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.

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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.