once had a 35-year-old patient having a severe allergic reaction-- hives from head to toe with crazy itching. I asked the doctor what he had done for the patient. He had given Benadryl PO. “What about epi?” I asked. “No, it is contraindicated,” he said. “She is hypertensive.” “What is her pressure?” “140/90.” Okay, so now I have boxed myself in. Once I get out in the ambulance I have to convince my patient to let me give her epi against her doctor’s wishes.* Another time I had a patient having an asthma attack, I gave the patient a breathing treatment in the doctor’s office – no issue here – but then I tried to also get an IV in the doctor's office. When I missed my first attempt, the doctor began yelling at me for wasting time and to get the patient to the ED now. Not a comfortable situation.

It has never happened to me, but I have heard many stories of medics starting care in a doctor’s office and getting into huge fights over the direction of the care. Sometimes the medic was right and sometimes the medic was wrong. Conflict like that doesn’t serve anyone well. One of the worst cases I heard of and this one sounds unavoidable, was a cardiac arrest in a foot doctor’s office in which the doctor insisted on running the code, using his own algorithms. The medic was new and wasn’t able to seize control back. I am always uncomfortable when calls become territorial, which is why I like to get on my ground.

These experiences have all led me to the general approach of situation 2. Get the history and get into your office – the back of your ambulance. This doesn’t mean that there aren’t situations where you have to stand your ground and do what you have to do. It is just that there are some cases where it might be easier for all to just vacate the doctor’s space. Some doctors do it for you. They leave the patient in the waiting room with only the receptionist or family member to give a report. They don’t want the patient taking up an exam room. I have taken care of patients unresponsive with head bleeds slumped in their waiting room seats clutching their CAT SCAN photos.

Situation 3 is relatively rare – a doctor both knowledgeable of prehospital care, engaged in the patient’s care, and respectful of prehospital’s domain. This situation, when it presents, should be seized upon. I have only had this happen one other time in a doctor’s office – where I was encouraged to work the patient right there before the doctor. That was for a semiresponsive hypoglycemic patient. The doctor was fascinated and very complimentary as we put in an IV and gave the patient D50. He had treated diabetics in his office for years, but this was the first time he had actually witnessed a patient crash in front of him and then seen the effects of D50.

None of all of this is to say that the majority of EMS interactions are not professional and courteous. Most of the cases involve getting a report, putting the patient on the stretcher and getting on the way. I have seen doctors who did not seem competent to me and I have had doctors pick up subtle ST elevation that I might have missed that turned out to be STEMIs.

As anything in EMS, whether to start working a patient in a doctor’s office (beyond 02 and a monitor) all comes down to the great saying, “It depends.” The point of this post is just to say to newer medics to beware of some of the drawbacks to doing your thing on the doctor’s turf, and unless necessary, it may be best to just get the report, ask any pertinent history questions you might have, thank the doctor, and get on your way.

* At the time epi was in our protocols as standing orders for this, now we would withhold epi and just treat with Benadryl unless the patient developed wheezing or become unstable. 

Working Man

 I’ve been fighting a respiratory infection for the last week. Every now and then I have a coughing fit that brings up lingering mucus from my chest. I have some medicine I can take to keep the cough under control if it gets too bad -- when my cough is so rough patients offer me their spot on the stretcher. I am actually feeling much better today. I even went running this morning before work -- just a short 2.4 mile neighborhood run to get my legs and air back.

Normally, the first thing I do once we put ourselves on-line with dispatch is get a large Diet Coke on ice at one of the local 7-11s. I could get a bottle from the vending machine in the crew room, but something about the Diet Coke on ice makes it taste so much better and helps relax me and tells me everything is all right with the world. I imagine it is how an alcoholic must feel when they pour their first drink of the day. I just sip that Diet Coke slow throughout the morning. If I have my cold, that’s when I pop the cough pill or a decongestant if I need one. Some mornings I don't get my Coke until after a call or two, and today, I go four deep before I finally get it. It has been busy.

I’m seven calls in already and this is the first chance I’ve had to get my netbook out and start recording. I started the day off with an unknown that turned out to be a guy who turned his ankle getting into a police car a couple days ago (I didn't ask about that story) and said it was swollen now and hurting him. He met us on the stoop outside his apartment building. My partner started to pull the stretcher, but the man said he was fine and would walk over to where we had the ambulance parked. When we got to the back of the ambulance, I offered to pull the stretcher again so he wouldn't have to climb in the back. But again, he said he was fine. I told him to watch his head as he climbed in. Once in the back, he at least agreed to lie down on the clean sheet we spread out the stretcher and be strapped in. At the hospital, the triage nurse told us to put him in a wheelchair and take him out to the waiting area. All of a sudden he made a big deal about how his leg was killing him and why couldn’t he have a room instead of having to sit in the waiting room? He walked out to the ambulance, my partner told the nurse as the man went through his theatre. She just shook her head at him and said "Waiting room."

As soon as we got back in the ambulance, we were dispatched for a stroke at a group home. Patient found that morning leaning to her right. Last time that happened the hospital diagnosed her with depression. She was depressed so she leaned to her right, instead of sitting up straight. She had no facial droop, clear speech, equal grips and no pronator drift. But she was leaning to her right. "Are you depressed?" I asked. "Yes," she said. She looked like someone leaning to her right because she was depressed rather than someone leaning to the right because they were stroking out. She was on a lot of heavy duty psych meds and lived in a small spare room with not much light in the home. If that was me, I'd probably lean to the right, too.

No sooner had we cleared that call then it was off to a surburbantown for a headache. Girl with severe left-sided head pain and an aversion to the light. She said she had two prior episodes recently with negative cat scans. BP was 120/60. Pulse 60. She wouldn’t open her eyes to let me look at her pupils. “”What do you think it is?” she asked. “A migraine,” I said.

There is a new ED at one of the hospitals and while it is an awesome ED, it is hard to get to the cafeteria now and for some reason my security badge isn’t working so if I go, I often have a hard time getting back to the ED. I have to wait for someone to come along and swipe me in. So instead of getting my Coke, I went back on-line figuring I could get my Coke at a 7-11 or fast food restaurant before we got another call. Wrong.

Man down behind the motel. Unknown. On the way there, I have a coughing fit and try to resolve it with a stick of gum, lacking any beverage to wet my throat. It is getting very hot and muggy out, which does not help. One moment, I am fine, the next I can’t breathe, but I manage to get it under control before we arrive.

The patient is intoxicated -- crawling on the ground looking for his glasses. He says he just got locked out of his room. I can smell the alcohol on his breath. We pick him up and put him on the stretcher. He takes a half-hearted swing at my partner, and when I tell him to cut it out, he takes a swing at me, which I easily deflect. He calls the police officer some names and says he still wants his glasses. The officer says he has looked for them and can’t find them so he is out of luck. As we load him into the back, he looks at me and spits. The spit doesn’t reach me, but I caution him.

“Please don’t spit at me,” I say. “I’m just a working man.”

I am getting the glucometer out to try to check his sugar when the cop opens the back door and says, "You’re in luck, I found your glasses." He hands them to me. I consider leaving them by the patient’s feet, but instead hand them to the patient. I'm willing to let bygones be bygones. If I treat him well, maybe he will reciprocate. He puts the glasses on, looks at me, and then launches another goober in my direction. Now just because I was willing to offer an olive branch, doesn't mean I have left my guard down. And I have been in EMS a long time, and like most who have been in EMS a long time, I have acquired a Matrix-like ability to evade bodily fluids, including spit. I do my best Keenau Reeves impression and for a brief second find my eyeball a bare millimeter from the spit gob. But I slowmo evade it. It falls back to earth, landing on my computer screen.

