Sunday, July 30, 2006

CPR

I did a code last week which ended the longest drought of my career when it comes to cardiac arrests. When I came back from the EMS Conference in Baltimore all excited to try the new CPR, I had no opportunities. Not to sound morbid, but when I walked into the basement bedroom and saw the officers doing CPR, I thought "Finally, a code."

The patient was in his late fifties. His family had been talking to him when he collapsed. I could see a dialysis catheter sticking out of his chest. He was asystole, no shock advised. He’d been down about ten minutes. I intubated him and put on the capnography – which revealed a good wave form and an ETCO2 reading of 17 to 23, which is a sign that he might indeed still be salvageable. While my partners took over CPR, I put in an EJ and started slamming the drugs. I gave him some calcium, and then as one of my partners was tiring doing the compressions I took over for a minute. I just started pounding away. Hard fast and deep. I felt like I was really priming the pump. I was John Henry against the steam drill. Then I looked over at the monitor and the ETCO2 number was 35. I stopped compressions and there was a rythmn. We checked his carotid and he had pulses. BP of 124/80. Wow, I thought!

We packaged him up, and as we got him outside, the capnography dropped down to 18 and we checked for pulses and they were gone. We gave him some more epi and got the capnography number back up and there were pulses again. We had a hard push up an outside hill to get back up to the driveway – it was either that or carry him up a steep flight of stairs and down some narrow furniture filled hallways in the house. We lost pulses again – and again it was flagged by the drop in the capnography.

On the way in – I had another paramedic with me – so we swapped back and forth doing compressions. I usually never do compressions because as the only medic on most calls, I am managing the airway or pushing drugs. Compressions are hard work. I kept yelling at the driver to slow down. He is the smoothest driver here and I couldn’t believe he was giving such a rough ride even though he was only going twenty – and then I realized it wasn’t so much he was giving a bad ride, but for the first time in years I was having to do compressions while standing up, trying to balance myself. It was hard – that and trying to do good deep, fast compressions. I kept switching back and forth with the other medic. At one point when the capnography was at 16, I told him if he could get it up to 20, I’d buy at Dunk’in Doughnuts. He started pounding away and slowly the number came up to twenty, and right on up – all the way to 28. If he slowed down the number dropped. Between us we kept the number in the high twenties, and then it shot up into the thirties and we had pulses back.

When we went to take the patient out of the back for some reason the wheels didn’t drop right and the patient slammed down on the steps and almost rolled off the stretcher. I looked at the monitor and was glad to see I still had a good capnography wave form so the tube hadn’t become dislodged.

Going down the hall the capnography number dropped again and we started CPR. They worked him awhile longer at the hospital, but he didn’t make it.

The capnography was very instructive. It did the following:

1) Confirmed placement of the tube.
2) Alerted us to ROSC three times.
3) Showed how well CPR could be done when we concentrated on it.
4) Confirmed continuously placement of tube.

Here’s the capnography trend summary showing the three episodes of Return of Spontaneous Circulation (ROSC).

Tuesday, July 25, 2006

SAVED ON TNT

Okay. The new TNT paramedic show SAVED. So what do I think about it? First, here’s the link to My Hollywood Adventure, which details how the producers of the show had read my books in preparing the pilot for the show and how I was then asked to be a technical advisor/possible writer and how in the end they offered me less money than I make here, and I had no choice but to turn them down.

I have had mixed feelings about the show. On the one hand I want it to stink because they got me all excited about working on the show, and then seriously low-balled me on pay and how on the other hand, I want it to be a success because paramedics deserve a good show about them and the more interest in paramedicine the more people are apt to buy my books and the greater the chance I can get more books published.

I have now seen I think four of the six or seven episodes and my feelings remain mixed. Overall I have to say I am glad I am not working on it. I say these for five reasons.

1) There has been a big backlash against the show from paramedics who feel the show negatively portrays the profession. I would not want their venom directed at me.

2) There have been many scenes that from a medical point of view border on the ridiculous. Again, I wouldn’t want to have to defend those scenes.

3) There have been some comments about doctors that would lose me all of my doctor friends. Ditto above.

4) The show repeatedly skewers a fictitious company called NMR “the evil empire”, a company probably modeled(incorrectly) after the company I work for. Imagine my being on leave of absence from NMR to help a show that in a continuing plotline portrays NMR and all its employees as uncaring idiots. I lose my job and the friendship of all my coworkers.

5) If I worked on the show I wouldn’t be out here in the streets doing the real thing, which I love. I also wouldn’t be in the community or with the people I love. Hollywood would have been a good story, but I am where I belong.

Despite some deserved criticism, I do think some perspective on the show is necessary.

1) It is TV. You couldn’t do a show about what the job is really like and have it be interesting every minute. EMS is long stretches of boredom broken up by a few moments of excitement and sometimes chaos. Imagine a show about ambulances posting on street corners or doing emergi-fers – transfers disguised as emergencies because the nursing home policy is to call 911 even if the patient just has a clogged Foley catheter.

2) When I spoke at length with the SAVED people, the producer’s assistant said the show was a cross between Emergency and M.A.S.H. The producer said it was a character driven drama about a guy who’s life is out of control, and only his job saves him. So this is really just a show about “Wyatt” who happens to work in EMS. It is not intended to be a show about EMS as it really is. EMS is just the background.

3) Even the medical scenes need to be cut some slack. You may save a baby, but that save may take place over twenty minutes. That would cut out all the other scenes.

4) For all the guff about the medic being unshaven and in a tee-shirt and not using gloves, look around – he’s not the only one.

