Courteous

We get sent for an EDP (emotionally disturbed person). The cop meets us outside and says it is an old lady with Alzheimers. She took the trash out in her nightgown even though the trash doesn't get picked up today. This has happened before -- the woman wandering the neighborhood in her nightgown. Her husband came out to get her and she attacked him, scratching him quite viciously. She is now saying the neighbors attacked the house with snowballs and beat her husband up. The cop says the husband can't handle her anymore.

We go inside and find a sweet old woman sitting in her nightgown in an arm chair in the living room.

"I don't want to go to the hospital," she says.

"You brought this on. You brought this all on yourself," the husband says.

Another police office tries to usher the husband back into the kitchen.

"But they attacked our house," she says. "The neighbors."

"In your dreams," the husband shouts. "In your dreams!"

"Will my husband be coming to the hospital with me?" the woman asks me.

"No," he shouts again. "Take her out with the trash for all I care!"

***

In the ambulance, I ask her questions to test her memory. She is able to answer some, but not others.

She thinks today is Christmas. She knows her birthday. She says she thinks they have lived in their house for twenty years.

I ask her how old she was when she met her husband. She says she was twenty-five, but she doesn't remember where she met him.

They had a big wedding. They are Greek. Niether of them were good dancers.

She doesn't remember the names of her children. They are grown up and married.

She doesn't know what happened today or why she is in the ambulance.

"What qualities did your husband have that made you want to marry him?" I ask.

She thinks a moment, then smiles, remembering. "He is a kind man," she says. "Always very considerate. Courteous. He always treats me well."

Pastry

The call is for severe bleeding. It turns out to be a burst abscess in a teenage male, who three weeks ago tore his hamstring. He bled internally , but the blood wasn't reabsorbed by the body and an abscess started to grow. He was scheduled to have surgery to remove the undrained blood. At first I didn't know what it was. His friend was holding pressure on it, and had told me about spurting blood. We removed the pressure and then after a moment's delay this huge bloblike hunk of blood began to flow out of the large open wound. I covered it right back up and held pressure. He screamed. When I uncovered it at the hospital for the doctor, I saw it was just pus. It was like pus from a boil, except it was at first, dark red, then pinky, almost pepperminty in color. The pus that flowed out just kept coming. It didn't stop.

I go down to the nurse's station to give my report to the nurse. He hasn't seen the patient yet. As I am giving my report the nurse is chowing down on these little pastries. He hands me a creme-filled one. I stare at it a moment, then back at the nurse. Then as soon as I am done with my report, I walk around the corner and drop the pastry in the trash can.

"I'm going down to the cafeteria," my partner says. "You coming?"

"I'll eat later," I say.

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.

Imagine

I rarely follow up with my patients. If they are in the ED when I come back with a new patient, I will stop in and see how thay are doing. Or I might ask a nurse or a doctor what was the deal with a certain recent patient from earlier in the day or maybe even the day before, but I am not one of these guys who is always going up to the floors to reintroduce myself to the patient as the paramedic who brought them in. Not that there is anything wrong with it. I did it a few times when I first started. Haven't for years.

A couple weeks ago, we did a code save. I wrote about it in an entry titled Blanket. It was my third code save this year. By "save" I am using the iffy terminology of a cardiac arrest patient brought to the ED with a blood pressure and still alive when we left the ED.

When it comes to cardiac arrests, unless they are talking to me when I leave the ER, I guess I just assume they die eventually. I was surprised once. I got called for a stroke. I found a man sitting on a neighbor's garbadge can, where he had been talking to them after driving up in his car, when he suddenly slumped over. We went lights and sirens to the hospital following the stoke protocol. I dug his ID out of his wallet and was shocked by the name. It was the same name as a man I had done in a cardiac arrest a year before. I'd gotten a pressure back, but never thought anything more of it. I just assumed he had died or was a vegetable in some nursing home. To make it an even better story, his massive stroke turned out to be a TIA and he was talking to me before we even reached the hospital. He was in fact the same guy. At the hospital I met his family and they said they had tried to get in contact with me. They had gone to the fire station to leave a message for me, but hadn't heard anything back. Niether had I. That day in the ER at our little reunion we all shook hands and hugged, and smiled a lot.

