Pediatric Cardiac Arrest

 

I just watched a fantastic and very thoughtful lecture of pediatric cardiac arrest given by Dr. Peter Antevy as part of the Refresh2021 free national registry program, which I encourage everyone in EMS to sign up for.

Register for Refresh 2021

 When I precepted as a paramedic in 1995, my preceptor told me when we had a baby code that we should “OJ Simpson” it.  This was in reference to the old OJ Simpson Hertz commercials where the former football star and future killer ran through the airport, leaping benches and cutting through the crowds like he was on a 100 yard touchdown run.  The point was, waste no time, get moving-- that way we don’t have to deal with everyone freaking out at the scene, and we can get the baby to the hospital and do what we can on the way. 

My first baby code I intercepted with a basic ambulance crew.  No sooner did I climb into the back of the ambulance, then the driver hit the gas and I went flying.  When I recovered myself, I saw his partner and a police officer doing CPR on an infant.  I managed to get the pedi pads on the infant and stop CPR long enough to see the baby was flatline on the monitor.  By the time I got my intubation kit out we were already at the hospital.   I had done nothing to help.  I hadn’t even had time to get much of the story other than the baby  was found not breathing in his crib.  The BLS crew took off so fast, they even left the family at the scene.  They didn’t even have the kid’s name.  Later I was congratulated for not delaying the transport.  You had a one minute intercept time.  That’s awesome.  It didn’t make me feel any better.  If time was what mattered, they shouldn’t have even stopped for me.  I hadn’t done anything to save the baby and that was true.  I hadn’t.

Still I held to the OJ Simpson mantra even sharing it with new paramedics I precepted.  We get a dead baby, I told them, snatch it and make feet to the ambulance.  Intubate or try to in the back of the ambulance hurtling through traffic with lights and sirens blazing.  In the old days before EZ-IOs we had the Jamshidi bone needle which he had to twist into the baby’s legs while holding it down.  Not the easiest thing to do when you are airborne.

Now it is true in many of these cases, the patients were already dead.  Many times I have run down stairwells holding a dead baby stiff as a doll in my hands and giving mouth to mouth to its cold lips, running from the screams in the apartment.  In other cases they were still warm, and I moved my fingers up and down on the chest in between breaths as I walked carefully down to the ambulance, and then the race was on again.

It is important to understand the chaos on many of those baby code scenes.  People are screaming and out of their minds.  I remember vividly one of the first ones I did.  A mother had rolled over her baby while they slept together and suffocated her.  The baby was dead, but everyone was screaming at me.  The firefighters were screaming at me.  What the hell took me so long to get there!  Do something! Get moving!  And the crowds -- it seemed nearly everyone who lived in the housing complex was screaming at me.  “Move, W-Boy!  That baby’s dead!  Do something!  Move!  I OJed it to the ambulance.  Even after we shut the doors, they banged on the ambulance until we peeled out.

Recently I had a baby in arrest, but this time I elected to stay on scene.  It just seemed like the right thing to do.  We cleared off space on the top of a dresser and laid the baby down.  We managed the airway, and epi through an IO.  We worked the child for at least twenty minutes with no luck --still asystole-- before we finally decided to make our way to the hospital.  I felt terrible leaving like we had given up, even though I knew the baby was dead.

I have had very poor luck with pediatric resuscitations.  I don’t know anyone who has.  There are many reasons for this.  Many of the children were already gone, others had died from congenital defects.  I guess also, I was always taught that pedis once they arrest, they are nearly impossible to bring back.

I have been complimented on my calm at many pedi-codes but that calm came largely from knowing the baby had either died or had little hope of recovery.  We were just going through the motions.  I never thought for a moment the babies would come back.  I had never seen it happen.

Dr. Antevy, in his lecture, advocates that we treat pedis in arrest, not like pedis, but like little adults. (The dogma for years has been pedis are not little adults and need to be treated differently).  Not in this case, Antevy says. They deserve the same stay and play attention.  Work them on sight until you get ROSC or until you have exhausted every hope.  Explain to the family why you are not running off to the hospital, that you are making your stand there.  Use pit crew CPR.  Know your pediatric dosing in advance, so you don’t have to lay them on a Braslow tape and do your calculations.  Get epi in early.  

A number of years ago when we adopted the stay and play for adult resuscitation, I started having people come back who I had never expected to make it.  Good CPR, defibrillation.  Early epi at least if you want pulses back.  Kids deserve the same chances, not just in the ED, but in the field.  Stay on scene.  Defend your ground.  Take a stand.

Antevy also advocates improving local dispatching to help them be quicker in giving CPR instructions to 911 callers.  His lecture concludes with an excellent section on bereavement, making certain you talk to the family at the hospital, explain what you did and why, let them know you care.   Administrators should follow up with the family, even in unsuccessful cases, offering to attend the funeral and send memory cards on birthdays.  

I am great at explanations on adult scenes.  I let the family watch the codes.  I narrate what we are doing and explain everything.  If we get pulses back, I let them kiss the patient before we go.  And in those cases where we finally decide to stop if we are unsuccessful, I let the family members hold the patient’s hand and say their goodbyes before we stop. Afterwards I stay on scene awhile and make certain they are okay.  But with pedi codes, I leave the grief counseling to the hospital and make myself a ghost.  Never again. 

Thank you, Dr. Antevy, for the fine lecture.  I can’t say I look forward to practicing the lessons, but if my number is called to respond, I will do my best to demonstrate what I have learned.  I only wish I had learned those lessons thirty years and too many resuscitations ago.

COVID Transfers

 

If you work in commercial EMS, you are also likely to do what we call transfers.  These are non-emergency calls where you take a patient to a destination that is not the emergency department.  This can be a trip to dialysis, from a hospital or nursing home to a home or from a home to a direct admit at a hospital or a trip to a doctor’s office.  If the patient is going to a doctor’s office or to a hospital for a procedure that doesn’t take too long, you often wait with the patient and then return them to where they started.  These trips are called wait and returns.  Dispatch tries to give them to the basic ambulance crews  in order to leave the paramedic ambulances available to take 911 calls, but on days when the paramedic rooster is full, medics can be asked to help out with the transfer load.

In the age of COVID, there are now COVID transfers.  I have been involved in a few of them.  Back shortly after the epidemic began in the spring the state started opening skilled nursing facilities (SNFs) solely for recovering COVID patients.  Several times I have transferred a patient from Hartford to a SNF over a hour’s drive away.  I drive while my BLS partner sits in the back with the coughing COVID patients, unless of course the patient needs ALS monitoring, in which case I am in the back.  This happened once.  You can’t maintain six feet of distance from a patient in the back of an ambulance.  You just gown up, turn on the exhaust vents and hope for the best.  Our PPE (personal protective equipment) are not self-contained biohazard suits, and even though the patient is wearing a surgical mask, they often have dementia or sometimes a simple unwillingness to keep their mask on properly, and even if they do have their mask on, COVID can still get around it.  The crew member is basically trapped in a COVID soup for the length of the trip.  Sixty minutes is too long.