“Again, not cool,” I say.

He spits again, but this time the glob lands back on his face. “Looks like you misfired,” I say.

I get a towel and with a straightarm wipe it off his face, and say, “I would appreciate it if you would stop. Nobody likes having spit on their face.”

He looks at me blankly and then I see him start to work on getting another mouthful of spit.

It is stuffy in the back of the ambulance and the switch for the AC is on the patient’s side of the ambulance. To hit it on, I will have to come again into his range. He senses my intention and spits again. I deflect it with the towel.

Suddenly, just then, a coughing fit comes on me. It begins with three asthma like gasps to get some air in, and then, four staccato, deep rattling coughs. If this blog had sound, imagine an old homeless man with a long greasy beard coughing up a deep aqualung wad of phlegm. That's what it sounds like. I can feel the mucus detaching itself from my lungs and shooting up in my throat. Now, let me just say here that I try to always be a gentlemen and subscribe to the highest ethical standards of professional conduct. As I cough, the patient suddenly looks quite uneasy. I would never spit on a human even in retaliation. I don't understand how a human could spit on another. But I suspect his view of human nature is different than mine. If he is capable of spitting on another human being, maybe he thinks I am capable of spitting on him. He doesn’t know me. He doesn’t know how I roll.

With a terrible sound, I hawk the mucus up into my mouth to keep from choking on it. The man is now clearly frightened by this display. I wonder if he is thinking about the positional advantage I have over him. I wonder if he is thinking just how nasty that mucus is in my mouth. In normal polite circumstances, I might force myself to quickly reswallowthe mucus. Instead I find myself raising the towel to my mouth and depositing my phlegm into it. “Forgive me,” I say,” “I’ve got this lingering respiratory infection. I 've been coughing up some serious phlegm. Green, yellow, very purulent.” Here I am exaggerating. It is clear mucus, but instead of showing it to him, I lie about its qualities.

He doesn’t take his eyes off me, but he doesn’t try to spit again the rest of the way. I wonder if this is how nuclear deterrence with Russia worked for so many years.

After the call, I make certain to wash my hands and carefully clean off the computer. I also borrow my partner’s badge so I can go down to the café and finally get my Diet Coke on ice.

The Diet Coke (with Lime) tastes good, and I sip it slow as we head off to a doctor’s office for a seizure. We find the man on the floor of an exam room. The doctor says the patient had four gran mal seizures without waking up. The patient has his eyes open looking at the ceiling. The man has the end of an OPA sticking three quarters out of his mouth that he is holding with his teeth. I pick one of his arms up and can feel he has good control over it. I question the doctor about what was observed, and then put the patient on the stretcher and transport. I work him up like he had a real seizure, check his sugar put him on the monitor. The transport is uneventful I tell the nurse at the hospital, no incontinence, no tongue biting. Seizure described as tonic-clonic full body lasting 30 seconds, repeated every three minutes until our arrival. I tell her I caught him watching me out of the corner of his eye when I got ready to do the IV. Then it’s off for another unknown which turns out to be a 24 year-old who tried to kill herself by slashing her wrists. Never mind that she failed to break the skin. She is upset because her boyfriend broke up with her. I feel bad for her. She has a big tattoo on her arm that says "Enrique" with a big heart around it. I hope Enrique is her son (if she has one) and not her boyfriend. She goes in the psych wing in the room next to the spitter who is now sound asleep, snoring.

We do a dialysis transfer and then stage for a psych, awaiting PD. The cops are very busy today also, but eventually an officer arrives and we and the firefighters follow him into the house where a woman says she wants her thirteen-year-old son brought to the hospital. She doesn’t want him in the house anymore because he doesn’t pay her any mind. It takes awhile to figure it out, but that is just it. She just doesn’t want him in the house because he doesn’t do what she asks. He isn’t out-of-control. He is not suicidal. She just doesn’t want him in the house. Meanwhile he is in his bedroom playing with his PSP and listening to music on his IPOD, turned up so loud I can hear the beat. Maybe the hospital can talk some sense into him, she says. The officer asks her if she has tried to discipline him. "I can do that?" she says. "Yes, you can." "Well, good, then, you can go. As soon as you leave I’m going to whoop his little behind." "Just don’t leave any bruises or marks," the officer says. "Show some judgment." "Oh, I will," she says. "He's going to feel my judgement all right." While the officer (aka social worker) further clarifies what as a parent she can and cannot do, we clear, no patient.

Then it is off to a doctor’s office for a man with chest pain for two days, skin warm and dry, normal 12-lead. I give him some ASA and then apply a tourniquet for the IV. “I have bad veins,” the man says. “That’s okay,” I say, “if I see one, I’ll try for it. I’m pretty good at it.” "Why don’t you wait until the hospital,” he says. This is a situation I encounter fairly often. Most of the time, I sink the IV and the patient says, “Wow, you’re great.” I love it when that happens. This time I try a 24 in the wrist and while I get a small flash, the line blows up when I push the flush. The man looks at me and shakes his head. I can tell he just wants to be at the hospital and out of my ambulance. I don't press the IV issue. I put a 4 X 4 on my miss, and then pick up my computer and start typing out my PCR. You can’t be a hero everyday.

Astray

 I read a recent article in the New York Times that disturbed me.

A Crash. A Call for Help. Then, a Bill tells the story of a 70-year old man in Chicago who was in a minor motor vehicle accident, not his fault, who was nevertheless forced to pay the local fire department $200 for their response. The article goes on to tell the larger story of the trend of first responder agencies billing victims for their services to help solve their departments' budget woes.

I can understand rescue agencies billing people who do foolish or unlawful things such as hiking in dangerous restricted areas leading to massive search and rescue efforts, but sending a bill to a 71-year-old victim – a bill his insurance does not cover -- is wrong.

What I initially loved about being in EMS (particularly coming from a recent background in government/politics) is that in EMS, we are the clear cut good guys, or at least we are supposed to be. People are in need, they call us for help, and we do the best we can for them. But as the years have past, I am coming to fear that we are not always doing the best for the public, and that in many cases, we are showing them our less munificent side.

I am not just talking about inappropriate billing. I see this with inappropriate use of helicopters (and sometimes ground transport for that matter), unnecessary RSI and other procedures because we can and not because we should, and in unrealistically portraying our abilities to try to increase our budgets.

Sure we are lifesavers and we sometimes actually do save lives. But to go in front of federal, state, city and town councils and swear upon the the every second counts, lights and sirens to the rescue, how dare anyone hold us accountable attitude is embarrassing.

We need to tell the truth about what we do and about why we are important.

The beauty and simplicity of EMS is that – whether we save lives or not -- above all we about being there in the time of need. We are about community. No, the outcomes for cardiac arrests are dismal, but you can’t put a price on helping a family whose father’s heart has stopped. You also can’t really put a price on someone being there to give an elderly woman some narcotic analgesia instead of just picking her up on a board and jostling her all the way to the hospital. We are about doing right for the people.

What I am afraid of is in our desire to expand or justify our existing budgets we may be losing our way and becoming something that we were not.