With that story in mind, and because on this code -- as I have written before, my two partners were a young man going through the EMT class and a two decades of experience plus EMT, both of whom it was their first code save -- I thought it would be nice to find out how the lady was doing. She was after all breathing on her own on the way in. I had found out that a week later she was still alive in the ICU although I had no report on her condition.

I began to imagine her alive. I imagined us visiting her back in her home with her family and all her granchildren and great grandchildren around her. I thought how happy my partners would feel. For one it would be the crowning achievement of his career, for the other, an indelible moment that would guide him toward a long rewarding lifetime in EMS.

I went in to see the hospital's EMS coordinator and ask him if he could look up the three code saves I had this year, particularly the last one, to see how they made out. He said it would take some leg work, but he would be happy to do it for me.

I thanked him, then went out to the car, and just happened to open up the newspaper. There she was on the obituary page. Our "save." A 93-year old great great grandmother. Died in the hospital. Rest in peace. I saw the coordinator later that day and thanked him for his offer, but told him not to bother looking up the others.

Alone

A sixty year old woman who lives alone feels her throat begining to swell. This is not the first time it has happened -- she has a history of angioedema -- so she knows what to do. She takes her closest epi-pen (She has ten scattered about the house) and injects herself with the lifesaving drug, and then calls 911.

She is still having some trouble swallowing when we get there. "It's getting easier," she says. "Thank you for coming so quickly."

I listen to her throat. There is a good flow of air.

She is sitting on the short steps that lead from the living room up to the second level of the house. "I was scared there for a moment," she says. She is a short, squat greyhaired woman, who speaks very deliberately. "It's been quite a week for me. I didn't need this."

"What hospital do you want to go to?"

"This is not how I wanted to spend the night." She sounds like she has the weight of the world on her shoulders.

"Someone has to let the dogs in," she says. "They can't be left outside. They're too old."

I offer to do it, even though I hate dogs. I open up the back door, and say, here, pouchies, then I hear some chains rattling and the rustle of two big dogs approaching and then I see they are German Shepards. I have had some terrible experiences with German Shepards in my life -- one taking a bite out of my butt when I was riding my bike as a five year old, and then another dog -- Stormy -- terrorizing me in the neighborhood when I was in junior high. But these dogs are nice, and give me no trouble and come right in and approach their owner who gives them hugs and tells them to be good, while she puts some water in their dishes.

On the way in to the hospital, the woman tells me she had just been diagnosed with cancer and is scheduled for surgery in January. "I'm going to have to put them down."

"They seem okay."

Her voice quivers. "No, they are old and incontinent and there will be no one to take care of them when I'm sick. With the surgery, and then the chemo, and the radiation, I don't want to put them through that."

"Don't you have family in the area? Someone to look after them."

She shakes her head. "No, it's just me."

"That's too bad."

"They've lived good lives."

"I guess maybe being put down isn't the worst way to go. In this job, you come to feel good for people who die in their sleep."

She breaks into a smile, as she looks almost inward. "You can't get much better than to die in the arms of someone who loves you."

And then there is silence between us.

She cries quietly.

Diamond in the Rough (Update)

Back in August I posted the first three chapters of a novel I have been revising called Diamond in the Rough. Instead of posting additional chapters on this site, I have set up a secondary site where the chapters can be read by those interested. I will post on here when I have added new chapters. Right now I have chapters 1-9 posted.

Before you read them and pass judgement, I need to add some cautions and qualifiers. There are characters in this book (particuarly Fred) who do things that I do not obviously endorse. My main character (the narrator), who I hope will be viewed as symphathetic, will do things that are clearly unacceptable. This novel is based on a true incident, and grew out of a challenge I gave myself to find out why someone did what they did, and to try to write a story that might explain how someone would come to do such a deed. While some people may take offense to the behavior of some EMTs in this story, as they should, I hope in the end that the book will offer some kind of redemption. Lastly while the book is based on a true incident, all of the characters are entirely fictional. Any resemblence to real people is entirely coincidental.

Here then is the link:

Diamond in the Rough

A Blanket

It is during the tail end of a snow storm that has left ten inches in six hours. We are on the way back from the hospital after a call where we had to wade through deep drifts to get to a patient's farmhouse. The roads are barely plowed. We get called for a 93-year old woman unresponsive with shallow breathing. Updated to respirations at six a minute, now irregular and gasping. I say it's going to be a code. When we get there instead of trying to haul the stretcher through the snow, we grab the equipment and go right in. We have to walk through a narrow hallway, through an open living room, then down some stairs to the basement, then down another corridor and into a small bedroom where a man and younger woman stand, and there on the bed is an old woman who from the door I could see is not breathing.