I don’t think the system has had time to properly process what a COVID transfer means.  This one didn’t happen to me, but I have heard of it happening to two other crews.  In the hospital patients are often kept on COVID wards where each room is biocontained.  That means, the medical staff dons PPE in a foyer, enters the room, treats the patient and then doffs their  PPE in the foyer before returning to the hallway and medical worker’s stations.  You can’t wear PPE in the hallway.  Now enter the EMS crew.  EMS dons their PPE in the foyer, enters the room, puts the patient on their stretcher, and then exits.  They are asked to remove their PPE.  No.  But you can’t be in the hallway with PPE on.  Well, how the hell do you get the patient down to the ambulance?  You can’t wear PPE in the hallway.  You will contaminate the rest of the building.  Do you have a chute we can put the patient in that will automatically deliver the patient into the back of our ambulance?  Because otherwise we need to walk through the hallways to get back to the ED and our ambulance.  Put a clean sheet on the patient.  And what about us?  You can’t wear PPE in the hallway of this ward.  We are not taking our PPE off.  See you later.  (I heard that a compromise was later reached on one floor where EMS doffs the PPE they wore in the room, then immediately puts on a new set of PPE and are permitted to leave enter the hallway with the patient who is covered in a clean sheet, except of course for their face covered with a surgical mask.)

In the meantime in the ER, EMS crews donned in full PPE with their COVID patients, wait in the same triage line snaking out the door as do crews with only surgical masks on with COVID negative (based on screening questions), and once assigned a space, the PPE covered EMS crews and their patients maneuver their stretchers down ED hallways with regular overflow patients sitting in chairs or lying on beds.  This is opposed to the early days of the epidemic where all possible COVID patients entered the ED through a separate decontamination room.

Then there are the COVID wait and returns—calls in which you can be with the same patient for several hours.  I did one of these recently.  The patient needed to go to the hospital for a procedure.  Taking a patient to a hospital for a procedure can involve many stops as you are directed from one floor to the next.  No, this is the wrong floor, you need to be in radiology, that’s down a floor, take a left when you get off the elevator, go down a hallway, turn right, go through the double door, and then it’s your next left. Those types of directions are common.

So imagine this.  An ambulance crew fully gowned in decontamination gear with a coughing COVID positive patient on oxygen on their stretcher wandering the halls of a hospital.  I wish I had a camera to record the terror on people’s faces.  We went to admissions where we had been told they would send someone down with a bed to take our patient, instead we were sent to another floor.  After several stops we finally ended up where we were supposed to be, which was a hospital office waiting room.  I waited with the patient in the hallway, while my partner checked the patient in.  Recognizing that the COVID patient was a potential hazard to the others in the hallway as well as the waiting room per their policy, we were escorted into a small room off the waiting room.  The appointment was not for another hour and a half so they wished us to wait there until with the patient until they were ready.  This is another common issue with wait and returns.  The nursing homes often schedule the pickups early compensating for the times the ambulance is late due to 911 call volumes, so we often end up arriving at the destination only to find we are an hour or two hours earl for their true appointment.  Our dispatchers don’t like us to wait more than twenty minutes.  Often we can unload the patient onto a hospital bed to wait for their appointment and send another crew to pick them up when ready, but the hospitals and the doctor’s offices  can’t always accommodate this.  They try to keep us there by saying they are almost ready and it shouldn’t be long, but the time keeps ticking away and we are stuck there.  On this call, the staff came back moments later and said not only did they not have a bed we could move the patient too, but they asked us to close the door to the room where we had the patient as keeping it open was in violation of their policy.  The room was not a patient room, but a closet sized consult room with barely enough room to fit the stretcher.  I told them if I closed the door if would be hazardous for my partner and I.  We discussed it and I asked them to call a member of their safety team.  The team member who was very pleasant explained the reasons the door had to be kept shut.  I understand those, I said, but do you believe it is safe for my partner and me to be in this confined space with this patient for an hour?  What about the ambulance? the safety person said.  Aren’t you confined there?  Well, we have exhaust vents and we are usually not in with the patient for an hour.  Point taken.  They moved us to another room which was larger.  By this time we were close to running out of oxygen, and then the room that they had moved us to, the staff who normally used the room were uncomfortable with us being in there with a COVID patient, so we were moved again to the hallway (waiting a further solution) where we stood and watched other visitors scurry past us.  In the end the hospital cancelled the procedure and we returned the patient to his facility with instructions to reschedule and to have the nursing facility send someone with the patient next time who could wait with him in whatever space they would try to figure out that they could safely border a COVID patient while waiting for his procedure.

When we returned to the SNF where our journey began, the guard at the door took all our temperatures per the facility policy before allowing us entry.  Fortunately none of us had fevers so we were allowed to go down a hallway, up an elevator, down two more hallways and through a set of double doors where we at last came to the patient's hallway, found his room, and returned the patient to his bed.

How likely were we to get COVID from this patient?  Well, I was just vaccinated, but only with the first shot and my partner had already been out for a few weeks with COVID pneumonia several months back, but they say it is possible to be reinfected.  We kept our PPE on the full time.  (I doffed mine each time I drove, and then had to put on a new set to reengage the patient).  I was glad the hospital safety officer was understanding and recognized the danger to us and responded to it.  No way was I going to close that door.  Scene safety at all times.

I am glad Connecticut has recognized EMS as a priority 1A group at risk for COVID exposure. 

COVID has been hard on everyone, and people are doing their best, adapting to the challenges.

 

Christmas - Winter's Fuel

 

These are two old Christmas posts I wrote years ago, reposted now.

***

Fifteen on the Scale

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

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

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

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

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

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

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

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

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

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

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

That's the jist of our relationship.

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

She chit chats with him.

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

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

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

"I'm pretty much done."

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

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

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

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

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

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

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

-Christmas 2006-

***
Christmas

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

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

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

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

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

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

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

-Christmas 2005

***

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

Connecticut Opioid Forum

 

On December 18, 2020, I participated in a panel hosted by United States Senator Richard Blumenthal and Connecticut Attorney General William Tong to discuss the opioid epidemic. 

I want to thank both of these fine public leaders for their consistent and longstanding involvement in the fight against opioid deaths.  We were joined by several other leaders in the state, including my friends, Mark Jenkins of the Greater Hartford Harm reduction Coalition and Bobby Lawler, of the New England HIDTA (High Intensity Drug Trafficking Area).  I also want to thank Brandon Bartell, the operations manager at American Medical Response Hartford, who let me adjust my paramedic shift at the last moment so I could participate.

It was a great discussion that can be viewed in its entirety at this link.  

Forum with Attorney General Tong and U.S. Sen. Blumenthal on the Opioid Crisis During the COVID-19 Pandemic

 

I start speaking at the 42 minute mark.  I was told I could speak for five minutes, and I managed to keep within my time.