We spend unjustified sums on the latest unproven medical technology. We respond to calls that we never went to before because it makes our numbers look better at budget time. (I've been on minor calls that have had five agencies responding). We change our staffing patterns to fit reimbursement rates. We shine artificial lights on our lifesaving myth and too few of us talk openly about our darker side. (For a truth-teller, read Rogue Medic’s Experts Debate Paramedic Intubation – JEMS.Com commentary in which he, without hyperbole, uses the term “serial killer” to describe a not unfamiliar type of paramedic.)

While these actions may seem to benefit us, the effect on the community is not always the same. Instead of being truth-tellers and true community advocates, we, in EMS, have become politicians, salesmen and marketers.

I don’t mean to be naïve. And I do not hold myself out as innocent in these issues (I acknowledge guilt of my own). I do understand that in these difficult economic times, to compete for diminishing dollars, we feel pressure to act more and more like every other interest group, business or political party. Perhaps it is inevitable. Hospitals went this route long ago. Why not us? Still it makes me uneasy.

Things aren't so black and white in EMS land anymore.

And here is clear evidence of it:

A 71-year old man who didn’t need us in the first place and who did nothing wrong gets a bill for $200, and he ends up writing out a check because he is a stand-up citizen who has always paid his bills (and is perhaps afraid of what will happen to him if he doesn’t pay even though he knows he's getting scammed).

Have we not gone astray?

Your First Day

It’s your first day here. You might be a new volunteer, a paramedic student, or a fresh hire. This may be your first time in an ambulance or maybe you worked ten years for a service in another state. You might be nervous or you could have so much confidence you had trouble fitting your head through the doorway. No matter who you are, this is my advice:

Show up early for your shift. By early, I don’t mean ring the bell at five AM for a six AM shift. Be here fifteen minutes early.

Come to work in clean clothes. I don’t care if your boots are spit-shined or not – mine aren’t -- just don’t have your shirt untucked, your shoe laces untied, or dirt under your fingernails. First impressions can be wrong, but they can be hard to overcome and they rarely turn out to be wrong.

Tell me your name and look me in the eye when you shake my hand the first time. Like I said first impressions count.

Years ago when I was an intern in Washington, D.C. working for a United States Senator, one of my first jobs was to do a massive collation project – the copiers back then didn’t always do it for you so you had to do it by hand, spreading the copies out on tables. I introduced myself to the lady in charge of the project and she said don’t even bother to tell me your name. I have seen so many interns come and go, I don’t even bother to learn their names anymore. That was so rude of her, but the point is true for many jobs – new people come and go, and for people who have been one place a long time, they may not pay a lot of attention to you unless you catch their eye in a good way or a bad way, and they may not learn your name until you have been around awhile. I outlasted her by over a decade, and yes, I remember her name.

Unless someone asks, don’t tell or elaborate on your experience. If they do ask, stick to the facts. If they don’t, show them your experience through your actions. We had a guy come through here a number of years back who boasted of how when he worked in Maryland, they did a shooting every morning before breakfast. If there was a shooting every morning, it was likely his coworkers firing shots at his car to keep him away as he quickly proved to be worthless. You may have some good stories and you may be able to back them up, but my experience has always been the more someone talks, the less they have behind it.

If you work with me, I will ask you about your experience. I don't care if this is your first time in an ambulance or if you have been doing it longer than I have. What you tell me won't make me like you more or less. I just want to know your comfort level and what to expect once we walk on a scene.

I tend to believe people, so when their brash talking doesn’t bear out, it’s worse than if they had never spoken.

Strong and silent works well in EMS when you are new. It works well if you’ve been around twenty years, too.

Now keep this in mind. The seasoned person they put you with may be a jerk. Or they could just be a nice person having a bad day. EMSers are often sleep deprived and many are under stress. You are not the center of their world. You want to get yourself off on the right foot, you need to study who you are assigned to as well as you would study a patient with psychiatric illness. Is it safe to ask this person questions? Am I talking too much? Do they just want to be left alone? You need some interpersonal skills to figure this stuff out.

When I was going through my ride time, I rode with some awesome paramedics and I rode with some real losers, some certified head cases. I rode with a female EMT-I who was a supervisor partnered with a new and very timid paramedic. The EMT-I , not only wouldn’t let me touch the patient, she wouldn’t let the medic touch the patient, and did the medic’s job, including giving medications while the medic sat next to her on the bench. When she wasn't telling the medic what to do, she was bitching to her about her husband. I still feel sorry for that man. I was scheduled to work two more shifts with this pair. I said nothing to either of them, but made certain to take myself off those shifts.

I worked with another medic when I was a student who was wound way too tight. We had been called for a seizure, the medic seeing the patient, shouted "Not you again!" and started swearing at him and basically told him to take-off in expletives. "You'r e not getting another F--ing ride from me!"

I had one chance at an IV that day – I missed it. The madman then knocked me out of the way. He proceeded to sink the IV, then removing the needle from the catheter, stabbed the needle into the bench seat, and then went about taping the line. I was offered no further attempts. Later in the shift the medic got in a shouting match with a supervisor because a doctor had complained he hadn’t c-spined a near-drowning we did. Maybe my trying to hand him a collar on that call had accentuated his reaction because after that he had nothing to say to me. At the end of the shift, I didn’t even bother to give him my evaluation form. I figured I needed at least an additional 12 hours of run time to unlearn what I had seen in those 12 hours.

Don’t let a poisonous person, poison you. Keep your mouth shut, don’t get in their way (unless they are about to kill someone), and see if you can’t tactfully find a way to ride with someone else the next time.

If you are asked to do skills on your first day under someone’s watch, be truthful. Don’t make up a blood pressure. Don’t do something you don’t know how to do or are uncomfortable doing. Don’t be afraid to step aside.

Keep your eyes open, think before you speak. The rule no question is a bad question only applies if you judge the person you are asking the question of to be a balanced and open individual. Never ask a stupid person any question unless you already know the right answer.

And the number one rule for you to follow is: Trash No One.

You might fit in quicker by talking smack along with everyone else, but just because you and another EMT are talking smack about someone else, doesn’t mean the EMT you think is your friend now won’t be talking smack about you as soon as you walk out of the room. Putting someone else down is no way to hold yourself up.

Be above the fray. Act professionally. And you will outlast lessor people.

. 

Jesus Took the Bullet

 The call is for a GSW. The address is familiar. I did another gun shot there many years ago. When we pulled in that night, everyone was running out the doors, while we ran in. The D.J. was on the ground, shot in the chest. He’d spun his last disc.

But this time it’s different. It isn’t night, it’s a Sunday morning, and people aren’t running out, they are standing up singing. It’s isn’t a nightclub anymore, it’s a church.

“He’s shot in the head and he won’t go to the hospital,” a church member tells me, as he leads us through the church and the singing congregation. “He’s up here,” he says pointing to a room off the main church floor.

I am thinking, this I have to see. I am expecting to walk into a horror movie and see a zombie hulk smoking a cigarette with half his head missing and brain and blood covering his shirt.

There is a crowd of concerned churchgoers gathered around the victim, blocking my view. They are all pleading with him to go to the hospital. I have to fight my way through and then I finally see him. He is a young man in his early twenties with a thrift shop Sunday suit and tie, wearing red Chuck Taylors and a New York Yankees baseball cap. In his hands, he clutches a Bible. He doesn’t appear to be shot at all.

“Show the man! Show the medic! He shot smack dab in the head!” a man says.

I ask the victim to remove his hat so I can examine him. There across his forehead is a band-aid with a small amount of blood stain in the middle. I remove the band-aid. There is no bullet hole there, just a lac.

“You’re not shot,” I say.