I'm thinking great, 93 years old not breathing. She is dead. Has the family even thought about what they want us to do? I say (I really do say) "Have you thought at all about what you would like us to do if she stops breathing or her heart stops and she dies." I feel for a pulse. There is none. "Like now. Would you like us to resuscitate her?"

The man seems understandably flustered by my question, and hesitates and then says something to the effect of well, yes, yes we do.

"It's a code," I tell my partner who has followed me down the narrow hallway and into the bedroom. "Let's get her on the floor." We pick her up and place her on the floor so there is room for one person at the head and room between the end of the bed and the dresser for someone to do compressions. I hand one partner the ambu bag, then the other partner -- an EMT student, the young ex-high school football player, who has been doing so well riding with us -- I tell to do compressions, (Let's do the new CPR, I say, 30 and 2) while I get the defib pads out, hook them up to the monitor, then slap them on. I have them stop for a moment, and I quickly see the woman is asystole.

I tell them to continue and not stop, while I get out my intubation kit. I also hand an oral airway to my partner, and tell him to take out her false teeth. The bottom teeth come out, but the top, he says are nailed in.

I take out a number 8 tube. I see the epiglottis, see the chords, have a little trouble getting the tube to go into the chords, as the lady's teeth stick up and there is not a lot of room between the blade, the teeth and the side's of her mouth. I reshape the tube, making it straighter and I am able to easily pass it. The bulb syringe test works. No sound in the belly. Equal and strong on the right and left. Vapor in the tube. I tie it up with the commercial holder. I hand it over to my partner and say, keep it in there. Squeeze the bag 8 times a minute.

Then, instead of dropping some epi down the tube like I always do, I delay and go for an IV. As I am pulling out my IV kit I remember I need to attach the capnography. I attach the capnography device between the tube and the bag and then into the machine. I glance at the reading. It says 35. I am shocked. 35 is normal. It is also an excellent prognosticator. On the other hand the lady looks dead and is asystole.

I get a 20 in the AC. I have them stop CPR. Still asystole, then I tell them to resume. I take out a milligram of epi and say, "All right, let's see if the epi can do it's job," and I slam the epi followed by an atropine.

I look up at the monitor and see a funky rhythm.

Shock or not shock. I hold off because it looks organized.

I give another epi. We continue CPR. The young man is doing deep strong compressions. We're bagging nice and slowly.

When we stop again, it looks like there is a qrs complex, then some loopy ventricular like rolls, then a qrs.

I go so far as to hit the charge button, but I hold off.

There is a rhythm trying to break in.

And there it is.

No question about it.

"Check for pulses," I say.

"Strong radial pulse," my partner says. "Very rapid."

I look at the monitor. A Sinus tack at 132 that over the next several minutes gradually comes down to the low 100s.

93 years old and we get her back -- at least temporarily. As we package her up, I stay vigilant waiting for the epi to wear off, but she's hanging right in there. Good rhythm, good end tidal. Good BP.

We have a difficult extrication. We can't get the stretcher in the house. We have to strap her to the board, securing her head with head blocks. A police officer and I carry her down the hall stopping every ten seconds or so to ventilate her. The stair is a bitch. We have to pass her up nearly vertical. Her family waits in the living room. Suddenly they are yelling at us. "Put a sheet on her." "You can't take her out like that." "Let me get a blanket." "Have some respect for her modesty."

I am doing my best to keep her from toppling off the board. I hadn't even thought about her exposed breasts. I was concerned with just getting her to the ambulance. They are yelling at me. It occurs to me then that they have no idea about her condition. I normally try to involve the family, and keep them updated, but due to the geography of the scene, I was isolated from them. I remember what I read in Thom Dick's book, People Care: Career-Friendly Practices for Professional Caregivers..

"People don't remember much about our medicine. But they do remember how we make them feel."-Thom Dick

We have no sheets handy. Our stretcher is outside in the snow. I set her down because I don't want to drop her and it's time for more ventilation.

"She'll be cold," a family member says.