The Hartford Courant wrote a nice article summarizing the meeting.

Connecticut projected to exceed last year’s number of fatal overdoses, as COVID-19 results in isolation and fentanyl drives deaths; over 1,300 fatalities expected in 2020

When thinking about what I was going to say, I focused on the question of why people die from opioid overdoses.  Most people involved know the larger causes of the opioid epidemic: over prescription, corporate greed, poor public policy, etc., but I wanted to focus on the causes, from my experiences as a paramedic, that are actually leading to people's deaths.

The two main reasons people overdose are low tolerance and excess potency.

Low tolerance occurs when someone who has just gotten out of prison or rehab, or someone who relapses from a period of abstinence, uses the same amount they used to use, and consequently they overdose because they have lost their former tolerance.  

Excess potency comes from buying a product that is stronger than you anticipated.  The best example of this would be (a few years back) buying a bag of heroin that is unexpectedly laced with fentanyl (hardly unexpected these days) or a bag of fentanyl that has a larger than normal percent of active ingredient compared to cut.  This can happen easily with fentanyl because the active amount of fentanyl is small and widely variable (you could easily have 0-10% or more in different $4 bags from the same batch).  Because fentanyl tends to clump, you don't get dilution like when you put food coloring in water and stir, instead you get the chocolate chip cookie effect, and your bag may have a deadly fentanyl chip of death in it.  

The major way to address tolerance is education.  Warn people to be careful if they haven’t used for awhile.  Just do a little at a time.

Excess potency can be addressed through quality control. The problem with street drugs is there is no quality control.  In addition to not knowing the strength, the drugs often contain other potent chemicals.  Xylazine is a horse tranquilizer increasingly implicated in opioid deaths in Connecticut.  We’ve seen PCP and other drugs added to the mix.  No one really knows what they are putting in their veins.  It’s Russian Roulette.  How about we try some medicinal fentanyl or heroin pilot projects where a trial group of users are allowed to receive medical quality heroin or fentanyl in a clinical setting under a physician's care?  They do this in England and other countries.  It may be considered outrageous by many, but it would reduce the problem of people dying from “hot spots” in batches mixed by street dealers.

New heroin-assisted treatment: Recent evidence and current practices of supervised injectable heroin treatment in Europe and beyond

Another method would be helping harm reduction clinics purchase lab equipment so users can test what's in the latest bags on the street.  This could less drugs for sale adulterated with other harmful additives.

Drug checking as a potential strategic overdose response in the fentanyl era

While addressing low tolerance and excess potency will help limit deaths, the number one reason people die is because they use alone.  If they use alone and their tolerance is down or they have a batch with excess potency, and they overdose, if no one discovers them in time, no amount of naloxone will bring them back.

Why do people use alone?  They use out of sight because stigma and law drive them into the shadows.  I have found people dead behind dumpsters, in porta-potties, down wooded ravines, in cars in secluded back parking lots, and behind locked bathroom and bedroom doors, as well as in solitary hotel rooms. Had any one of these people used with someone else or used in a public location where they could have been spotted, they would have survived to live among their loved ones another day.

Think of all the parents who find their children cold and dead behind their locked bedroom doors.  What if it was normalized for users to dose in the kitchen (as part of their care plan or a simple stay alive pact) under their parent’s eyes with an injector of narcan on the table?  Think of the tragedies avoided.

People hide their drug use because addiction is thought of as a character flaw, not a disease.  People hide because they don’t want others to see their struggle.  They hide because they have to break the laws of our country to get what they need to fight off the sickness of withdrawal.  We recognize them as victims of a larger societal, medical and governmental failure to keep its citizens safe, yet we treat those with addiction as outcasts.

How do we stop our loved ones, our neighbors, and our nation’s citizens from using alone?  End the stigma with education campaigns.  Decriminalize drug use and possession of drug paraphernalia.  Reverse the justice department’s position on the federal crack house statutes and their opposition to overdose prevention sites. Fund harm reduction including money to establish these same overdose prevention sites where they can dose themselves under the eyes of trained professionals who can not only administer naloxone, but who are there to talk with them and perhaps help guide them to treatment if they are ready.

Hear the drums beat.  Twelve hundred (1200) dead in Connecticut in 2019 with 1300 or more expected in 2021.  It’s time to do what’s necessary to save lives.  If we don’t want people to die we have to find ways to help them use under supervision.  Let’s end the stigma, and bring our people in from the cold.  Let’s welcome them back to our communities.  Let's welcome them home.

***

How Biden’s win could help S.F. address skyrocketing drug overdoses and other issues

Safe Injection Sites

Judge Rules for Safe Injection Site

 

Vaccinated!

The American Hospital Association, the American Medical Association, and the American Nurses Association issued a joint release today urging health care professionals to “to get the COVID-19 vaccine and share your experience with others.”

They wrote:

“While the arrival of vaccines is good news in the fight to defeat COVID-19, it does not signal an immediate end to our nation’s suffering. Just as we have been pushing for adoption of the precautions we all know work – masking, hand hygiene and physical distancing – we must also push for high rates of vaccination within the U.S. population if we hope to overcome this virus.  This will require trust in the COVID vaccination process, from the development, distribution and administration of a safe and effective vaccine as well as a willing public to get vaccinated….As frontline caregivers, our essential role in protecting the health and wellbeing of our communities goes beyond the care we provide. As a valued and trusted voice, our example is perhaps the strongest health resource we have.”

Here is my story.

I was extremely fortunate to be among the first group of providers at our hospital to get vaccinated on Wednesday.  (The top dogs got the vaccine on Tuesday!}  I had no qualms about getting it.  I read about it, talked to experts and was sold.  A few key points:

1. You can’t get COVID from the shot. It contains no dead virus or attenuated (weakened virus.)  Corona virus consists of 25 proteins; the vaccine tells the body to make one protein.
2. The mRNA cannot mess with your DNA. It enters the cell, but not the nucleus.  MRNA viruses have been given safely to cancer patients for years without major issues.
3. While vaccines typically take much longer to approve, thanks to advances in technology, including the mapping of the human genome, great strides were possible. Red tape was removed, funding was plentiful, the best minds worked on it, and most importantly, no shortcuts were taken in the final clinical portion of the trial.  Over 70,000 doses of the vaccines were given to people before approval and independent safety boards found no major concerns.
4. The vaccine is 95% efficacious.
5. My man Dr. Fauci says it’s good enough for him, so it’s good enough for me.