Okay, here’s what I have hated about the show;

1) The portrayal of NMR. I found the scene where the NMR people outside the gay bar were not going in until they had donned their Space suits was insulting not only to people at NMR but to any responder. The bit about defibrillating the dog was also stupid.

2) The medicine. The scene at the end of the first episode where he can’t decide whether the cardiac arrest patient is in V-Tack or an SVT with aberrancy and one medic suggests he give Verapamil. I wanted to say, hand over your certs so I can rip them up. The cardiac tamponade scene in an episode a week ago was also ridiculous. I could go on.

3) The hero, or anti-hero, Wyatt is hard to like. Despite the big speech he made at the end of one episode, unshaven face and unshined boots are not the ingredients of a good medic and clean-cut grooming and shined boots are not the ingredients of a horrible robot medic. Me, my boots need shining, my hair needs a trim, but it has absolutely nothing to do with whether or not my medicine is any good. And even though my hair needs a trim and my boots need shining I would never deliberately cause an accident with the joyriders following the ambulance. You do that and any compassion you have for any human goes out the door.

And I have been wanting to say to the guy “So you have Daddy problems? Try growing up.” His father actually seems to be a decent guy. He loves his son and just wants a good life for him. Why can’t Wyatt see that? Then last night, his partner said to Wyatt, “What you need are real world problems.” What a great line. Exactly what I felt about the guy. Maybe he is just what the producers intended. Maybe we will see growth.

Now, here is what I have liked.

1) I like watching to see what they do right and what they do wrong. I was glad to see at around the 4th episode they finally started inflating the nonrebreathers.

2) The soundtrack is great.

3) They do some scene scenes pretty well.

4) I like some of the themes they are exploring – loyalty, the unexpected nature of life.

Now, let’s talk about last night’s episode – this is the one where the girl who needs the liver transplant dies, Wyatt’s partner is taking speed, the old lady thinks Wyatt is her husband, etc. What a great episode! Seriously, they did a lot of it really, really well. I loved the scene where they take the dying girl out to look at the sunset. This was really good writing. A nice show that aside from a baby in respiratory distress really didn’t have a lot of EMS action. (Wait, I just remembered the OD/arrest – still only two “big” calls.) The relationship between both sets of partners was well done. Anyone watching this show couldn’t help but come away impressed with paramedics, their compassion and the work they do. Bravo on many accounts.

I hope it keeps getting better and gets picked up for another season.

Monday, July 24, 2006

Doldrums/Novel Excerpts

I don't know if its me or the calls or what, but lately I just don't feel like I have anything to write about. It is getting so bad I am thinking about stopping my daily blog altogether to concentrate on one quality post a week here. Part of it is I have been so occupied with other things I just haven't focused on the truly interesting things about this job that you can see if you just look -- Whether its the patients, the situations, random moments or deeper thoughts about our profession. I apologize.

I have been spending much of my writing time lately working on my two EMS novels. I have rewritten Diamond in the Rough, but recieved a scathing review on it from a long-time friend and reader of my work whose judgement I trust. She said she disliked all the characters and it wasn't until the end that she felt any emphathy at all for them. Not good. The story, which involves an EMT, who is a thief, depends on my ability to make him not only sympathetic, but understandable. I'm not ready to give up, but I have my work cut out for me. The other novel, Mortal Men, which I have higher hopes for, is coming along better. I am going to post several chapters below. And while I may post more chapters in the future, it will not be my intention to post the entire novel, as I did briefly and may do again with Mortal Men.

One of the things I like about fiction, which I am a little frustrated about with my blogs is that in fiction I can get into areas I can't with the blog. There are areas in true life writing that are off-limits.

Anyway, I hope to start posting again about interesting calls and situations -- as soon as I happen upon some. Also, I am planning one of these days to write about the TNT show SAVED.

Now below, the first three chapters of Mortal Men:

*****


“…mortals, who come out like leaves in summer and eat the fruit of the field and presently fall lifeless to the ground.”
-Homer

“Glory to fill the world…”
-Ovid


Chapter 1

“482. 140 Scarborough Street. Shooting to the head. On a one.”

“Scarborough Street?” Troy said. “No gang-bangers in that neighborhood.”

“Where’s Scarborough?” I asked.

“Take Broad down to Asylum, bang a left. I’ll show you.”

I hit the lights and sirens on. Our red and white ambulance surged north on Broad, then swung west up Asylum.

“It’s got to be a barrel for breakfast job,” Troy said. “Some big-shot suit. Bought the yen when he should have sold. Can’t afford his country club dues anymore. Trophy wife divorcing him. Pow! That’s what I bet. I don’t think the Latin gangs have quite extended their territory into the West End.”

Troy was twenty-eight years-old, a broad shouldered six foot three, with a smile that said he owned the world, or at least could have his way with it. I hadn’t known him an hour, but already I wasn’t too keen for him. Maybe it was the New York Yankees hat he wore or the bullet-proof manner he’d explained he was the paramedic and I was the EMT. My job was to drive and act only on his command. I didn’t show it, but I didn’t take that well. I had a good sixteen years on him and, coming from Maine, I preferred the Red Sox.

“404 to dispatch,” a voice on the company radio frequency said, “I’m turning onto Scarborough now. I’ll be there in one.”

“Seurat,” Troy said with disdain. “He’s always jumping my calls. Step on it.”

I switched the siren to wail. Ben Seurat was the chief paramedic. I’d met him only briefly that morning. When he assigned me to Troy as his temporary partner, by the way he’d smiled and Troy had grunted, I sensed there was bad blood between the two of them.