I want to explain what I have just read in the new AHA guidelines about the benefits of hypothermia and how keeping her from getting too hot is good for her. "Her situation is very critical," I say. "We need to get her to the ambulance." I glance at the monitor. Still holding her own. "We'll get her covered up." I nod to the officer to pick her up again.

Normally, on a code I always pause, and have the family say something to the patient, even though she may not be able to hear. I do it for the family to let them at least have a chance to say goodbye because most of the time the patient is dead by the time they arrive. But I am not even thinking about that now. I'm just thinking about getting her out to the ambulance through the snow before she loses her pulse.

We back out the door, and down the icy steps, and out to where to the stretcher is set up. There we bag her again, and throw a blanket on her. In the back of the ambulance, we switch her to the main 02, and head to the hospital. Everything status quo. The EMT student is bagging. I compliment him on how well he has done on the call, but I tell him we can't expect the woman to ever walk out of the hospital. At her age and given the condition we found her in, it just isn't going to happen. He nods and says nothing.

A moment later the woman moves suddenly. It startles both of us. And then we see her chest heave again. And again. And to my amazement she is breathing on her own.

"But then again," I say. "I could be wrong."

At the hospital, her pressure is 130/60. Her heart rate is 104. Her respiratory rate is 10.

The doctor congratulates us and I praise my crew. My regular partner has worked EMS as a volunteer for 20 years and this is his first save. The EMT student has just begun his career. I am still startled that we got back a 93 year old woman from asystole. She had to have stopped breathing just minutes before our arrival. I tried to use the new AHA guidelines. Good CPR, less ventilations. No drugs down the tube. Even unconsciously hypothermia. And while the AHA guidelines say our cardiac drugs have never been proven to help. I know she responded to the epi. I have seen it before. Epi IV has gotten me back many an arrested patient, or at least gotten them to the hospital alive.

But before I congratulate myself too much, after I have written the run form and dropped it off with the nurse, I glance at the patient's room and see two family members sitting in armless chairs by her side. Their eyes meet mine. They stare at me but give no expression. I feel like they are waiting for me to say something.

I approach, and bow my head slightly. They remain seated. "I am sorry about not covering her up," I say. I should have gotten a blanket."

"That's all right," the woman says. "Thank you."

"I wanted to get her out to the ambulance. I wasn't thinking."

"Thank you," she says. "Thank you for helping."

I bow my head slightly again, and then head back down the hall.

Lesson learned.

People Care

If you are looking to get someone in EMS a great Christmas present, here is the book for them or for yourself:

People Care: Career-Friendly Practices for Professional Caregivers

Thom Dick is the author of Street Talk, a book of essays that came out about the time I was in EMT school in 1989. It was extremely influential in instructing me in what it meant to be a caregiver. It encouraged me to see the patient as a person, to respect the people I work with, to take the time to be kind, and other important lessons that helped me become a better EMT.

A few years later I heard him speak at an EMS convention and he was fantastic. He got you fired up to go out there and hold old ladies' hands. He made you feel like the work you did, even the mundane parts, was special. I read his book often over the years and it always charged me up. Now I don't pretend to have always lived up to his standards. I know I haven't. But I do try.

His new book seems to be a expansion/complilation of his prior book and the talks he gives all over the country. It is enhanced by cartoons by Steve Berry, who does the I am Not an Ambulance Driver cartoon series.

"When you kneel in front of somebody's granpa who's sitting on his couch and denying his chest pain, you need to recognize the pain he says isn't there, detect the shortness of breath he hasn't mentioned and sense the fear that's absolutely dominating his conciousness. You need to appreciate the fact that his spouse, seated right there next to him, is scared to death she's never going to sleep with him again. And somehow, you need to make everything better in just a few minutes.

These are the dynamics of even the simplest emergency response. They presuppose the presence of gifts in us that not even the greatest teacher can impart -- gifts that unfortunately, come without instructions.

This book is an examination of those gifts and a collection of the instructions that didn't come with them. It's based on the collective experience and wisdom of dozens of professional paramedics and EMTs worlwide who learned to love the lifelong pursuit of helping others.

We hope it helps you to join their number."