“Point Blank he shot me,” the young man says.

“You’re not shot.”

“The Lord and I know what I am and what I am not.”

“Why don’t you tell me happened?”

“Early this morning -- around two o clock -- I was walking down this very street. A man approached me from behind, grabbed me, took my cell phone and my money, then he had me get down on my knees and he showed me his gun, and I said please don’t shoot me. He said sorry, but he had too -- he had orders to shoot me. The man held a gun to my head and pulled the trigger…:

“And…

“And Jesus took the bullet! Praise Be!”

“He may have hit you with the gun, but you are not shot. There isn't even a powder burn.”

“Don’t tell me what I know. I prayed to Jesus and said, please don’t let him shoot me. Please! It was two o’clock this morning, right outside this church. Please! I prayed. The man pulled the trigger and then Jesus! Praise Be! – took the bullet! It’s a miracle! I’m a living miracle, testament to our savior, testament to this holy place. That’s why I come to this church today.”

“You got to go to the hospital and let them check you,” a woman in a fine Sunday hat says. “You could still have a bullet in your brain. Let them check you.”

"He told the sister here the story this morning so we had to call you."

“Brother, brother, you gotta go with these paramedics here. They going to take good care of you. We all praying for you, but you gotta be seen.”

“The praying already be done. The Lord protected me and and I’m fine. Jesus already done the checking. They ain’t no bullet in my head anymore. Jesus have that bullet now. Praise Be! This here where I belong right now. This the safe place for me. This is my sanctuary. Praise be! Amen!”

I admit to being at a temporary loss for words.

The cops are here now trying to find out what is going on. I am sure of one thing. No bullet pierced his forehead. I suspect a second thing -- he is likely off his meds.

“And Jesus took the bullet!” he tells the officer.

The officer wants to know what the disposition will be. Am I taking him to the hospital or leaving him here?

“He needs to go to the hospital,” I say.

Finally, with enough convincing, and a comment from one of the deacons about how the Lord always be looking out for him, he agrees to go.

The congregation is singing “Jesus Build a Fence.” As we wheel him back out through the main room, he has a beatific smile on his face, clutching his Bible to his chest.

At triage, the hospital registrar wants to know why the patient is here. “I am tempted to say. “GSW to the head” just to watch the consternation. Instead I say “psych.”

I tell the longer narrative to the triage nurse and she just shakes her head. Meanwhile a resident has listened in on the story. He puts on some gloves and walks over to the man and has him take off his hat and then removes the Band-Aid that I had placed back on his wound.

“Lock-down,” the nurse says to me without waiting for a decision from the doctor.

The patient and I had a conversation on the way over to the hospital in the back of the ambulance.

“I am a lucky man,” he said. “Jesus lives on my street.”

“You are a lucky man,” I say.

“Praise Be.”

But I am not thinking about him. I’m thinking back about the poor DJ who took his last breath in that very building – before Jesus signed the lease.

A Lift

 I worked with one of my old partners last week. Jerry and I used to do the dedicated Hartford car. Jerry is just a few years younger than me, although he doesn’t use Grecian formula like I do so he has had a mane of silver hair for almost as long as I have known him. He is a nice man – always courteous to the patients, no ego of his own, and if he has a complaint, it is a considered one. He is a good solid EMT.

He was only scheduled to work eight hours that morning, but when he saw I didn’t have a partner for my 12-hour gig, he offered to stay four hours later if they would team us together which they did.

I’ve written before that one of the best things about EMS is, provided you have a good partner, the job really is more hanging out than work. Sure, you do calls, but for the most part, you are just out hanging out, shooting the shit, drinking cokes or coffee instead of beers, having some laughs along the way.

We only did one call worth writing about, but it was a good day, and I hope we’ll get to work together again soon. There is some talk about rebidding the shifts, and if it ever worked out that we could be regular partners doing 3 – 12s together that would be awesome.

The one call we did that I am going to write about was for a woman with a swollen foot. We pulled into the address and Jerry said, “I’m getting a bad feeling about this. I think this might be a bariatric call.”

Now it was around four in the afternoon and the city was going nuts. There were no other cars available and our bariatric truck – a specially designed car with a wide power stretcher capable of handling the biggest patients -- was already out on a call.

“Maybe we’ll get lucky,” I said.

At least there was a ramp up to the porch, but that also seemed to suggest that maybe Jerry was right. We walked in the door and there she was, sitting in her extra-large wheelchair.

There is always that moment on a call when you are walking into a house – and when I walk into a house, I am always thinking about how I am going to get a patient out even before I see them – when you realize this is going to be a lift. You are going to have to work for this one. This was the case.

Now just a few days before, working with another partner, we had opened an apartment door to see quite a large man sitting in his extra-large wheel chair, and while we were able to get him to stand and pivot onto our stretcher, we still had to get the stretcher from the low position to the high position. He was big, and worse, he was retaining water, and people who are retaining water are always heavier than they look. Back in the suburbs, we had stretchers with the power lift buttons so for the last three years, instead of getting in my dead lift stance and proving my strength, I just pushed a button or my partner pushed a button while I did the magician’s levitate command, slowly moving my hand up into the air in time with the stretcher. Shazam! No more. I bent my knees, got a good grip on the rail at the stretcher’s head and then on go, tried to drive my legs up, but the stretcher wasn’t going up. My partner offered to switch sides, but vain as always, I said, give me a second and we’ll try again. This time I stretched before hand, and then let out a Gold’s Gym grunt as I drove my legs up. But again, the stretcher wasn’t going up and this time, I started to feel the start of a tear in my pectoral muscles, so I said uncle, and we stopped. We switched sides and got a bystander to help with the head end and only then got the patient up all the way. The man said he was 370. He may have been more. I know in the past my partners and I have done 400 pounders without assistance. Still, it made me think about getting back into the gym, not just to swim, bike and run, which is what I have been doing, but to lift steel. Pump those muscles up to beat back Father Time.

So anyway, back to Jerry and me, and our extra-large lady. Jerry, who I said, does not share my ego, was already on his cell phone to dispatch asking for an assist, only to be told, it would be awhile.

“Please,” the woman said, “You don’t need to call for help. I know I look big, but you two big strong man – I ain’t that big – I lost twenty pounds this month. I don’t need that fat bus no more. You can do it, I know you can. Look at those muscles you got. Please, I know I’m big, but I’m losing weight. You don’t need that fat bus or that big stretcher for me.”

I looked at Jerry, and he looked at me. This was no medical emergency. The woman’s foot had been swollen for a week. We could sit there for an hour and wait for a lift assist, or…

“One try,” I said.

Jerry shook his head – not to say no, but to acknowledge he understood I didn’t want to be beat by this.

“Okay,” he said.

We did some stretches first. “Excuse us,” I told the woman. “We’re on the old side here and need a little prelift warmup.”

“You not old, you two fine young men in your prime, big and strong, but you go on warm up, just so you don’t have to call the fat bus for me.”

So we stretched and limbered up and loosened, and then we took our positions. Knees bent. One two three.

“I knew you strong!” she exclaimed delighted as we lifted her up. “I told you I lost that weight. I don’t need no special stretcher for me.”

“Light as a ballerina!” I said.

The patient and I slapped a high five.

Jerry just laughed to himself, and shook his head.

“We don’t need no lift assist,” I said.

“That’s right!” she said. “You two fine strong men.”

“We’re not too old,” I said to Jerry later.

Again, he just shook his head.