“Time’s a ticking,” Troy said.

I ran the ambulance hard on the center line parting traffic to the sides of the road. We crossed Woodland. The road dipped and then curved.

“404 out.”

Troy cursed under his breath. “Take this right up here.”

I swung around a stopped city bus and then turned right onto Scarborough. It was a long flat street lined by giant maple trees. Large, stately homes were set well back from the road, many behind hedges or iron gates.

“Keep going. It’ll be down toward the Albany end on the right hand side. We should see the cars in the drive. There they are -- down there.”

A Capital Ambulance fly car, its red lights still whirling, was parked behind three police cars in the circular driveway of the white columned brick house. I shut off the siren as I drove through the entrance.

We wheeled the stretcher across the damp recently cut lawn. A police officer met at us at the front door. “You’re not going to need that. It’s a 78. In the library. I hope you have a strong stomach.”

We walked through a living room, where moving boxes were piled. The walls held only picture hooks.

Ben Seurat stood by the French doors open to a brick terrace. A man in his mid-thirties, he had the red complexion of someone with high blood pressure. He wore a white supervisor shirt with a gold badge over the left breast pocket. He nodded solemnly to us. “C-MED 404,” he said into his portable radio, “a patch to Saint Fran with med control, please.”

“Med 8 and stand by.”

Brahms played from an unseen source. There was a Persian rug in front of a large marble-faced fireplace. Empty bookcases lined the high-ceilinged room. A man sat in a chair behind a massive mahogany desk. I looked at the face. There was nothing there. No eyes. No nose. No mouth. Just torn bloody flesh. Bits of tissue, blood, hair and bone stuck to the ceiling. You could still smell the acrid discharge of gunpowder.

On the desk was a single photo of a man and his family. Taken in front of a ski lift, the man stood with his arm around the waist of a pretty smiling woman, two teenage girls stood in front of them.

A policeman took pictures of the shotgun that lay on the floor by the man’s feet.
Ben’s heart monitor was on the desk, still attached to the corpse. A green flat line with occasional complexes scrolled across the small dark screen.

“He’s still got a rhythm here,” Troy said.

“Agonal,” Ben replied. “I’m just waiting for medical control for permission to presume.”

“Go ahead 404, Saint Fran’s on.”

“Hey!” the officer shouted at Troy. “This is a crime scene.”

Troy had the man out of the chair, lifting him like he was a doll and laying him down on the floor.

“No, it’s a resuscitation scene,” Troy said. “I could use some help here.”

“The man’s dead,” Ben said. “He doesn’t have a face.”

Troy had the airway kit out. “Protocol says all medics must agree with the termination decision.” He snapped a curved steel blade on to the laryngoscope. “I oppose.”

Ben just shook his head.

Kneeling over the body, Troy stuck the blade into the goop. He peered down into the opening, and then passed the long plastic tube into the mess like a straw into Jell-O. “I’m in.” He looked up at me. “If you’re on the clock, I could use an ambu-bag and some compressions.”

I handed him the ambu-bag from Ben’s gear. I looked at Ben who still hadn’t moved as I got down on my knees and placed my hands on the man’s sternum.

“Go ahead, 404. Saint Francis is on the line,” Ben’s radio crackled.

“Disregard,” Ben said into his portable.

I started compressions.

“So what? He’s not dead?” the officer said.

Ben opened his IV kit. “No, I guess not, not for another twenty minutes anyway, and not here.”

Troy squeezed the ambu-bag he’d connected to the tube, forcing air into the man’s lungs.

Ben wrapped a tourniquet around the man’s arm, and then reached for a catheter. “This is completely wrong. He’s a suicide.”

“Yeah, well, maybe he changed his mind at the last minute, maybe that’s why he took his face off instead of the back of his head.”

“Maybe he just had bad luck.”

“Well, his luck’s changed.” Troy winked at me. “I’m here.”

“Oh, please,” Ben said.


The trauma center was little more than a mile away. While Ben and Troy did CPR on the man in back, I followed Ben’s directions and took a right on Albany, and followed the street down into the Hartford north end, passing a housing project, turning right down onto Homestead Avenue, where brick factories stood behind barbed wire.

“Check this out,” I heard Troy shout. “We have a pulse.”

“It’s just the epi talking,” Ben said. “It won’t last.”

I turned right onto Woodland. Potholes jostled the ambulance.

“Slow down,” Ben shouted.

At the hospital when I opened the ambulance’s back doors to pull the stretcher, Troy unwrapped the blood pressure cuff from the man’s limp arm. “180/100,” he said. “I’ll take it.” Ben, with a sour look, kept squeezing the ambu-bag. Troy laid the IV bags on the man’s chest and resecured the straps. “Okay, let’s get him moving,” he said.

The trauma team, garbed in green scrubs with surgical hats and gloves on, waited around for as we entered the trauma room off the main hallway. We lifted the man on the board from our stretcher to the trauma table.

“He was in ventricular asystole when I arrived,” Troy said. “Intubated with a number 9.0. He’s gotten two rounds of epinephrine. One of atropine. He’s in a sinus tack now with a BP of 180/100. He’s got a 16 in his right AC and a 14 in the left. Lungs sounds equal with good compliance.”

“My God,” Doctor Eckstein said. “How did you get a tube in that?”

“I wiggled it around a little bit till I found the right spot,” Troy said. He handed the ambu-bag to the respiratory therapist at the head of the gurney. A tech cut the man’s pants off with trauma shears.