For those looking for more facts, here’s an excellent link from Rebel-EM on the Pfizer Vaccine, which is the one I received:

COVID-19 Update: The COVID-19 Pfizer Vaccine

I received the shot at noon on Wednesdays and as I write now over thirty hours later, I have had no fever, no aches and no fatigue.  I didn’t feel the needle go in and I did not bleed.  Once in the night when I lay on my left shoulder, I could feel I had a shot there.  Once, I had a five second shiver, but that was  due to an unpleasant thought.  I was going to take it easy today, but we had a Nor’easter last night that dumped more than a foot of snow on us, and with the wind drifts, almost buried my car in the driveway.  For my 25^th work anniversary gift (we get to pick it from a catalog), I chose my first ever snow blower, which I assembled last night.  Unfortunately, The storm was too much for it.  It wasn’t very powerful, and crapped out before my driveway was a third done.  I grabbed the manual shovel and like John Henry, I showed the machine who was the man.

 

I did have some help from my youngest daughter.

Still feeling good, I’m ready to hit the streets tomorrow.  COVID is still out there, and I don’t think the vaccine kicks in fully for a week or so (I will have to get a booster in 21 days) but I will be armed with my mask and PPE and be ready to do my job.

I hope everyone gets a chance to get the vaccine soon and that they will act on it.  Protect yourself.  Protect your family and protect your community.  That’s what we do in EMS.  It’s our job.

Peace to all and a middle finger to COVID.

Also, many grateful props to the scientists who developed the vaccine and all who helped make it a reality.  Thank you.

Refresh2021-Free EMT/Paramedic Refresher

 How would you like to have a FREE on-line NREMT-Paramedic and EMT refresher (good for 30 hours), available to you ON DEMAND?  CAPCE Approved.

Thanks to Tom Bouthillet (of EMS 12-Lead fame) and his assembled crew of top educators in the country, it is becoming a reality starting on December 15.

The course is presented in honor of EMS professionals everywhere.

 

Sign up here: http://link.prodigyems.com/refresh2021 

I signed up today.

COVID and Harm Reduction

 Just Say No didn’t work for the War on Drugs and it doesn’t seem to be working for COVID messaging.  Maybe it is time for a harm reduction approach.  This according to a thought-provoking article in the LA Times today.

Many aren’t buying public officials’ ‘stay-at-home’ message. Experts say there’s a better way

“Harm reduction aims to mitigate the risks of dangerous behaviors instead of trying to get people to cease altogether.”

Harm reduction is about straight talk and giving people the tools to make good decisions.

There is a growing clash even in a largely obedient state like Connecticut between wanting to “do the right thing” and “live our lives.”  We were all pretty good during the first wave, but the prospect of bunkering in again for our second wave (this one in the winter) is bleak.

A group of Doctors recently met with Governor Lamont calling on him to shut down gyms and indoor dinning.  While recognizing their concerns, he has held off for the most part on draconian shutdowns.  Even the Hartford Courant has questioned why he is slow to act.

Dozens of Connecticut doctors ask Gov. Lamont to close gyms and indoor dining as COVID-19 hospitalizations continue to spike

Editorial: More Connecticut residents have died from coronavirus than in World War II, Korea and Vietnam combined. It’s time for Gov. Lamont -- once again -- to take decisive action.

There are people who happily embrace the shutdowns, others are outraged by them, and still others who are confused and distrustful.

While I support the public health needs of taking precautions, the shutdowns do seem arbitrary.  Why is my daughter’s basketball team prohibited from practicing in empty gyms while wearing masks while pros and college teams can play without masks?  Why are people told to stay home when indoor dining is still allowed and stores are open?  The state recently issued an edit that only four people could swim in our town’s 11 lane Olympic pool at the same time while allowing four people to sit in a hot tub provided they kept six feet apart.  Fortunately, this was overturned by outcry and now 11 people can swim again one to a lane.

I guess for me, I hope that we can all wear masks and keep some sort of distance from each and avoid places of high risk.  We don’t have to close down everything or close down everything that doesn’t have money and power tied to it.  If you are going to have basketball, allow it with no fans or a small number of fans only in large arenas, and have safety measures in place.  Treat a large cavernous gym differently from a small gym with no ventilation.  Teach people where the risks are and allow them to choose.  Issue edicts in only the most serious of instances. 

I can see people accepting mandatory masks if it enables you to keep other aspects of life open. 

I think Connecticut did an okay job with much of their reopening after the first wave.  You don’t have to close schools, with imagination; we can find safe ways to keep them open.

People will not follow rules that are seen as arbitrary or political.  Work with people.  Find common ground.  Speak the truth, warn of dangers, and take steps to mitigate the risks.

If we can regain people’s trust (hard given all the truth warfare/alternate reality of the last four years), we may have more success than the free for all we have now.

Honest talk, harm reduction, mitigating danger will always work better than forced abstinence and government fiat.

Self-Service

 

I had my third COVID test of this pandemic today.  It was part of the hospital survey of asymptomatic clinical employees to gauge the prevalence of COVID.  Last time I did this they went medieval on my nose and brain, shoving that swab all the way down and scrapping.  Ohh, it was unpleasant. Today, was much different.  We self-swabbed, and only went into the nares, ten swirls on each side.  Very tolerable.  You put the swab in the test tube, sealed it, put it in a bag and then stuck it in another bag being held by the testing assistant.  I got the result eight hours later.

I'm hoping to keep COVID-Free until I get the vaccine, which could be later this month.  I hope so.

 

Stress in EMS

 Based on my twenty-five years as a full-time street paramedic, here are the five most stressful situations in EMS (for me, at least).

5. Pedi Codes. There are two kinds of pedi (pediatric) codes. Those were the patient is dead and is not coming back and those where you have a chance. The second are obviously more stressful than the first, but even the obviously dead kid is a highly stressful situation. The family is largely hysterical. You new partner may be freezing because she has never seen a dead baby before, and you have to manage it all. I usually always pick up the baby and do CPR all the way out to the ambulance. I have had quite a number of calls where the pedi was already cold and as stiff as mannequin baby. While we presume many of our cardiac arrests dead on scene and do not transport, it is uncommon to do so with a child. We usually show our best efforts and get everyone to the hospital where there are grief counselors and more staff to handle the collateral issues. If the baby is workable, that is hard too, because despite all the PALS classes, it is not as usual for us as when we do adult arrests. The tendency is also to just get the baby out to the ambulance, but I still believe in working them right there – or at least until you can get them stabilized. I can’t do as good CPR walking with the baby as I can when I lay them on a table or counter. The sad fact is most of the time a baby is in arrest it is for a reason that you cannot reverse. I have done too many of these calls and they are always sad, although with time I have learned how to disassociate myself from the chaos both of the scene and of my emotions. These are the calls that remind you of what you asked to do as an EMT or paramedic.

4. COVID patients. This is a cumulative stress of having to gown up and then trying to take care of a sick person who is vomiting or gasping for air with PPE that doesn’t fit. It’s hard to see through a fogged up face shield, hear through masks, maneuver with gowns, deal with the roaring sound of the exhaust fan, and all the while worrying that the germ is going to somehow slip through your defenses and find purchase in your lungs, and every time you get a sniffle or an ache or irregular bowels, you worry its COVID and then in two weeks you’re going to be in an ICU, and listening to a nervous doctor tell you need to be intubated. It’s the unrelenting nature of these calls that frays and exhausts the nerves. I knew I would have to do pedi codes, but I never imagined having to deal with a pandemic like this one.  A quarter million dead and rising.