- from back cover of book

"People don't remember much about our medicine. But they do remember how we make them feel."
-Thom Dick

"It's not enough to be the most competent EMT you can be. You need to be nice. And it's not enough to be nice. You need to be competent and nice."
-Thom Dick

New AHA CPR and ECG Guidelines

I'm like a kid before Christmas waiting for the new AHA CPR and ECC guidelines to come out. For almost a year I have been following the evidence sheets posted on the Heart Association web site, and nearly everyday in November checked the site for the new guidelines to be posted. When they finally came out over a week ago, I downloaded them and have been pouring over them. The guidelines are exciting to me because they represent the synthesis of expert's opinions after reviewing all the studies of the last five years, they give a glimpse of how EMS will be in the near future and they are full of instructive PEARLS. (Reading them line by line is an excellent educational learning experience. My copy of the 2000 guidelines is heavily highlighted and dog-eared.) Also, as someone involved in writing my region's protocols, I am interested in how they may have to be rewritten.

There are some interesting changes in the new guidelines, some of which have already made the news:

Cardiac Arrest:
CPR for lay people is now 30 compressions to 2 respirations for adults instead of 15:2.

When EMS response to a cardiac arrest is 4-5 minutes or when EMS responders did not witness the arrest, EMS providers may do 2 minutes of CPR prior to defibrillation.

1 shock instead of 3 stacked: Rescuers should resume CPR immediately after shocking and continue for 2 minutes before checking for pulse or to shock again. Rescuers should continue CPR during the charging phase of defib until time to clear.

The first shock should be 360 monophasic or 150-200 for biphasic.

The focus is on compressions. "Simply put: rescuers should push hard, push fast, allow full chest recoil, minimize interruptions in compressions, and defibrillate promptly when appropriate."

Ventilations should be 8 to 10 per minute in the intubated patient in arrest; 10 to 12 with a perfusing rhytmn.

Pacing for asystole is no longer recommended.

Unless special siuations are present (hypothermia)"cessation of efforts in the out-of-hospital setting, following system-specific criteria and under direct medical control, should be standard practice in all EMS systems."

Cardiac arrest associated with Trauma
If intubation is performed in the field, it should be done during transport.

Volume infusion for trauma is recommended only for patients with isolated head or extremity trauma with goal of systolic >100.

Tachycardias
Lidociane is no longer in the algorithm for tachycardia with pulses. It's amiodarone.

Rapid afib has new language that says "we recommend expert consultation if the patient is stable." The phrase runs throughout the section. "Stable patients may await expert consultation because treatment has the potential for harm."

ACS
Nitro has new restrictions in the setting of ACS. No nitro for heart rates less than 50 and more than 100. And no nitro if the BP is 30 mm Hg below patient's baseline, rather than just below 90 mm Hg.

Asthma
Steroids should be administered to all asthma patients as early as possible.

Anaphylaxis
Epi 1:1000 should be administered IM not SQ.

***

I am anxious to discuss the new guidelines at our MAC meeting next week and hear other people's opinions.

Much of it makes sense to me. The focus on compressions I think is huge. As I have written before I have been on many scenes where CPR just doesn't get done. Someone's going for the tube, someone's going for the IV, someones getting the board and no one is on compressions. And it seems everytime I come upon a code where only first responders are there, all I hear is the defib unit going, "checking pulses, if no pulses..." and everyone just standing there. When compressions do get done, they are often done poorly. When I started really focusing on compressions, my save rate (at least rate to the hospital with pulses) went up considerably.

I worry a little about the ventilations not getting done. I also worry about people getting shocked as they want compressions to continue even when the defib is charging. Still I'm for the changes. What we have right now isn't working very well. Hopefully this will be better.

From a medic standpoint I was a little discouraged that I got a bit of an anti-medic feeling reading the guidelines. Now let me say, I believe these guidelines are pro-patient, and anything pro-patient has to also be pro-medic because medics are for what is best for the patient. What I mean is that so much that medics do seems to be being discredited -- and maybe for the best. From fluid rescusitation for trauma, to intubation(the text is full of caution about the pitfalls of intubation), to the curious language of seeking "expert consultation," the message seems to be just take them to the hospital without harming them. You can't argue with "Do No Harm" if it is harm that we have been doing.

On the other hand, there is full recognition that if we can't bring someone back in the field, they will not be brought back in the ED. (It is time to end futile resuscitations and senseless transports of dead people.)