Dr. Eckstein nodded for the therapist to give a couple squeezes of the bag as she listened for lung sounds on the left and right sides of the chest. The doctor was a tall woman with Buddy Holly glasses and a girlish face – I guessed her to be in her early thirties. “I don’t believe I’m even looking at this. What happened?”

“The police got a call for a distraught man,” Ben said. “They heard the blast when they were at the front door.”

She turned to the trauma team. “Let’s go people, what are you gawking at? I want a pressure, another line, get some x-rays, and let’s get him prepped.”


While I stood outside the ER cleaning the stretcher, Ben and Troy argued in front of the ER doors.

Troy pointed to the patch on his shoulder with his bottle of Coke. “Paramedic,” he said. “I save lives.”

“Who are you kidding?” Ben said. “You didn’t do anyone any favors.” He turned and walked away.

Troy noticed me watching then. “A little excitement for your first call. I told you it was going to be a guy eating steel.”

I nodded without committing myself.

“All in a day’s work,” Troy said.

“Something like that.”

He raised his Coca-Cola to his lips and guzzled it empty. He tossed the bottle end over end toward the trash can fifteen feet away. It clanked in. He pumped his fist.



Chapter 2

“So you’ve worked the road before?” Troy said as we left the hospital after the call.

“Yeah. I’ve worked a few places.”

“Well, you did a fine job. Don’t mind Ben, he’s a prick.”

I just headed down the road. I had worked a few places, starting in Maine and most recently in California. Being an EMT was a handy job – there was work most places you went. The pay wasn’t great, but you could work as much as you wanted. I’d met people in this line of work like Troy -- cocky, talented, and set up to have life knock the stuffing right out of them.

“Where am I headed?” I asked.

“Right on Farmington, left on Sisson, then hop on the highway West. We’re going back to the office to resupply. I already called and told them we were coming in. I need to see Linda, my regular partner, so I told them we need to decon and change the main. She’s out on light duty. Don’t get used to working with me because as soon as the doctor clears her, she’s going to be sitting in your seat. You’ll be working with someone else. You’re all right, but she and I are a team.”

“I’ll work with anyone,” I said. “It doesn’t matter to me.”

“Seurat has her helping him with QA while Karen Priest, his assistant chief medic, is on vacation. Linda should be back in a couple days. She was supposed to talk to the doctor this morning. Hopefully he gives her the okay.”

I said nothing because I really didn’t care. At this point in my life work was just about the money. I wasn’t too interested in making friends.


Linda Sullivan was in the hallway posting the monthly QA stats on the bulletin board when we walked in. She hugged Troy and kissed him on the neck. His hand went right to the small of her back. A tall slender woman of no more than twenty-six years old, she had lively brown eyes, freckles on her face, and brown hair back in a ponytail. She wore the same navy blue uniform as the road personnel. I could only imagine what she looked like in a dress. I wouldn’t have been a man if I hadn’t felt a jealousy in the way she smiled at Troy.

“Great news,” she said.

“You got cleared?”

“No, Ben just offered me the assistant chief medic job.”

“That’s Karen Priest’s job.”

“No, Ben just got word, she’s moving back to Illinois to take care of her sick father. She’s not coming back. I guess she’s got a job lined up back there. Ben needed someone so he asked me.”

“You didn’t take it did you?”

“Of course I took it. It’s a raise and regular hours. I can take my kids to school and be home to cook them dinner.”

“But you’d be giving up the road.”

“You think that’s bad? With my back?”

“But they didn’t even post the job.”

“They don’t have to. Don said he could hire whoever he wanted.”

“So we’re not going to work together anymore?”

She gave him a light stiff arm away. “Don’t be so happy for me.”

“I’m sorry, I am happy for you. Its just I was expecting you back with me.”

“Oh, you’re so cute when you’re sad.” She pulled him back towards her. “I’ll miss you too, but this is a raise -- and the hours – it’s perfect for me. You should come over tonight when you get off. We can celebrate.”

“I can’t. I’m heading to New Hampshire after work to hook up with Pat at his family’s cabin. We’re going hunting at four in the morning. I told you about that.”

“Don’t say I never invite you over.”

A female voice on the intercom said, “Linda, if you’re in the building, there’s a call for you on your line.”

“I’ll be right back,” she said. “It’s probably the doctor.”

“A lot of good that does now,” Troy muttered as he watched her go. He looked troubled, almost like it was the last time he was going to be seeing her. Then Ben stepped out of the men’s room. “Nice,” Troy said to Ben’s back.

Ben turned, still rubbing his hands with a paper towel. “You heard about my new assistant?” he said. He didn’t try to hide his delight at Troy’s reaction.

“I’m sure your motives were pure.”

“She was the best person for the job.”

“You never even posted the job. You don’t know who would have applied.”

“Oh, you mean you wanted to be my office girl?”

Troy wasn’t ready for that. He stammered a moment.

“I know you liked working with her,” Ben said, “But even if she didn’t take the job, you wouldn’t be working with her anymore anyway.”

“How’s that?”

“Get used to Lee as your partner. We have another new policy. No more double medic cars. No more dedicated emergency cars.”

“What are you crazy?”

A voice from behind us said, “It comes from me.”

I turned to see a man of medium build walking toward us. He was in his early thirties with a sweeping black mustache, curly black hair and a deeply tanned face and arms. In his red slacks and black polo shirt, he looked like he’d just gotten off the golf course.

Troy’s eyes narrowed. “I should have known you were in on it too, Don.”