3. Legitimate obstructed airway calls. We get called for choking all the time and usually by the time we have arrived, the person is breathing fine. The object has been removed or it was a false alarm in the first place or the person says they ate some fish and feel like they have a fish bone stuck in their throat when most likely it is just a scratch there. I am talking about the turning blue, losing consciousness. If you can’t get the airway cleared with the Heimlich or with your McGill forceps, the person is going to die. You only choice is to cut the neck, and you know there will be blood, and you know it may not work, and if it doesn’t, you will be questioned why. Others will question you and you will question your fitness.  These are the calls that end medic’s careers.

2. Vent transfers and vent transfers with IV pumps. Most of the calls I do are emergency 911 with a few transfers thrown in. Every couple months, I get called for a vent run taking a patient out of an ER or ICU going to another ICU. We have a vent that I have been trained on multiple times (I got to every vent training they offer), but every time I use the vent, I feel like I have never used it before. I nervously review the manual on the way to the patient's room. The problem is the patient who may be very stable on the hospital vent has difficulty adapting to our vent. I always try to transfer them to our vent while they are still in their bed. I wait at least ten minutes before leaving with them. Despite that I have had numerous episodes where they suddenly desaturate, and I end up having to play with the vents dials (and our vent has a ton of them and lots of flashing lights and alarms –not like the simple three dial one we had when I first started). My adjustments don’t always work and I  end up having to manually ventilate the patient the patient with a bag-valve mask. Add to this meds pumps that also malfunction and beep for air in the lines or other problems (I once had an old med pump that malfunctioned and the messages it flashed were all in French), and some of these meds need to be run constantly at a steady rate or the patient will crash. Their pressure could tank; if they are sedated, they could suddenly wake up in a rage and pull their ET tube. I am sometimes all alone in the back and quite far from the destination hospital or you are in a driving rain storm or both. I don’t do enough critical care transports to be at ease.  I have finally learned to refuse transfers that I consider unsafe.  Sometimes the ERs or floors just want the patient gone and they will pressure you to take them, but I will no longer do it, and our training backs us up.  Never take a critical patient you are uncomfortable with.  When I was newer, I took everything for fear of being judged.  I took patients I had no business transferring.  I took them and prayed nothing went wrong.  No longer.  Give me another medic, another set of hands in the back or call us back when the patient is stable.  I’d rather being doing a cardiac arrest in the field than doing vent runs. Maybe that’s just me.  I can't take the stress of it.  If all I did was critical care transports, I would more comfortable.

1. And the number one stressor. .. If you are not in EMS, you may find this hard to believe, but if you are in EMS,  you likely understand. It’s waiting out the last fifteen minutes of your shift. You’re in the bone zone, and you’re just hoping, please no late call, don’t call my number, please tones don’t go off. After twelve plus hours at work, you’re already half home. You have plans, things you need to do. Dinner’s on the table, your daughter’s softball game is starting, the gym or the liquor store (your preference) are closing, you want to go for a run before the sun sets, whatever it is you do after work, you’re not going to be able to do if they give you a late call. Please no. Don't get me wrong.  I like doing calls.  I bust it all day long, but when its time to go, it's time to go.  I hate being held late and I hate late calls.  The dispatcher calls your number with urgency. F---! Is he toying with you? Is he going to say, “Never mind, head on in.” Or is he going to say, “471-Priority one. Main Street for the unconscious.” Even if dispatch does send you in, those fifteen minutes of waiting it out, the constant stress of not knowing if you’re going to be able to make your plans, get your few moments of nonEMS time to yourself before having to come back to work the next day and do it all again takes years off our lives. Years. That’s the street truth.

 

Anti Black racism Course Thoughts

 

I had some trepidation about taking an Anti-Black Racism course (which was offered free to employees at our hospital, and all students, faculty and staff affiliated with the University of Connecticut) but I was enthused to engage and learn so I could better understand what is going in America and how I could can better help change this country into the country that I love.  Trump had a slogan Make America Great Again, but after hearing a Bruce Springsteen sound tracked campaign ad encouraging people to vote in Pennsylvania, I reimagined that slogan into Make America Recognizable again.  This comes from the song “Streets of Philadelphia” about a person with AIDs who because of the way he is treated/shunned, loses nearly everything, and is now "bruised and battered, unrecognizable to myself."  I have felt that America has been unrecognizable to my vision of it – a land that is a world leader and is an example for others of democracy, rule of law, truth, human rights and compassion for its less fortunate.  We don’t separate kids from their parents, refuse to disavow white supremists or call those who served and died in our military "suckers."  And above all, we are truthful about the difficulties we face (COVID as prime example) and are willing to sacrifice for the greater good. That vision of America has too often been a dream rather than a reality.

What I came to understand in the class is there are two Americas -- the real-life America and the the vision of America.  I studied history from kindergarten where I learned about George Washington never telling a lie to the University of Virginia where I took a course about slavery, that featured a book “Roll, Jordan Roll,” that talked about how slaves and slaveowners learned to get along and survive by humanizing each other.  I did not understand at the time how people could criticize Thomas Jefferson for owning slaves because to me, he was just a prisoner of his time, and that he deserved credit for treating them humanely.  I do not believe now that he is above reproach. 

I have always been an advocate for civil rights and affirmative action, and have spent much of my life as a paramedic working in a predominately black inner city, and care deeply about the city and its people.  I have also taken affront to the term "white privilege" and for criticisms of white people who advocate for black rights, but somehow "don't get it."  I preferred, and still prefer the term, “black disadvantage” because I think the “privileges” whites have are not privileges at all, but basic human rights that should belong to everyone.  It may be semantics, but I think the term white privilege is alienating, and counterproductive to the cause of a better society in the same way I believe “Defund the Police” is an awful term that sets back the cause of improving our police force and addressing the conditions that allow and sometimes condone police brutality.  Rest in Peace George Floyd and so many others.

So what did I learn in this class?  One, the history I was taught in school was stilted and missing key chapters and viewpoints.  I know black people have always had a hard go, but I had no idea how bad it really was and how bad for many it continues to be, how rigged the system is against black people and many minorities.  Even in health care, I always thought black people were more prone to cardiovascular disease due to their genetics (their genetics are virtually the same as white people).  I had not considered how deeply economic and societal disadvantage can affect health and other key aspects of everyday existence.  It is not so easy to take an aerobics class, eat organic food or go for a run in the neighborhood when most of your time is spent just trying to survive from week to week with food on the table, a roof over your head, electricity on, and the kids getting to school.

I was surprised that the course was "so black."  By that I mean all the teachers were black and the point of view all came from the black perspective.  In the end, I didn't mind.  I feel like I had the "privilege" (there we go with that word again) of being sat down in someone else's home and being told the story of their lives, and in the end coming as close as I could to seeing through their eyes what they had been through and continue to go through.  Like any decision someone makes, it always helps to hear from the people who will be affected, and to hear both sides.  This class presented a side (compelling) that  I needed to hear.