Change

 They wrote everyone up for not doing the new ambulance maintenance checklist. A couple weeks ago, they started handing out the checklist. Lights, motor oil, mileage, cleanliness, tire pressure. Scratches, dents. You name it, it is on there. I did it the first couple days and then stopped doing it because they stopped passing it around and it seemed like no one else was doing it.

But the write up caught my attention. I had no problem signing my bad. I could have argued for the specifics – what day and shift did I not turn one in, but the point was I hadn’t paid much attention to it, and the company was now saying it is important enough that we will write you and everyone else up. So I’m doing the automotive checklist now – or if not me, my partner is doing it.

I think as a rule, we are resistant to change in routine. I can think of a number of changes over the years that we fought against, but now are routine. They instituted a policy back several years ago about coming to a complete stop at all intersections. Most of us thought that was stupid. It’s common practice now. Makes sense, too. I’ll all for safety and safe driving. Backing up your partner. Stupid, we thought. People do it now. Locking the ambulance when you leave it unattended. Becoming more common now. Using not just two stretcher straps, and not just three straps, but three straps with a shoulder harness. Seems like everyone does it. Again safety.

Signatures on paperwork. Many years ago, they used to hardly ever enforce it. That's key, you don't enforce something, you are telling me it is not important, and I may be less likely to comply if I am not in full agreement with it. I do remember one time they did enforce the signature rule, but it was an odd one. I was working with my old partner Arthur and they kicked back a run form to us for not getting the patient signature. It had been a cardiac arrest. Faced with the blank signature, Arthur took out his pen and wrote “PATIENT DEAD” in big letters. “That ought to take care of it,” he said.

Now with the electronic PCRs, you can’t advance the chart unless you get a signature, but there is a place to write Patient unable to sign due to (fill in reason). And you can write PATIENT DEAD there if you want.

The older I get the easier it becomes to just do what they want you to do. I'm happy to have a job and the company's checks have always been good at the bank. And besides, as much as I may not like changes to my routine, there is usually a good reason behind it.

The Grand Tour

 You drive the streets of the city or towns where you work and you go by houses, intersections, businesses where you have done calls. The longer you are at it, the more memory pins are dropped on your street map.

Over here on our left was the great lumber yard fire. I sat on that standby for 11 hours. The first hour was fascinating, watching the spectacular flames jump and burn as fire companies from all over the region tried to douse it. But after a couple hours, I was bored. I was a new medic then and wanted to be doing calls, wanted to be in the action.

On the right is the Laundromat where we pick up the drunks, and do more than a fair share of seizures. Rest in peace, Eli, Papa Santo, Ronnie Ray, Annie Moore, and others whose names I have forgotten. I did a pedestrian struck up ahead here. I saw the entire thing happen, car hit the young man threw him straight up onto the windshield. I was on the radio when it happened. “471, we’re clear ref…Holy Shit!” Apologies to the FCC.

See the apartments back down behind the barber shop. I’ve done lots of calls in there, old people not feeling well mostly. There used to be a four hundred pounder up on the second floor who’d get back pain and couldn’t get out of bed. A BLS crew called us for a lift assist the first time I went there. I gave him 15 of morphine (in three doses of 5). Instead of us having to lift him and carry him down the stairs, he was able to stand and walk down to the ambulance. Worked every time after that. Out in the parking lot, I did a code -- man behind the wheel still as death with an inhaler in his hand.

Let’s turn down this street up ahead. See that house – crack house, did lots of ODs in there. Gave narcan to some heroin ODs. Ran a strip and called the time on some others. Also did a major trauma out front. Guy jumped out of the window after being chased by the police. Landed on his face. He was seizing when we got there. Severe head injury with multiple fractures. We were in the trauma room in four minutes.

Over there we did a minor MVA. An insurance adjuster rear ended another car. By the time we got there seven people were either laying on the ground or walking around holding their backs all claiming to be hurt with more joining them. Only one of them had been in the car at the time of the accident. “I’m going to the hospital and I’m going to get paid,” a toothless woman cried. “Com’on Jimmy, Let’s go the hospital. We’re all going to get paid!”

Store on the corner, the grocer got shot. He was laying on the ground on his back, moving his arms, a snow angel blood print surrounding him. Behind him were several avacodos that had exploded, spreading guacamole on the shelves. That house there, I pulled up as the fire department was coming out of the house, two firefighters carrying a lifeless child. It was my second pedicode in a week. We didn’t have the EZ-IO then. After I tubed the child, I used a bone needle, screwing it into the leg, but the needle bent and I couldn’t get it out. I’m tugging and pulling and its stuck. I finally got it out just as we got to the ED. They worked the kid another thirty minutes, but he was asystole the entire time. Turns out he was a special needs kid and his death wasn’t unexpected. Still the family took it hard. The mother was beside herself. I was haunted by her primal wail.

Mrs. Jonesbury used to live on the first floor apartment of that house. She’d call in the middle of the night. Big heavy woman with swollen extremities, too weak to get off the toilet. We’d come in and wipe the shit off her legs and help her back into bed. Sometimes we’d bring in clean hospital sheets and change her bed for her. I wasn’t on the day they found her dead, and ran the six second strip. I would have liked to have been there for her, to say a couple of words beyond just calling out the time of presumption.

I have stories for almost every street on the city map. I can tell you about the poorest streets and I can tell you about the mansions on Scarborough and Prospect Streets, (the banker’s wife cutting her wrists sideways and laying in the bathtub waiting for us to come), the office suites up in city place where a man with a view looking out over all the city, crying that he might be dying, and wanting his attractive secretary to call his wife and her seeming upset by that, the man testifying before the legislature whose internal defibrillator kept going off every time he tried to answer a question, or the cook passed out on the grease caked floor of one of the city’s five-star restaurants, while the orders kept going out all around us.

This city like all cities has its stories. You could tour the historic homes, the insurance companies, the old state house, the parks, the art museum, the riverfront, and learn about Mark Twain and Harriet Beecher Stowe and Samuel Colt and other historical figures from the city’s past, or you could ride with me* on the medic’s grand tour.

“Step right up
Come on in…
There are things I could tell you,
Some things I know will chill you to the bone.”-The Grand Tour
George Jones

* Or any medic that has been here more than a couple years.

City Life

 Two months back in the city and I have already given more Narcan and Haldol than in the last two years in the suburbs.

I like the morning routine of punching in, getting the narc keys and computer, grabbing the ALS gear, checking it out fully, and then walking out to the ambulance and going through the vehicle. I have a different partner every day except Fridays, and I’m in a different ambulance each of my three work day, but I am easy about that. I have never bee particular about ambulances and I like all the partners I’ve had.

I’m over my anxiety of the new computer software and actually think it is a decent program.

I still know the streets, but I forgot how steep the stairs were in some of the city buildings.

Carry downs and carry ups, my arms are definitely more toned than when I was using the tractor stair chairs and the power stretcher, although we do have some of the tread stair chairs and rumor is we are getting the power stretchers in the city.

Today, at the hospital, I put my stretcher in the back of my old suburban ambulance by mistake.

Posting on street corners, and thus unable to ride my bike around the ambulance headquarters for exercise, I have entered my own pushup challenge. Putting my hands on a bath blanket to avoid rocks, glass shards and other nasties, I try to do 300 pushups a shift in groups of 100. I don’t do 100 in a row. I might do 30-20-30-20 over five minutes. The most I have done in a row is 61, but from 50-61 I was cheating, counting small bends at the elbow as full pushups. My dream is to one day do 100 in a row – 100 no cheating pushups. I’ve got a 150 done today with six hours to go in the shift.