Don Seurat, Ben’s younger brother, was the operations manager. He was the one I spoke to when I called from Las Vegas to inquire about work. He told me he could schedule me seven days a week if I wanted. When I said that was my intention, he’d given me the job right there on the phone.

“Don’t flatter yourself,” Don told Troy now. “It’s a business decision. We’re losing transfers. The hospitals have been calling Champion. We don’t shape up we’re going to keep losing business. From now on the closest car will get the call whether it’s a transfer or an emergency. We’re going to spread our medics around. Every medic gets a basic partner.”

“That’s not right.”

“Maybe not, but that’s the way it is. We need the flexibility. You want to keep your job, don’t you?”

“You’re a menace. I never thought I’d miss Sidney.”

“I run the show now. You work here. Your job isn’t a right. How about I fire you for insubordination?”

“If you didn’t need me so much, maybe you would. But in the meantime, insubordinate this.” Troy raised his middle finger. “The both of you.” Then he turned and walked out.

“Keep an eye on him,” Ben said to me.

I nodded. They were the same words he’d said to me that morning when he’d assigned me to Troy for the day.


When we cleared from our resupply, dispatch sent us downtown to area ten. I glanced at Troy as I drove on the highway.

“Where are we supposed to post down here?” I asked as I got off the Asylum Street exit.

“Take a right, go under the railroad bridge, then take your second left on Union Place.”

He had me park across from the train station in front of a restaurant called Papa’s that served pizza and sandwiches. He stepped out of the ambulance, unbuttoned his paramedic shirt and tossed it onto the passenger seat.

“I’m going into Dooley’s.”

“In there?”

Dooley’s was next door to Papa’s. A neon Budweiser sign glowed in the window.

“That’s what I said. You have a problem with that?”

“You might want to take this with you.” I handed him his portable radio.

He suddenly smiled. “Hey, you’re all right.”

He clipped the portable on his belt, and then walked into the bar that promised “Happy Hour -- Two for One Drinks.”

I sat in the ambulance and ate the roast beef sandwich and apple I’d brought in my small cooler. I read through Troy’s Hartford Courant. The Red Sox had lost a heartbreaker on the west coast the night before. City and state officials were holding an emergency meeting about the escalating gang-violence in Hartford. Gang members jailed several years ago in a major crackdown were now getting out of prison and flexing their muscles. The resulting turf wars had the city on a record homicide pace. The day before there had been a double slaying at the Charter Oak - Rice Heights housing project. On the front of the Connecticut section there was a photo of Troy bagging one of the victims as the patient was wheeled across the grass, another EMT riding the stretcher doing compressions.

Ten minutes went by. No sign of Troy.

“482,” dispatch called.

“482,” I answered slowly.

“170 Sisson Avenue Building 3, apartment 247, for the swollen legs. Priority 2.”

“170 Sisson Avenue,” I repeated.

I watched the door of the bar, but it stayed closed. I waited. Troy did not come out.

After three minutes, I picked up the radio. “482. We’re having trouble getting the engine started. I think it’s flooded. Just letting you know we’re going to be a little late, if we can get it going at all.”

“Okay 82. 463, can you take that call? 170 Sisson for the swollen legs?”

Still no partner.

“482? Where are you so we can get a mechanic down there?”

“Union Street. Down by the train station,” I said.

“We’ll send him right down.”

“Okay,” I said. I waited another five minutes, and then called dispatch back. “482, I’ve got it going now. Sorry. You can cancel the mechanic.”

“Okay, just keep it running. Stay in Area 10.”

I took off my company shirt, turned on my portable radio, and headed into Dooley’s.

It was dark, the air was heavy with cigarette smoke. The Rolling Stones “Get Off My Cloud” blared on the jukebox. Troy sat on a stool with his back to the bar watching the action on the pool table. The bartender set a drink down beside his radio and empty glass. “Vodka and OJ,” he announced, more to me than to Troy.

“We just passed a call,” I said.

“Look at those two. Wow. How’d you like some of that?”


A slender Farrah Fawcett blonde in a white tank top and a pierced bellybutton intently lined up a shot, showing ample cleavage, while her friend, a giggly brunette, tried to coach her.

The blonde hit the cue ball. It flew a foot in the air, bounced twice, and went right off the table.

The blonde cursed while her friend couldn’t contain her laughter.

The cue ball rolled toward us.

“We really ought to get back in the truck,” I said.

But Troy was already off his stool, scooping up the ball.

“Who taught you who how to shoot pool?” He placed the ball back on the table. “That was terrible.”

Two thick-necked young men with beer bottles in their hands stepped away from the wall.

“Haven’t these guys taught you anything?” Troy said.

“That’s all right, pal,” the biggest of the escorts – the one with the shaved head - said. “We’re doing fine here. Let the girls play.”

Troy turned and faced him. In his black tee shirt you could see the lean muscled strength in Troy’s body.

“Yeah,” the other escort said. “You want conversation, talk to the bartender.”
“This is great. I love it,” Troy said. “Two on two.”

The young men looked momentarily confused. “Your friend doesn’t look like he’s ready to join in,” the smaller one said.

I had my hand on Troy’s shoulder, trying to ease him away.

Troy held up his arm. “Oh, no, he’s just my cut man, but you can see I’m too pretty to ever need his services.” He grinned. “I’m talking about…” He slapped his biceps. “These bad boys.” He leaned into a boxer’s crouch, his fists up, his head bobbing.

“Who do you think you are?”

“Troy, please,” I said.

“Allow me to introduce myself.” Fists still clenched, he raised both arms above his head. “I am the King of the World!” He stepped toward them and roared, “The King of the Woooorld!”