I believe in and trust experts, I just hope however that there were medics or at least pro-medic people at the table to see that the evidence was interpreted in a way that wasn't biased against what we do, or interpreted with a proper understanding of what and how we do what we do.

Lastly, I must say just because the meds we give during codes haven't been proven to work doesn't mean medics aren't worth anything. It means the meds aren't worth anything. I believe medics are very important, but they are only as good as their education, their training, their oversight, and the equipment, meds, and tools they are given to do the job.

***

Major Changes in the 2005 AHA Guidelines for CPR and ECC. Reaching the Tipping Point for Change

And a link to all the abstracts:

Circulation Selected Abstracts


***

Added 12/11/05

There are three publications that can be downloaded:

View the C2005 International Consensus on CPR and ECC Science with Treatment Recommendations

View the 2005 AHA Guidelines for CPR and ECC

Currents 2005 Highlights


Eventually, I'm guessing in the spring, the AHA will be selling paperbound copies of the guidlines and science as they have done in the past.

Bathroom Break

Today I did something for the first time I had never ever done before while working in EMS. In this job you learn when you are sitting around waiting for a call that if the urge to use the bathroom comes upon you, you act on it because it sucks to be suddenly hurtling down the road on your way to a cardiac arrest having thinking to yourself, "Boy do I have to pee. Damn, I should have peed when I had the urge." Or worse. Once you get on the call, however, your adrenaline takes over and your urge fades to the background at least until you get to the hospital, then as soon as you have unloaded your patient and turned over care, you make a beeline to the bathroom.

Here's what happened today. We get called for "leg pain" and climb the stairs of an apartment to the second floor to find a large(220 plus) 50-year old woman sitting on the bedspread of a kingsize bed on top of a bed pan, with her pajama pants pulled down. Her aged mother says the patient, her daughter, hasn't gotten out of bed for five days even though there is nothing wrong with her. She has a history of mental illness but has not been on any medications or seen any doctors for over a year. She refuses to get out of bed for us. I ask the patient why she can't get out of bed, she says her leg is stiff, but when we approach, she seems to be moving it very well when she tries to kick us. Her mother says she is also diabetic, so to check her sugar, it takes three of us to hold her down while she kicks and tries to swing her arms and bite us. Her sugar is 148 -- normal.

We discuss our options then with the police officer. I say it is clear she is a threat to herself. She is obviously mentally ill. He questions her some and agrees. We each take a turn trying to persuade her that she needs to come with us, but she will have none of it. Even our threat to remove her by force doesn't phase her. "Bring it on," she says, "I ain't going."

We are on the second floor and stairwell is narrow. None of us is looking forward to wrestling with her, and fighting with her down the stairs. We decide to try to just medicate her. I tell everyone that once I give her the medicine we will need to wait at least ten minutes for it to take effect. A few weeks ago, I sedated a 16-year old in the city and the cops were impatient and tried to move her before the medicine had a chance to really work so she fought us, kicking and screaming all the way out to the ambulance, and only then after we had tied her down did she fall asleep.

The cop starts writing a PEER(Police Emergency Evaluation Request) that gives us the power to take her against her will. I prepare my two syringes. As I lay out my equipment -- the narc kit which has the ativan, the med kit which has the haldol, the IV kit that has the syringes and alcohol -- I think that I should have a premade sedation kit (like the OB kits), but one that would include a tape of relaxation music -- the sound of waves or light rainfall -- to put on the music player and maybe candles or incense to burn. When I am ready, the others hold her down, while I wipe her arm down then inject her, first with the Ativan, then with the haldol. Then we sit back and wait.

Suddenly I have a terrible stomach ache. I try to ignore it, but it only worsens. I have had stomach aches before on the job, but then I was always caught up in the call and managed to fight through it. But here I am standing waiting -- at least ten minutes for the drugs to take effect -- and I am about fifteen feet from the patient's open bathroom door. I try to suck it in, but it is like a stabbing knife. I think about my ability to keep it in if the medicine maybe doesn't work that well -- the patient is a big woman, and we have to carry her fighting down the stairs. Finally I can't take it anymore. I ask the patient's mother if I may use the bathroom. She says yes, and a few minutes later, I walk back out. Are you okay? they ask. I nodd. Just fine, thank you. I am a new man.