“This is why my boots never go home.” A cop said this to me on our last call.

“I hear you,” I said.

GI bleed for three weeks, didn’t feel like going to the hospital. No one to check on him, until another boarder complained of the smell.

Doing lots of psychs, ODs and assaults.

I was worried I wouldn’t get as many opportunities to help people in pain as in the suburbs, but pain is pretty universal. Hip fractures, pancreatitis, burns. But here is who I didn’t medicate:

43-year old man with chronic back pain who claims he was mugged the day before and the thief stole his oxy.

22-year old female from the lockup with undifferentiated abd pain and a discharge diagnosis from the evening before for pelvic inflammatory disease.

37-year old man with arm pain and ETOH on his breath who says he was hit by a car three days ago and got tired walking to the hospital so he sat down on the side of the road and had someone call an ambulance for him.

I been eating a lot of pizza slices. Pizza slices are the best EMS food – hot, ready for pickup, reasonably priced. Available all over town and every place has their own unique style. Shout-outs to Lena’s First and last and Stretch’s.

Still eating the Spanish and Jamaican food. The other day, I ordered some Fish soup which comes in a Styrofoam coffee cup. I walked back out to the ambulance, opened the passenger door, and standing outside, I took the lid off and took a sip. I don’t know if you have ever seen the show 10,000 Ways to Die, but picture this as an episode. Medic sips fish soup – secret Jamaican spice, likely Scotch Bonnet Pepper is sucked into medic’s windpipe, causing immediate larengyospasm. Medic takes five big deep inhalations that bring no air in. My partner was reaching for the mike to call for another medic when I finally got some air in. 10,000 Ways to Die will have to wait.

Time for more pushups, but before I get halfway out the passenger door, its time for another assault.

Last Supper

85-year-old drives his Plymouth to the diner out by the highway every night at seven where he eats his dinner, then walks back out the door and gets in his car to head home.

I stand by the open driver’s door and look at the man, who stares at me vacantly. His skin is cool and diaphoretic. “We may have a diabetic,” I say to my partner.

“He’s not a diabetic,” the waitress says. She stands by the front bumper smoking a cigarette. “Jolene, you ever hear him talk about being a diabetic?”

“No,” the other waitress says. “I’m a diabetic and he never said a thing to me about it. Besides, he just ate.”

“Good point,” I say, “Thanks.” To my partner, I say, “Let’s get him on the stretcher.”

We lift him out and set him down. While we strap him in, I ask the waitress if she noticed anything unusual about him tonight.

“He ate diner here like he does every night, steak, eggs and toast. He was his normal self, polite, small talk. He walked out to the car, and then we noticed he was still out here, so we come out to see if he was okay. He was just sitting there not responding to us so we called you.”

“So 15 minutes ago he was last seen at his norm?”

“That’s right.”

On the way to the hospital, I check his sugar (it’s part of our protocol) and of course it is fine. His right side is now flaccid. I call in a stroke alert and do my best to manage his airway when he throws up his dinner.

Later the doctor shows me the Cat Scan. It is not subtle. You can see the huge white lake on one side of the brain. The ED has a hard time finding out if the man has any family. They do reach his personal physician who relates the man has been estranged from his children for many years. Finally a message is left with a son in California.

After work, I think about heading out to the diner to let the waitresses there know how he is doing. I go home instead and sit down in the living room with a beer and close my eyes and let my head fill with the sounds of my family about me. 

The Heart of Health Care

Last week, as I stood in an ED room for the first time in many years getting ready to take a patient out instead of bringing a patient in, the nurse walked in to say goodbye to the elderly patient as we spread out a clean white sheet on our stretcher.

The nurse said, "Well, good luck Mr. Jones. I hope you are feeling better."

"Thank you, Joe," the old man said to the nurse. "You were very nice to me. You have a comforting bedside manner. You are a good guy, and I appreciate it."

You have these moments in life. Sometimes you see something for the first time. Other times you are just reminded of basic truths. This was such a moment for me when you see the world very clearly.

I spoke up then, and said to the nurse. "What a high compliment he just gave you. You should be very proud of that."

The nurse blushed and lowered his eyes and said, "Thank you, most people think I tell bad jokes."

***

So we put the man on our stretcher, fluffed his pillow and wrapped him against the cold, and we drove him through the city streets to the highway, where we headed north to his town. When we found his small house on a quiet residential street, we backed into the drive, and then went and got the door open and ready before we took him out of the back, where the heat was keeping him warm. We carried him into the house on our stretcher and then went out and got the stair chair and carried him up the stairs to his bedroom, where his wife of fifty-three years was preparing his room. "This beautiful woman can't possibly be your wife," I said, "Unless of course you are a lucky man, which I now see you are." The wife smiled broadly and the man laughed and they looked at each other in the way people do who have spent their lives together through good and bad, and know they have never lost their faith or their sense of humor. We got him settled into bed and and we joked some more and exchanged well wishes with them. And then the man and his wife thanked us again for helping them.

And my partner and I left and drove back to the city.

***

I mentioned in my last post I am reading this book called Outliers: The Road to Success. The book examines the lives of people like Bill Gates, and professional hockey players, concert violinists, top Wall Street lawyers and children from disadvantaged neighborhoods who have gone on to be the first member of their family to go to college and others who have risen to the top of their fields. The one overriding theme in all of their lives is that effort equals reward. People who are most satisfied with their work and lives are those in fields where they can see the result of their labor.

What I like about EMS and health care is that if you view the work not as about saving lives, but as about treating people well, then on a day to day basis, your effort will be rewarded. And the reward is more than a check that is good at the bank at the end of the week, it is the simple feeling about being happy with your life's work -- taking care of people. This is not a thankless job. The people who matter -- our patients (most of them anyway) -- appreciate what we do. And of course, we get to tell bad jokes. 

Part One:

Picture this: One of those walk bridges over a canyon. You know the kind that sways when you walk on it, and has missing boards, and all you can hold on to is the fraying rope, and you are suspended 1000 feet up over rocks and a raging river. Well, it wasn’t quite like that, but if I tell the story enough that’s where it will end up.

Let me begin. Picture this. It is a nasty winter day. You are at work at your EMS job. You’re sitting back in your warm recliner, feet propped up, eating a hot meatball sub, watching Die Hard on the wide screen TV as the sleet clatters off the windows. One partner is snoring, the other is laughing manically as he texts on his Blackberry.

Got it.

Now picture this. A man arrives at the home he shares with his brother who he last saw this morning. The man does not have his key, so he knocks on the door, but no one comes, so he walks around the house through the deep snow peering in the windows. In the living room, he sees the TV on – Die Hard perhaps -- and he sees his brother sitting in his chair. His head is slumped down. The brother knocks hard on the window, but his brother does not respond. He is dead motionless. The brother in the snow shouts and bangs again and again. No response. He takes out his cell phone and dials 911.

With me still? Nothing really unusual here. You could change the scenario to any potentially serious 911 call. A car off the road. A man down in the snow. A baby not breathing. And as for the responders, you could change that up to. Maybe instead of the big screen TV, it is a scratchy old set dug out of the trash with tin foil on the antenna. Maybe instead of Die Hard, it is American Pie. Pizza instead of a meatball grinder. Maybe the crew is sitting in an ambulance on a street corner watching the movie on a portable DVD or an I-phone. One partner – snoring or texting – instead of two.