Years later in a bar, I would tell co-workers how Troy Johnson gave them a serious beat down, breaking pool cues, smashing chairs, even throwing one muscle man through the front plate glass window. I would tell how his foes vanquished, Troy calmly finished his drink. Then as I held the back door open, he strolled out with a woman on each arm. Moments later as police cars skidded to the curb out front, an ambulance drove slowly past, visible in the back window, a smiling paramedic with two likewise bare-chested women doing things normally only seen at a fifty cent peep show.

It was a story worthy of Troy’s legend, but not what happened. The truth was the guys looked into Troy’s eyes and saw just what I did -- a maniac -- and they stood down. It was as simple as that. The would-be bruisers ended up at the bar, badmouthing women in general, while Troy ate the girls’ pizza and gave them lessons in the art of nine-ball. I handed his drink to the bartender and had him replace it with OJ and seltzer water. When I pulled Troy away to respond to a motor vehicle at Main and Church, he left the girls behind, though he did get both their phone numbers. The next week he spent parts of several afternoons at Mandy the blonde’s apartment on West Boulevard, his portable radio on the nightstand. I was parked outside in the ambulance, engine idling.

Chapter 3

“482, Respond to 1640 Main, 2nd Floor for difficulty breathing on a one.”

North on Main Street, the SANDS housing project dominated the vista, a ten story eye-sore, surrounded by with several equally ugly three story buildings. Any promise the project once held of a model life for its residents was gone. It was instead a drab graffiti ridden concrete jungle run by drug dealers and gangs. We parked around back behind one of the smaller buildings, next to a panel truck with smashed windows.

“You should see this place on a hot summer evening,” Victor Sanchez said as we got out. “Everyone outside in the heat, drinking their forties, music blaring, dealing drugs.”

We left the stretcher at the base of the outside stairs. I took the oxygen tank. Victor carried the house bag and the heart monitor. Victor was a short bull-chested young man who’d been with the company almost ten years, working his way up from a handicapped van driver to paramedic.

“It’s probably BS,” he said, as we climbed the cement stairwell. “Most calls around here are. You never know. I carry everything.”

On the third floor, a young woman wearing a Chicago Bulls jersey that went down to her knees, answered the door. “You here already? I wasn’t expecting you so soon. Gimme a few minutes to get dressed and for my sister to come over.”

“Is there a child here having difficulty breathing?” Victor asked.

“My boy been stuffed up for two weeks and the medicine the doctor give him yesterday not helping. I want to take him back and show him he still sick.”

As she let us in the apartment, I could see a child sitting on the couch watching Wyle E. Coyote chase the Roadrunner on a big screen TV.

“The paper said you always late,” the woman said, routing in the closet and coming up with a gray pair of sweatpants. “When I called yesterday it took ten minutes. Today I hardly put down the phone and you there beating down my door. All the complaining having an effect, huh?”

“Yeah,” Victor said, “They don’t let us stop for doughnuts anymore.”

“I wouldn’t have minded that. I haven’t had breakfast yet. My sister should be here soon. Let me just put these on and get my shoes.”

“Don’t let us rush you,” Victor said.

I carried the equipment down to the ambulance.


After we’d taken the boy to the hospital, where he and his mom were put out into the crowded waiting room, I stood with Victor in the EMS room and listened to people bitch about how the paper was on everybody about response times. Victor tried to fill me in.

“A couple weeks ago there was another gang shooting at an apartment on Wethersfield Avenue,” he said. “The paper said it took the ambulance twenty minutes to get there. The TV news picked it up and we’ve been getting dissed hard. They had an editorial cartoon that showed a giant turtle with an EMT sitting on it holding the reins. It said Capitol Ambulance on the shell. They had a shot guy crying for help in the middle of the road, and a guy in a black hood already digging his grave.”

“Were we twenty minutes late?”

“No. Maybe ten. The problem was the PD wouldn’t let the crew in. They said the scene wasn’t safe. Of course, when Troy gets there he charges through the police tape. The guy is shot eleven times, and Troy starts working him. Pissed the cops off. Trashed their crime scene and nearly started a riot. The home crowd thinking the cops had let him die.”

“The guy didn’t make it, did he?”

“No, he was shot eleven times. Troy will work anybody that isn’t stiff.”

“I heard about your guy yesterday,” Joel Morre, another medic, said to me. “Doctor Eckstein told me the guy had no face. Ben was pissed off, huh?”

“He seemed a little upset.”

“Ben and Troy are always butting heads.”

“I thought there was some history there.”

“Ben thinks younger medics should defer to his experience,” Victor said, “but Troy doesn’t defer to anyone. When Troy was new medic, Ben was in the crew room talking with some of the older medics about the state exam. Medics have to test every two years. Every time it’s the same test. Ben always gets a 98 – the best score in the company. He can’t figure out what two questions he gets wrong. The test has to be fixed. He thinks there are two deliberately wrong questions. The state doesn’t want anyone getting a perfect score and thinking they know everything. Troy takes a piece of paper out of his wallet, goes over to the Xerox machine, runs off five copies and hands them to each of the medics. It’s his test results. 100 in each category. The other medics laugh, but it steams Ben up. To Ben you are a new medic, you don’t say a word till you’ve been there two years. You have to prove yourself. Troy was cocky the day his mother popped him out.