What are my takeaways?  The real life America is not as great what it typically made been made out to be.  The real life America has never been perfect (though it has had great moments).  I remember in high school (I went to a prep school in New Hampshire), I was sitting with a group of friends, many of whom were "John Wayne" Americans, and they were very upset when a professor was making this same argument to them.  There was a song on the radio at the time that was a tribute to America and how we always helped the world in need.  It was very patriotic.  The professor pointed out instances where America acted not humanely but in its own political self-interest, chapters that we tended to either gloss over or not be aware of, where we had supported oppressive dictators who willfully violated human rights, and we supported them because they were anti-communist so we ignored their atrocities.  This was back in the 1970's.

Now before anyone accuses me of not liking our country or being unAmerican, I need to say this.  America is not and never has been perfect.  Nor have Republicans or Democrats been shinning examples of what America should be about. In many cases, not even close.  But I believe not in the real life America (and certainly not the America of the last four years), but I believe in the dream of America and in its promise.  I believe it can be a country where we all have equal opportunity, where we find common ground, and where we always strive to do better.  I really liked Spike Lee's documentary “Two Fists Up” about University of Missouri students protesting the racial indifference of the school leaders, protests that led to the administrators resignations after the football team joined in the protest, refusing to play until there was change in the school’s treatment and support of its black students.  I am moved by the Black Lives Matter protests, and hope that the momentum continues.  I agree with what the course posited in the end that the goal is not to make black lives better because they have been getting screwed, the goal is to live in a world where all lives matter, and the hard fact is right now black lives have not mattered so we need to fight to change that so that we can say we all live in a just world, and a just world is a better world for all of us, black and white and all the colors of the rainbow.

I have always told me daughters that when they go to the cafeteria at lunch time and one person is sitting alone because they have no friends or are different, that they are to go and ask them if it is okay they sit down with them, not because they feel sorry for them, but because they should never be a part of a world that shuns those who are different.  And I taught them to stand tall against the bully even when the bully has the crowd.  I taught them to play for the long run, to set an example for others.  A bloody nose is better than slinking away a coward.  Speak up. 

Anyway, sorry for the pontificating.  It was a great course, I learned a lot. I hope it will make me a better person and a better paramedic as I work the streets of Hartford.

Power to the people.  Be kind.  Be just.    

Dark Red

 

I follow COVID ACTNOW daily for a look at how the epidemic is progressing or retreating.  It looks now like it is advancing so severely that they have had to add a new color/category risk level to their map.  Previously red was the worse you could do and it signaled critical - "Active or Imminent Outbreak."  Things have gotten so bad, they have had to add dark red, signifying SEVERE outbreak.  I only pray we don't reach the next likely level -- black, meaning - DEAD, APOCALYPTIC, BEYOND HOPE, DEFEATED, WASTELAND.

God Bless America and wear your damn masks!

Black Friday/EMS Books

It's Black Friday.  When thinking of Christmas gifts, consider supporting EMS authors.

My new book, Killing Season: A Paramedic's Dispatches from the Front Lines of the Opioid Epidemic,   is coming out on April 6, 2021, but if you order two books (or spend $50 now, you can get them for 40% off under a special promotion.  Good through 12/6.  Use code HHSA when checking out at the Johns Hopkins University Press Bookstore.

My first two books, Paramedic: on the Front Lines of Medicine and Rescue 471: A Paramedics's Stories are still available both in print and as ebooks.

 

I have two works of fiction available as ebooks.

Diamond in the Rough tells the story of a young EMT's wayward journey through EMS. It takes place in Hartford in the similar setting to my first novel, Mortal Men: Paramedics on the Streets of Hartford.  The book has caused some controversy because the EMT narrator is a thief, who steals from his patients.  He, of course, eventually pays the price for his actions, but he does, despite his crimes, manage to find some redemption and a path toward grace.  After writing two nonfiction books about EMS in Hartford, I have turned to fiction because it offered a freer reign to explore the world of EMS and tell atypical stories.  

You can read sample chapters of Diamond in the Rough here:

Anthropophagi

Temptation to Steal

 

Mortal Men is a more traditional story.  Paramedic Troy Johnson battles trauma and sickness on the streets of Hartford, Connecticut. When a fellow medic is shot to death responding to a 911 call, a grief-stricken Troy vows to avenge the death, while struggling to come to grips with his own mortality.

i appreciate your buying and reading my books and blog!

***

Here are some of my favorites from other EMS authors you should consider:

 

Lights and Sirens: The Education of a Paramedic by Kevin Grange published by Berkley. This a great account of a young man going through paramedic school. I reviewed it in more detail in this post:

Lights and Sirens

***

Michael Morse first two excellent books Rescuing Providence and Rescue 1 Responding are combined into one book and published by Post Hill Press and distributed by Simon and Shuster.  I reviewed Rescue 1 Responding in this post:

Responding

***

A Thousand Naked Strangers: A Paramedic's Wild Ride to the Edge and Back by Kevin Hazzard published by Scribner. This is also a tremendously well written book covering the EMS career of an Atlanta, Georgia paramedic from eager EMT to eventual burn out and fade away nearly a decade later.

***

Kelly Grayson's En Route is a great read by the author of the Ambulance Driver Files.

Grayson is an EMS Mark Twain -- a gifted humorist who packs a serious punch. He does a great job of describing what it is like to be in EMS -- the good and the bad, the high points and the lows.  

***

Turning to EMS Fiction, a little known, but excellent book is Black Flies by Shannon Burke, which retells Joseph Conrad's Heart of Darkness with EMS as the background.

I reviewed this book many years ago on this blog:

Black Flies Review 

Thanksgiving

 I wrote this post on Thanksgiving 2005.  

***

It’s Thanksgiving morning. I awake at 5:10, shower and dress, then open up the garage door to see a couple inches of snow on the ground. It’s beautiful, but I hate winter, hate the cold weather, hate driving in snow.

When I get to the base, I can see from the tracks in the snow by the ambulance doors. The night crew is out on a call. Ten minutes later I hear them clear with a presumption. I sit in the office and drink a diet coke while I read the morning paper.

This week a thirty-year-old female cop in one of the suburban towns was murdered by her ex-boyfriend, a state cop. We had two cars on standby while they looked for the shooter. They found him a couple hours later, also dead. The paper said he parked his car at a park, and then walked over to her house so she wouldn’t see him. He lay in wait for her and when she returned from work, he ambushed her, shooting her three times, twice in the chest and once in the head. He was supposed to turn himself into court today on a police charge, but instead he called his lawyer and said there was a change in plans. The lawyer got the message a couple hours later and alerted police. Her new boyfriend — another cop — came home and found her.