We wait another five minutes, and then pick the woman up with minimal resistance, place her on the stair chair, carry her down to the stretcher, and she sleeps all the way to the hospital.

Scandanavian Beauty

We get a third party call for a woman with abdominal pain coughing up blood. The neighbor meets us at the door and tells us the older woman is feeling woozy, and has been coughing up bright red blood. She also mentions that she hasn't been acting quite right. Yesterday she was out raking the other neighbor's yard instead of her own.

As we walk through the old farmhouse, which is immaculately kept with beautiful hardwood floors and antique furniture. I begin to remember being in this house before. And once I see the old woman in her upstairs bedroom, it all comes back to me. Several years ago we were called to this same house because no one would answer the phone and the woman who lived here hadn't been seen for awhile. We pounded on the door. No answer. We finally broke in and walked quickly through the rooms of the house looking for someone on the ground with a broken hip, someone stroked out, or maybe someone cold rigored and stiff. The cop and I walked right through the bedroom and into the large bathroom, then turned around and came back through the bedroom and there she was sitting in a big velvet backed arm chair by her bed, completely naked, looking like she had just gotten out of a sauna, watching us without saying a word, off in her own world, a cup of hot tea in her hands. She was in her eighties, but all I can say is she was a Scandanavian beauty with a chest that Raquel Welch would have been proud of. Tonight she is sitting in the same chair, except she has a bathrobe on and her skin is jaundiced, and she looks frail and much older. The clean carpet is scattered with tissues tinged with blood. She still has her tea and we let her finish drinking it before we carry her down in the stair chair.

Apnea

On another site I keep a daily journal. I record evey call I do in a day along with some observations. It is from this journal that I draw most of the material for this blog. Here I try to write simple stories that I have given some thought too. There I just write whatever I think of when I get home. Some days its pretty boring, some its repetitive. Because of the nature of confidentiality, I don't use my name on that site because it identifies the calls as date specific, and even though I may change many of the details, I just prefer to leave it more anynomous. Reviewing what I have written over the last year, shows too many days when all I am writing about is a broken EMS system. Here is part of a recent entry(I did rewrite it some. I can't help myself).

A 97 year-old-man whith a poor gait falls twice in his apartment in a residential community. He is not hurt, but according to the nurse he is not as spry as he used to be(like when he was 96) and hasn't been eating as much and, fall once, you get a free pass, fall twice, it's a trip to the hospital. We go to a distant hospital because that's where his doctor is based, not that his doctor is going to come in and see him on a Sunday.

A nursing home calls a commercial service to transport a patient not as responsive as usual, which usually isn't much. The commercial call-taker hears the word "unresponsive" and passes(as directed by state mandate) the call to us -- the local 911 provider. Because it is now a 911 call, our police dispatcher sends two police cars lights and sirens, in addition to us, who are coming from the distant hospital. The cops skid into the curb, run inside and find no nurses or aides. They find a patient "not breathing" and put her on oxygen and she immediately starts breathing. They finally find a nurse and what develops is a heated arguement about elder abuse, complete with "I want your name" and "I want your name."

That's when we come in. Now I have often been to this nursing home and found patients in dire straights with no nurses anywhere to be found to give me a report, and the nurse who is here today is one of the worst offenders, but when I enter the room, the patient seems fine. She does have periods of apnea, but I have taken her in before and that is normal for her. Sometimes she just isn't as perky in her semi-responsive way as she is on better days. The patient has every diagnosis possible: CVA, Dementia, diaylsis, MI, CHF, NIDDM, Alzheimers, HTN, Seizure, etc. And of course she is a full code. I guess the officers came in during one of the apnea periods. They thought she wasn't breathing, they put her on an 02 mask and whalla, she started breathing.

The officers should never have been sent in the first place. It was after all just a nursing home "emergifer(emergency transfer/unscheduled transfer)." And of course they were never told it was an commercial pass. They thought they were responding to a life and death emergency. They found a patient "not breathing" unattended by a nurse or even a nurse's aide. From where they are coming from, they were rightly upset. But to the nurse it was just a transfer and she had other patients to attend to because the truth is nursing homes are notoriously understaffed.

I love being a medic and like working on the regional EMS committees. But somedays I wish I was in charge of the whole shebang with unlimited power, then I could fix some of these things. Fix the apnea in the system.