“The real rivalry between Troy and Ben started the day Sidney coded,” Joel said. “Sidney Seuss -- he’s the guy in the portrait in the front office. He founded the place. A real old time ambulance man. He’d just finished his dialysis treatment – he had his own machine in his office - when he crumpled to the ground. His secretary screams. When Ben gets there, he sees Sidney lying on the carpet. He’s blue. No breathing, no pulse. Ben rips Sidney’s shirt open, puts the paddles on his chest. He’s in v-fib. He shocks him. 200 Joules. No change. Shocks him again. 300 Joules. Nothing. 360. Nothing.

“The secretary starts CPR while Ben goes for the airway. Sidney’s a big broad guy with no neck. A difficult tube. Ben’s looking down into his throat, trying to move his tongue out of the way. He sees the chords for a moment, passes the tube. Puke comes up. He’s in the esophagus."

“That’s when Troy and I come in,” Victor said. “We’d been in the office resupplying. Troy sidesteps the puke, and while Ben tries again, Troy slams an IV in Sidney’s arm. Ben’s still struggling with the tube, Troy says, ‘Let me try.’ He takes the scope from him. Then like that -- ‘I’m in,’ he says. Ben pushes epi and lidocaine into the IV line. They shock him again 360 joules. No change.

“’Calcium,’ Troy says.

“‘Calcium?’ Ben says. We carry it, but it’s not in the routine protocol.

“‘Calcium. His kidneys suck.’

“Ben goes ahead and gives it to him. They shock him again.

“Ben looks at the monitor -- sees a rhythm. You don’t have to feel a pulse. You can just look at his neck and see it pounding.

“Then Sidney opens his eyes and he’s looking right up at Troy. He looks a little confused like maybe he was expecting to see Satan or St. Peter. Instead Troy Johnson is the one grinning at him.

“‘Afternoon, boss,’ Troy says. ‘I see I’m not the only slacker around this place likes to get in a good snooze.’

“Troy was the golden boy after that. Sidney gave Troy his own dedicated ambulance, his own shift whatever hours he wanted to work, and let him pick whatever partner he wanted. Told the dispatchers no transfers for Troy. They have to leave him free for the big bad ones. The Deputy mayor coded. Troy saved him. One of the high-ranking police brass coded. Troy brought him back to life. Head of the chamber of commerce choked on a piece of meat the size of his fist; Troy yanked it out with a pair of McGill’s. The guy was well enough to give the after dinner speech.

“Every save Troy got, Sidney made a show of visiting the patient in the hospital, and bringing a photographer along. Ben wasn’t happy about it -- ,that and the fact every time Sidney saw Ben and Troy together he ribbed Ben about it. ‘Good, I got my bodyguard here to keep my chief paramedic from killing me.’ The truth is we got some good publicity in those days. We were miracle workers. The pride of the city. Paramedics. We were all like Johnny and Roy on that old Emergency show. You could walk tall.”

“Not any more?”

“No, that’s the past. Sidney’s dead. Things are changing for the worse. They don’t get better, we could be out of business. We could all be looking for jobs. So you can understand why no one’s happy.”

Friday, July 14, 2006

National Registry Project Trip Report

My relief comes in two hours early so I can get to the airport -- I am headed the Ohio to serve on a committee for the National Registry looking into paramedics competencies -- whatever that means. I will soon find out.

The flight is on time, but the plane is small and rattles when the landing gear drops. I catch the shuttle to a Marriot Hotel and have a steak dinner and two beers and then head back to my room to watch SAVED. (More about the show in a later post).

I'm supposed to meet someone from the registry in the lobby at 8:30 the next morning.

***

They have selected nine field medics from across the country with various experiences and from various types of services to spend two days with a facilitator from Ohio State to do a duty/task analysis of what paramedics do to help develop a curriculm and tests based on the real world. I am the representative from the Northeast region. There are people from Georgia, Missouri, Pennsylvania, North Dakota, Idaho, Texas, New Mexico and California ranging from one year experience to fourteen -- all of them have been nominated either by a state director, company president, EMS panel or medical control authority.

Our work will just be the begining of a long process that will eventually create a definition of what paramedics do, what our core competencies are, and what should be taught and tested to produce competent medics who the public can trust.

We are to complete a breakdown of duties and tasks that will later be further broken down into job steps. Our work will be reviewed by 1000 other paramedics selected from the registry's lists, and then gone over by a panel of EMS experts from the registry's board.

A Duty is a cluster of related ideas. A Task is specific units of work. Steps are what enable you to perform the task. An example of a job, duty, task, step would be as follows:

Job: Homeowner
Duty: Maintain the yard
Task: Mow the lawn
Step: Start the Mower.

Anyway, we start out by making a comprehensive list of things we do, going around the table until we are exhausted -- everything from check the oil on the truck to defibrillate to provide grief counseling. The lists are then hung on the wall and left there. Next we try to come up with the Duty List. I think we end up with 12 or 14. I didn't write them down by they were something like this: Maintain Response Readiness, Access the Incident, Scene Management, Perform Assesment, Provide Emotional Support, Manage Cardiac Care, Respiratory care, etc, Resolve the Incident, Legal Documentation, Operations Support, Community Relations, Professional Development. Then we had to take each duty and break it down into tasks. We got through two of the duties, and then called it a day.

They took us on a tour of the National Registry Building, which was quite nice, and gave us a little talk on what the Registry was up to as far as moving to online application and renewals, as well as some of their research projects, including one almost finished that shows EMS professionals suffer from sleep deprivation to a degree unlike any other recorded profession. One of the questions was something like "Have you ever gone to a friend's house to visit and fallen asleep on the couch?"