I knew her by face, not by name. I’d been on calls with her a few times over the six years. I remember when she first started working. She was gorgeous. It was hard to believe someone that good-looking would chose to be a cop. Lately I noticed she’d started to wear a bit more makeup around her eyes, her face seemed a little heavier. She never had much to say to us, at least on the calls I went on. She was all business. If she pulled you over, I don’t think you’d want to sweet talk her. I’m sure she had a warm side she showed to those who knew her.

The paper in the news rack the next day had a headline “A Cop’s Fury.” It had pictures of the two dead on the front. It made me think, you are here one day, and the next people are walking by the news rack with your picture on it, only you aren’t one of the people walking by to see it.

**

We did a call in her town this morning, and said our condolences to the two cops who were there. They had black bands over their badges. The call was for an old woman who said she had taken a handful of painkillers. She said she did it because she was stupid. She said her ex-husband and her doctor would be mad. I got the feeling from the cops they were at this house all the time for similar vague complaints of taking too many pills. “I don’t need this today,” one cop said to me.

**

All week I have found myself in idle moments thinking about the dead policewoman. I guess she probably never figured her death was coming that day. She comes home from work, sits down with computer and then suddenly there is the angry man in her house, gun drawn coming at it. Did she know she was going to die?

When do heart attack victims get that sense that right now what is happening — this sudden pain in their chest — might be their end? And car crash victims – they start to loose control and see the tree or the truck careening toward them?

Last New Year’s Eve another cop in the same department was gunned down at a domestic. I knew him too, but also just in passing. We’d been on calls together. A nice, big friendly man. He walked down the basement stairs and then shooter pulled the trigger on a machine gun. Did he have time to realize his end had come?

This summer a paramedic student who rode with me was on a jet ski with his girl friend in Florida when they were blindsided by a boat. I heard about it when I saw his obituary posted at the office. Did he hear the roar of the engine? Did he turn to see it bearing down on him? What did he think in those moments?

Last Saturday they held a memorial for a flight nurse who died in a helicopter crash 13 years ago. I was working in the health department at the time and remember the late night call I got telling me about the crash. I’d seen her around the ER a few times when I brought in patients as a volunteer EMT. And I had ridden in the helicopter as a third rider only a month before. The accident happened when the copter clipped a wire while trying to land near a highway rest stop, a rest stop that now bears her name. When the copter started spinning, did she know?

I don’t mean to be morbid.

The saddest thing about all these deaths is not just the fear they must have felt when they saw what was happening to them, but that fact that everything that would have happened in their lives and all the people they would have affected is just gone. The children they might have had, the things those children would have gone on to do, the memories – all of it vanished. That’s the tragedy.

Death happens everyday and we see it in this job, but it doesn’t impact as much unless it is one of us. You can grow immune to it until it comes close like it has again this week.

But I don’t worry as much about dying as I used to. I’ve lived awhile now and feel lucky to have made it as long as I have. If the deal was when I was born, I agreed to come out of the womb, but in return I would only have these 47 years, I’d take that deal anytime.

I have many, many years ahead I hope. But if I were to die today, if the door were to open and death were to be there, I would be terrified, but I can’t say that I would have been cheated. Life, with its share of sadness and disappointments, has been largely good to me. And today I am as excited about life and its possibilities as I ever have been, excited not in the wild way I was as a youth, but in the more realistic sense that I can enjoy the moments now and not just the thought of the goal.

I want to live fully and feel, for the most part, I have been. I work a lot, but I like my job and the money I make will help me keep doing what I love – being a paramedic, writing, going to foreign countries to help the poor, getting good seats to a Red Sox game every year, living in my house which I feel comfortable in, being able to eat a good steak, and drink a cold beer when I want without having to count nickels on the liquor store counter.

I have much to be thankful for today.

I hope I continue to live a full life and that the door doesn’t open for me any time soon.

Please not any time soon.

I don’t want my picture on the news rack, my obit posted on some bulletin board, people thinking, yeah, I knew that guy. We did a few calls together. I used to see him around.

***

Postscript: Thanksgiving 2020.  Well, I made it fifteen years, though not all those I have shared the front cab of an ambulance with did.  I think about them.  Joe Chipman.  Ransford Smith, Dave Fackleman.  Chris Schmeck.  Wayne Cabral.  Jeff Huffmire.  Susy Ribero Rynaski.  Donavan Alden.  John Michael St. George.  Turk Atkinson.  Kim Butler.  Anita Russo.  Ed Grant.  Ross Chagnon.  Zellie Block.

Of the bunch only Anita and Zellie had what you would call full live spans. You could make a good case that EMS killed (or at least contributed to the deaths) of a number of these fine people.   I remember working with each of them like it was yesterday.  

I hope everyone has a safe Thanksgiving.  Give thanks for what you have.  Stay safe, enjoy your closest family and friends and be careful of the COVID.  

 

Special Glasses

This week I received in the mail special glasses I ordered from the back of an old comic book.  They enable me to see COVID.  He is a tiny little green monster with a coat of suction cups.  He is not just one fellow, but an army of millions of little green monsters.

I sit in the ambulance and watch COVID soldiers pour out of my patient's nose, which keeps sticking out from his sagging mask.  Other hordes of green mercenaries slip out from the bottom and sides of the mask, even a few blow right through the mask.  Some of them float about in the air like spacemen in zero gravity. Many bounce off my face shield but others find purchase with their suction cups.  They stick to my gown and my hair and my pant legs which are too long for the gown that does not fit me. I try not to breathe too much as I do a 12-lead ECG, and put in an IV giving him fluid to try to rehydrate him. The green men begin to accumulate on the floor and pile up upon each other and the green man level rises like a flood, above my boots, and up my pant legs, till I was sitting half-buried in the soft green little buggers.

When we arrive at the hospital, the gowned EMT opens the back door, and the little green men tumble out like millions of tiny ping pong balls.  Some float up into the air and I can see their shapes against the lights of the hospital room, many stories high, and I can even see their reflections against the moon.  

We wait with our patient in triage along with other stretchers of gowned crews and masked patients coughing,  Patients on stretchers coughing and patients in chairs coughing.  Green clouds emerge like dragon’s breath. Clouds of COVID civilizations float in the air like blow bubbles from a child   Some bubbles bounce off the walls while others burst on contact with patients and staff alike.  When it strikes them in just the right spot, there is a puff of green and the person turns entirely green just like my patient.  The COVID civilization bubbles move slowly away from those who are now green so they won’t waste their time targeting someone who is already colonized.

I doff my equipment and then head to the EMS room where none of three people already in the room wear masks, not even the one who is already green himselves.  I sit in an armchair with my mask on while the big screen shows a green man riding a motorcycle.

I look in the mirror in the restroom and while I am covered in green dust, my eyes are still brown, my teeth dull white. 

At night, I throw all my green clothes in the washer and then wearing only my underwear walk up to the bedroom where I shower until the water at my feet no longer has even a hint of green.