Nothing unusual here. Either way -- the tones go off, they call your number over the radio or your pager vibrates. One way or another, you get up – leaving John McClain to fend for himself – and soon your sirens are wailing and you are on your way to another run.

Now you have been lucky so far during this storm. All your calls have been at nursing homes or doctor’s offices and all the hospitals you have transported to have had covered awnings. You have barely gotten your boots wet. But you know this won't last.

The address is in the mountains. You partner thinks he has been there before. Thinks it is a regular, but the address does not seem familiar. You know the road, but the street number doesn’t recall anything. The CMED dispatcher has no information for you. You wait to hear if the cops are out, but nothing comes over the radio. A part of you is expecting to hear them put out and a minute later (after they have kicked in the door) hear “CPR in progress,” but nothing.

When you get on the road, you see the cops patrolling looking for the number. One cop turns around realizing he has just passed it. “I guess I haven’t been here before,” your partner says. The driveway you discover is barely visible. It is likely a dirt road, but who can tell with all the snow. There is brush on either side of the road, barely passable for a police car. No way for the ambulance.

You get out and walk. No house in sight. The road is like an ice rink that hasn’t been cleaned by a Zamboni. It’s a good thing you are wearing your Fort Smith Boots in this sleet storm because the water and freezing slush and ice are treacherous. You walk carefully. The last thing you need is for you or your partner to go feet up in the air, head and butt slamming to the ground. Talk about a call from frozen over hell. Over the radio you hear one of the officers say he will come back and get you, but no car appears. You hear now his cruiser is stuck. Still no word from the other officer who is surely trying to gain access to the house that likely holds a cardiac arrest to test you and your crew's mettle. You start to think about how once you get there -- if you get there -- you are going to get the patient out. You picture your crew doing CPR in the sleet all the way back to the ambulance here on this wild frozen trail in this first episode of a new reality TV show "Ice Road Paramedics."

Finally at the end of a bend, the road drops down a hill where you see the two cruisers. There is a small turn-around but the road is sheer ice. You consider throwing your house bag down and using it as a sled to get down the hill, but you are worried that you will not be able to stop, only to shoot off the end of the land and into the raging rapids in the gorge below. That's right -- icy, churning rapids. The house which you now see is on the other side of the raging river (I am exaggerating slightly -- it is more a raging mountain stream).

You make your way down through the snow on the side of the road. It is there that you first see the bridge -- a ricketedy wooden foot bridge -- thirty feet above that insane niagrous Artic megastream. You can’t believe what you have discovered. You think you know your town, but you have never been here before, never knew this place existed. The house is in fact on an island, completely surrounded by moving water.

And on the other side, a man inside a still locked house, slumped down in his chair. You can make out now the shape of a police man standing by the front door, raising a crow bar and smashing it against the door that will not open. Bang, Bang Bang!

And now you must make the crossing... 

So there I was (ala Commander McBragg) thirty feet about the frigid raging waters, having traversed an icy treacherous roadway on foot. My MediC Stat pack on my back, my hands out holding the sides of the narrow wooden foot bridge for balance, trying not to look down at certain death below (should the rickety boards below me give out). And ahead of me, the house on that rock island, the house surrounded by deep snow drifts, the house whose front door was being pummeled by an axe-swinging (again I exaggerate -- crow bar banging) police officer, and somewhere inside slumped in a chair is what I believe to be a dead or dying man.

I think -- if he is departed and beyond resucitation, let him be cold and stiff by a warm fire. Let there be no grey in the decision to work or not to work his body. And while I am praying, please don't let me slip and fall -- I am already halfway across -- please I do not wish to plummet to my icy death or to land on the jagged rocks at the river's edge. If the bridge is to give out, let it break first at the far side and go one board at a time like in the cartoons and let me run fast, one board ahead of disaster. Please no Wyle Coyote falls for me.

One by one we -- my crew -- make it across, and then step through the deep snow to the doorway, where the door, deadbolted has still not given way, despite the Paul Bunyonesque slams of the officer's mighty crow bar (He was actually prying, banging in the appropriate manner). I ask the quiet and worried brother standing with us when he last saw his older brother, who he tells me is in his 80's. He last saw him at sunrise, many hours ago now. He is dead, I am convinced of it, but I say nothing, just nodd.

The officer runs at the door now with his shoulder, and light from inside now shines through. Another ram and a kick and the door is open and we dash in. Through the foyer, and through the kitchen, down a hall, and through a dining room we go. Ahead I see the living room and hear the TV, now in sight -- Let's Make a Deal is on. I see the man now -- his back is to me -- slumped in his chair. I simultaneously see a grey pale face and a large hearing aide behind his left ear. The officer shouts as I reach for the man expecting another icy surface.

The dead man raises his head. "Oh, good day," he says with a smile.

***

Not the first time that has happened.

***

A hour later after much time in the snow and ice helping free trapped vehicles and get them up the hill, and then making that long ice road journey back to our ambulance parked on the road, we are again in our warm quarters. I -- in the recliner -- hold the TV remote. Click, click, click and we are back to Die Hard which seems to always be on one channel or another.

Memory

 The man has dementia to the point he forgets that he called us. He forgets that he went to the hospital yesterday for the same complaint, forgets that they saw him and sent him home, forgets what they told him about it. “You were the one who called them,” his wife says, after he demands to know why we are in his bedroom.

He looks confused, but doesn’t deny that he might have called. It is as if he has some recollection of it, and is not certain enough to swear he didn’t.

“Is there anything wrong?” I ask.

“Me got pain here,” and he points below his belly button, same as yesterday. “Bothering me all night,” he says.

The house is disorderly. Yesterday I made the decision to put the man in a wheel chair and wheel him out to the breezeway where we had the stretcher set up. That way we didn't have to move furniture and could maneuver well enough through the obstacles.

And so yesterday I wheeled him right to the door, leaving space to open it. I set the brake, opened the door and stepped into the breezeway. My plan was to help him step down, and then I could pivot him onto the stretcher. But before I could react, he felt the cold blast of air, and tried to kick the door shut. "COOOOLD!" he shouted. "YA trying to FREEEZE Me! Get out of Me House! Get out of Me House Now!"

And so ensued a struggle to keep him from locking us out while we braced the door against his kicks and negotiated to get back in the house and the whole time he was yelling at us like we were bandits come to rob him and then leave him out in the cold.

Today I say to my different partner, I want the stretcher brought into the bedroom. He looks at me like I am crazy. I acknowledge that we will have to move some furniture to get the stretcher in to the bedroom, but that is what we will need to do.

Memory.

The furniture moved, the patient wrapped tightly with thick blankets and our trademark towell around his head like a babushka, we carry out though the porch and then outside across the snow to our ambulance.

"Cold out," he says rather calmly.

Old Paramedics

 I have been getting in and out of ambulances for over 20 years now. That means just what it does. Twenty years ago my knees and back and all my bones and joints were twenty years younger than they are today. I’m in good shape, but still, I find now when I get out of the back of the ambulance when we arrive at the hospital my partners tend to offer me their hand to help me down. I ignore their help of course, but I do admit I’m not jumping down as spryly as I used to.

I read this article -- As Doctors Age, Worries About Their Ability Grow in the New York Times this week and it made me think for a moment in the same way I think for a moment when I read the “Will you have enough Money for Retirement?” articles. I think I can put worrying about this off for awhile longer, but I sense that someday these articles will be my front page stories. Just not yet.