At night we went out to a great steak restaurant and had a wonderful dinner with cold beers and got to know each other better. I was very impressed with the other medics, as well as the people at the Registry.

Back at the hotel, I turned on the wanning minutes of the All-Star game and like a typical sleep deprived EMS professional fell asleep with the TV on in the middle of the American League's rally.

***

Back to work in the morning. We moved a little quicker, completing the task lists, and then compiling lists of general knowledge and skills needed for the job, worker behaviors, tools, equipment, supplies and materials, and future trends and concerns. In the end, the faciltator said he was very impressed by the array of work we did. We had 169 seperate identified tasks. He said generally each task equates to $1,000 of income, so we should be making $169,000 a year based on our responsibilities.



All and all it was an interesting process. I tried to emphasize pain management, research, and "people care" as important or needed aspects of our job, along with capnography as an important new technology. As I said before, I don't know how this will all turn out -- our role was just getting the process started.

I flew home, landed safely and after a day off, will be back at work.

Friday, July 07, 2006

Competencies and Components

A couple months ago I recieved the following letter:

Dear Mr. Canning,

The National Registry of EMTs is forming a committee to help define the essential competencies of paramedic practice. This committee will consist of paramedics from around the country who will participate in a focus group lead by faculty members from The Ohio State University Center on Education and Training for Employment. You have been nominated for this committee by -------.

The meeting will be held in Columbus, OH on July 11-12, 2006. The National Registry will cover all reasonable and customary travel expenses for your participation. There will be no pre-meeting preparation, and minimal post meeting follow-up. We are primarily interested in your experiences as a paramedic and what you feel are the essential components of your job.

If you are interested and able to participate in this important project, please forward me a copy of your current resume and/or a brief summary of your background. If you are selected, I forward more detailed information and instructions on how to make your travel arrangements. I hope you are interested, and I am looking forward to the opportunity to work together.

Sincerely,


Gregg S. Margolis, Ph.D., NREMT-P
Associate Director
National Registry of EMTs


Well, anyway I was selected and am going. I'm not exactly certain what they mean by competencies and components(I'm guessing it has something to do with the scope of practice issue), but I am ready to add my voice.

In addition to the basic stuff, I have three things I think all paramedics should be trained in and should be using as part of their practice.

1) Pain Management
2) Capnography
3) Research Training

I'm not leaving until Monday, and I will give you all a report on how it goes, but in the mean time if anyone has any ideas, send me your comments.

What do you feel are the essential components of your job?

Dread Life



Spent a week in Jamaica. It was my third time there, but the first time I stayed outside of an all-Inclusive resort. This time I really got to see the country and to "eat the fruit off the tree." I grew grey-whiskered stubble on my face, listened to reggae music, swam in the ocean and spent a couple days in the hills. I drank Red Stripe beer, ate akee with saltfish, pineapple, lots of mango, plaintain, gnip, Jamaican pears, and lots of jerk pork and chicken, along with curry goat. By the end of the week I could actually understand the local patois.

I had this conversation with a man on the roadside while my friend's brodda was in a small market looking for dinner.

Stranger: Wa-gwan-mon?
Me: Nothing wa-gwon.

What's going on man?
Nothing's going on.

My friend's brother came out empty handed. He said. "No fish today, sea ruff."

He is a Rasta and only eats fish, no pork. Not me.

The roads there are terrible, although they have gotten much better over the years. While they used to be all curvy, there are some highways now that are straight for some stretches. People pass each other at will there. A one lane highway(one car going in each direction) can easily become a two lane highway, and then a three in one direction, and at times four lane. Four cars all flooring it all headed in one direction like a race at Daytona, then you hear the big horn of a truck, and they all whip back into line, always cutting it close.



There are no open container laws there -- people can drive with a bottle of Red Strip in their hands. You have a certain feeling of comfort in the matter, as if that's the way it is and everything is going to be awright, mon. Then you open up the daily paper and read about all the fatalities or start counting the number of burned out wrecks by the side of the road.

The same with the crime there. We stayed one night in the house of a local in an area judging from the graffitti and narrow alleyways and barbed wire, had some crime. While we were safe -- I was a little tired from the pounding reggae I heard till late hours -- again I read in the papers about gangs of gunmen in another Parrish, invading homes, robbing the places, killing the occupants, then setting everything ablaze.

Walking the streets, I kept a close feel for my wallet, but I had no problems. I felt quite at home. People were very friendly. There was some begging when we went into Ochos Rios, but nothing persistent.

I encountered the same questions I had in the Dominican. One one hand there is a lot of poverty, on another, as one of the dreads I met showed me, what a better life than to go swimming every morning in the ocean with your kids and to eat the fruit out of the trees.



I was talking to another guy named "Stone", who worked building stone walls -- unbelievably perfect walls -- he cut the stones himself by hand -- and I was telling him how much money he could make in the states, but then I added, you had to get the job done on time, which I think the Jamaican way is more, take your time, take a break, have a beer, light up a spliff, take it easy. I asked him why he didn't try to get work at the big new all-inclusive being built along the ocean in a nearbye town, he said the wages were terrible, the foremen worked the people like dogs, and that several people had already died during construction -- a fact that was being kept from the papers. It was no kind of life, so he was content to make his stone walls at his own pace about his small town in the hills, to work for food, beers, ganja and a few dollars. He seemed quite happy. No worries.

There is something to be said for the simple life -- but there's something to be said for a government that doesn't seem to look after its people.

Anyway, I'm back, rested, and as soon as I shave, I'm ready for work at 6:00 A.M. tomorrow.