I have a restless night.  I dream of little green men inside me battling with my body's natural battalions.  In the morning I stand in front of the mirror with the glasses by the sink.  I am afraid to put them on.

Passengers

Friday night in the city on a dead end street.  Light beams out of the ambulance’s open back doors.  Inside the EMT spreads a clean white sheet on the black stretcher mattress.  He hits the exhaust button on the wall, and then exits from the side doors. My masked patient steps up into the back where he lays down on the stretcher.  I stand in full PPE gear, and take in a last breath of the fresh night air and then enter the compartment.  I sit on the bench seat.  The EMT closes the door and it is just me, the patient and COVID, under the bright fluorescent lights.

A Simple Dream

Twenty-seven years ago, in a retaliatory shooting, a man in Hartford’s north end opened fire with an automatic weapon, killing his target.  He was sentenced to fifty years in prison.  He left at home a baby daughter,

***

I get called for the unconscious.  I arrive first and climb windy wooden stairs to the third floor apartment, where a terrified young woman, holding a toddler, kneels in the hallway by the open bathroom door.   “He collapsed and he won’t wake up!”.

An older man with a grey beard lays on his back, eyes rolled into his head, gurgling.  His arms are stiff.  His carotid pounds..

“What kind of medical history does he have?” I ask.

“I don’t know,'' she says.  “He, he takes pills.”

“Is he diabetic?  Has he ever had a stroke?  Or seizures?”

“I don’t know!”

I have an ambu bag out and with the help of the arriving fire department we pull the man out into the middle of the living room floor, where we start breathing for him.

“Does he do drugs or drink?”

“No, no.”

“What's your relation to him?”

“He’s my father.”

“Does he live here?”

 “Is he going to be alright?”

His pressure is 170/100.  I can’t get a good look at his pupils.  I am leaning stroke, but his respirations are slow (6-8 a minute) so I gave him two of narcan in the nose just in case.

With bagging. his oxygen saturation is 100% and his end tidal is 59.  The ambulance crew arrives and I tell them I am not certain what is going on.  

The other medic asks if I want to give him more narcan, but I say hold off.  He is breathing well enough that we don’t need to bag him.  If it's an OD we’ll know soon enough.  As they get the stair chair ready,  his respiratory drive picks up

The man opens his eyes.

“Well, that answers that,” I say.  “What did you take?” I ask.him.

“Huh?” He says.  He has that uh-ho surprised look to the left look to the right look that so many overdose patients have when they suddenly wake up and find the room filled with people in uniforms standing over them

“Nothing,” he says.  “I’m fine.”

“Fine?  You weren’t breathing, you were unresponsive.”

“I got high blood pressure,” he says.

“No, you used heroin,” one of the firefighters says.

“He used drugs?” the daughter says.

She turns on him.  “You’re gone twenty-seven years and you come back now and you're going to leave me again like that, after you promised to never leave me again.  Are you going to bring this into our house?  With me and my son?”

The man says nothing.  I feel bad for him.  And for his daughter and grandchild. 

“He just got out of jail,” she says to me.  “One week he’s been here.  One week and he goes and does this.”

Twenty-seven years ago, I imagine a man could sniff a bag of heroin and it was nothing but a nice peaceful easy feeling.  Not today.

I tell the daughter about fentanyl, which she knows about. She lives and is raising her son in this neighborhood where drug trafficking and use as well as violence are daily facts of life. I tell her to be patient with her father, that he no doubt loves her, but this transition must be hard for him and he is going to need her.  He is going to need both of them.  She wipes tears from her eyes and hugs her son.  I tell her how she should have narcan in the house and where she can get it.  Even if he promises to never use again, opioids are a powerful force, and if he does slip up again, she can help keep him alive, until more help comes as it did today..  I give her a wrist band with the harm reduction center number on it. You're not in this alone.

The daughter, holding her toddler and I follow her father and the crew down the stairs.  Outside, they load him into the back of the ambulance.  Daughter and father eye each other, saying nothing as the door closes.

“He should be back in a couple hours,” I say. “Don’t be too hard on him.”

She watches the ambulance drive slowly down the street, its red lights no longer swirling, and then she and her boy go back into the house.

I get into my response vehicle where I write my patient care form.  Then I Google the man and learn what happened twenty-seven years before, not five blocks from the apartment where he, his daughter and his grandchild will try to become a family, and live the simplest of all our dreams.

***

A study in the New England Journal of Medicine found that prisoners in Washington State were twelve times more likely to die in their first two weeks after release than were members of the general population (matched for age, sex, and race), and tellingly the ex-cons were 129 times more likely to die of an overdose.

Ingrid A. Binswanger, Marc F. Stern, Richard A. Deyo, Patrick J. Heagerty, Allen Cheadle, Joann G. Elmore, and Thomas D. Koepsell, “Release from Prison—a High Risk of Death for Former Inmates,” New England Journal of Medicine 356, no. 2 (2007): 157–65.

Gun Violence 2020

 

Every morning when I report to work, I check my gear,  my heart monitor, my medic bag, and the blood cooler.  Our service has been carrying whole blood stored in a paramedic response vehicle for a couple months now, and none too soon.  

In the midst of two serious epidemics -- COVID-19 and the opioid crisis, a third forgotten epidemic has risen up again amidst the chaos.  Gun violence is racking Hartford as it is in many cities in the United States.  In Hartford shootings are up 60% in 2020 and are already at a six year high with many days left in the years.  

Brazen shootings frustrate Hartford police as surge in gun violence continues despite crackdown

No one knows why the violence is up.  An article in the Hartford Courant offers two theories.  Decreased probation and violence prevention services during the pandemic and the effects of new police accountability rules that may encourage criminals to be bolder.  From a paramedic’s perspective all I know is the bullets are flying again just like in the days when the Latin Kings and Los Solidos battled over the drug trade back in the mid 1990’s when I first started as a paramedic in the city.

I haven’t used the blood yet, but it has already been credited with saving at least one life.  The medics were able to start infusing blood on the scene and doctors later told them the infusion likely prevented the patient from arresting and provided valuable time to get him to the OR.  Credit to Saint Francis Hospital and Medical Center in partnership with American Medical Response for instituting the program.

I thought I was going to use the blood recently when I responded to a shooting in the north end, with the police urgently hailing me as I arrived on scene.  The patient, who was ambushed in his backyard, was still alert, and  his vitals weren’t within the parameters to start blood (BP less than 90 or pulse above 120).  The man was surprisingly calm for being shot, and being in considerable pain despite my giving him 100 mcgs of fentanyl.  As many shooting victims seem to do, he chatted on his cell phone on the way to the hospital, telling a friend that he had been shot, and in phrases no doubt understandable to the person on the other end, conveyed who he felt was behind it.  After he hung up, he looked me in the eyes and said,  “My days of preaching nonviolence have come to an end.”

There were five more shootings in the city in the next three days.  The paper said it wasn’t clear if any of them were related.