The physical deterioration of these years is slow, but undeniable. When I went to nursing school a couple years ago, I found I had to buy a pair of reading glasses so I could see the fine markings on the insulin syringe so I could draw up just the exact amount before handing it to my examiner to verify. On calls now, sometimes I squint to see the tiny vein I am trying to thread a 24 into in. A month or so go when I intubated a patient, I, for a moment saw two sets of vocal chords side by side. During cardiac arrests now I have learned not to relay on my view of the monitor beyond two arms length. What may look like asystole, if examined may actually be a defined rhythm with low voltage. I make it a practice now to print or have the strip printed out and handed to me so I can verify it.

When it comes to hearing, I have always been annoyed with patients who don’t speak up when I ask them questions, but lately I have found myself saying “Huh?" and “What?” more often than before, and finally asking them to please speak up blaming my difficulty hearing on the noise of the engine.

I used to love breaking into locked homes to rescue patients unable to get to their doors to let us in,. I'd divehead first into windows (while getting a boost from my partner) or climb up onto roofs to access second story bedrooms. Now, just as with carrying our heavier equipment, I sometimes defer to stronger more agile partners or responders on scene.

A few times I have seen a tremble in my hand and asked, is this the first hint of a condition that will change my life or am I merely suffering from lack of sleep or caffeine withdrawal? (A reassurance, I just checked both hands, and today as I sit in front of the computer, each hand is as steady as a gunfighter’s, although quite lacking the gunfighter’s speed).

One of my partners is ten years older than I am. Sometimes his slow deliberate way is frustrating to me. His scene clock is slower than mine, but then when I work with younger people, I sense they may feel the same about my pace. I like to think that I move quickly when I have to, but as in a game of softball, I no longer have the reflexes to snare a blazing line drive in the infield.

A few years back I came on the scene of a rollover, a car on its side with a women still in there, although with only minor injuries. While I pondered what to do, considering the best approach, another medic arrived on the scene, and was in the car before I could even say “good day” to him.

I like to think my approach was mature, deliberate and proper, but I do wonder if someday it will tick past the mature deliberate safe response and into the doddering greys of early dementia.

My hearing is not so bad that I can’t at a distance hear the tick tick tick of the finite clock that beats for all of us.

Paramedics and EMTs

 Back in 1995 when I started working fulltime as a paramedic in the city, paramedics got to choose their own partners. This was great for the paramedics and could also be great for the EMT partners. You worked three twelve hour shifts together and you always knew what to expect. You picked someone you were compatible with, liked and could work together without too many issues. Partners rarely called in sick or booked off for fear of leaving their partner with someone they couldn’t stand. On a bad call, your partner was right there. You were going to tube someone. You reached back and your partner laid the right size tube in your hand. You had each other's back. You took care of each other.

While my first partner was assigned to me because I was new and medical control felt I needed a strong partner and an IV tech, once he moved on, I was free to choose my next partner. I remember then I was approached by another medic who offered me his partner. They had worked together a long time and had finally come to a place where they needed a change. The medic wanted his partner taken care of so he sought me out. That was how I originally became partners with Arthur, who I have written about extensively. The other medic and I shook on the deal and I gave him a Snickers bar in ceremonial payment. Years later when I moved on to another shift, I found Arthur his next partner. My payment in return was a mini Snickers bar. Arthur was upset that he had apparently lost value. I took the rap. I'm sorry, I said, I wore you out. Your the worse for the wear and tear. At least he kept a decent shift and a paramedic partner and didn't have to hump transfers all day.

The drawback to having paramedics choose their partners was the issue of seniority for the EMTs. A medic might pick a new hire for their primo shift while a ten-year EMT might be stuck working a lousy shift. As the EMTs gained power in the union and with the service takeover by a new company, things changed. A six month bidding system was put into place. Not only did you have to rebid for your shift every six months, but you were assigned with whatever EMT won the bid for the EMT half of the shift. Needless to say, there were some mismatched pairings.

A couple years after that, I was lucky enough to gain a position in a contract town. While I still worked multiple overtime days in the city, I could pick and choose my overtime shifts to work with partners I liked. Working with someone you like wasn’t like working at all, it was getting paid to hang out. Spending a day with a disliked partner sometimes wasn’t worth the wages you were paid.

Being in the suburbs working with volunteer partners now poses its own challenges. Instead of one partner who knows your routine, you can work with multiple partners in the course of a day, much less a week. I come in at six AM and have one set of partners. At eight I might get a new partner or two, and then again at one. On my sixteen hour days, a new set of partners would also come in at six in the evening.

This can be a problem when I leave the ambulance in one condition after a call, and then on the next call find my new partner has rearranged things. The BP cuff is no longer on the bench where I like it, but zippered up into a BP cuff case and placed in a cabinet out of reach. The worst is the oxygen. I leave the portable oxygen open. A new partner comes in, checks the oxygen and then shuts it off, but doesn't bleed it down. We get a patient, I put them on a cannula, and it is not until we get to the hospital when I disconnect the cannula do I realize the tank had been turned off.

But really, it isn’t so bad. In practice, I often have one partner for ten of the twelve hours, and since I have been out here for over ten years now, I have gotten used to most of my partners and they have gotten used to me. Some of the partners I have out here I have worked on and off with the entire time I have been out here. Thus more often than not, we are in sync.

I think it is more difficult for the EMTs to get used to the four different medics who work with them. All the medics like their stretchers put together differently. We all put electrodes in a different spot. We all have our own ways of working a call. Unless a patient needs immediate treatment, I prefer to get them out to the ambulance and on to the hospital, doing everything on the way. Some medics let their partners jump all over the patient taking vitals, asking history questions. Me, I prefer to be the one who asks the questions. I can’t stand it when a partner walks over me when I am interviewing the patient.

I pretty much insist on doing calls my way. I have been doing this for over twenty years now and have become fairly set in my style. Sometimes I will ask a partner for advice or a better idea on logistical issues, but for the most part I am comfortable with my own solutions.

Working as a single medic, I am always in charge. The calls are mine unless I turn them over to my partner to BLS it. Once I do, they are free to do the call the way they want. That said, I often will do the BLS call myself instead of turning it over depending on the patient’s issue and the partner I am working with. Some of my partners prefer to always drive, so when working with them, I tech all calls all the time, ALS and BLS.

Years ago, I saw a very funny cartoon which showed how people in EMS viewed each other. I don’t remember the whole cartoon, I just remembered how the EMT viewed the paramedic. The paramedic was drawn as Darth Vader.

I like to think I am benevolent. I rarely ever raise my voice or express displeasure. And when it comes to driving, I let my partner handle that. Unless they are driving like a mad person or unless they ask for directions, they control that aspect. I know some medics not only run the calls, but also do all the driving to the calls and from the hospitals back to town. The only time they don’t drive in when they are teching an ALS call.

This all is not to say that medics can’t learn a lot from their partners. A new medic particularly would be wise to listen to a more road experienced partner. The saying "Paramedics save patients, EMTs save paramedics" has a great deal of truth to it. A partner who knows what they are doing and what is expected of them can make or break a call for you. Even today, sometimes a partner will point something out to me I might have missed, and I am grateful for that.

A medic needs to know what their partner is capable of and plan accordingly. If you don’t think you can trust your partner’s blood pressure reading, then don’t trust it. Only assign them do what you know they are capable of. You can have them do anything, but you need to verify anything you are uncertain about. If a call goes bad, the medic has to take the rap. Publicly blaming a partner is not an excuse.