An Encounter

It's been snowing all day -- a blizzard. Eight or nine inches on the ground already. Now it's night and I'm hungry, so we drive out through the snow to get a hot pizza.

At the pizza shop, I notice a grey faced woman say hello to me as I go in the door, then when I come out she is lingering in the heavy snowfall.

"You took care of my mother," she says. "I wanted to thank you."

"You're welcome. Thank you for saying that," I say. "How is she doing?"

"She's dead."

"Oh, I'm sorry."

"They had her on life support for six days."

"I'm very sorry."

"You partner was upset with her beacuse she wanted to take her jewlery off. You knew she was having a heart attack, but you didn't tell me."

I'm not really certain what to say.The woman is standing there in the driving snow, looking at me hard. She looks very unhappy. I'm not certain if she is grateful or upset. She takes a deep drag on her cigarette, and stares at me.

I just stand there. I have no words for her. I don't even remember the call or ever seeing her before in my life.

"God bless you," she says.

"Well, thank you," I say again, "You have a good night. Try to stay warm." I start toward the ambulance.

She stays there standing in the snow watching me as I get in the front seat. As my partner starts to drive away, she gives a short salute like wave and I wave back.

I have this sense that she will always be there in my memory, standing in the driving snow on a cold night, smoking her cigarette down till the butt is gone, extinguished against her cool skin. She stares at me.

I have no idea what she sees.

Compressions

Last night one of our long-time members came in at ten to relieve the on duty crew. He has been an EMT for over twenty years and helps teach the EMT class here in the suburbs. He heard about the code we did yesterday and talked to the new kid about it.

"I wanted to make sure he was okay," he told me. "You never know how young kids take their first code."

That was when it dawned on me. It was the kid's first code. I knew it was his first code, but I never really thought what that meant. I felt really bad about it. There I getting on the kid to do better CPR and he was probably thinking "oh my god, I'm doing CPR on a real person and I'm killing them."

To me, it was just another call, another code, another dead body. I was more concerned about my capnography reading than the kid's physce.

"Put some muscle into it!" I said to him.

He was giving these little pushes as he muttered "one, two, three, four, five."

"Stop counting. You don't need to count. Just pound away."

"It's my first time doing CPR on a real person," he whimpered.

"I know, so do it like I'm telling you. Look at the monitor. Make some waves. The line shouldn't be flat, it needs to look like this..." And I leaned over and pounded hard so that on the monitor, you could see big rythmic waves. "You have to get the blood flowing in there."

And so he pressed harder.

"That's better. And stop counting!"


When he left that night, I did call after him. "Good job today."

I don't think he heard me. He walked out, his head looking down at his shoes.

***

8:00 A.M. on the dime this morning, he presents himself, wearing his shirt with his silver badge on it. I ask him how he is doing. He says okay. I ask if he has any questions about the code.

"She was asystole, right," he says, "That's pretty much dead, right?"

"You got it. She was dead and she wasn't coming back."

"That's what I thought."

"We didn't kill her and at least you learned how to do CPR on a real patient."

"I know -- that was my first time."

"I'm sorry I yelled at you," I say.

"That's all right," he says, and looks back down at his shoes again.

"We'll try again today. I'm glad you're here."

He nods.

"Now, go check out the truck."

He grabs a checkoff sheet and heads to the garage with determination.

It's a slow day. We only do two calls. A nursing home fall and a rollover, where the fire department had to come and take the front windshield off the car, which was on its side, so we could get the 74 year old lady out. She was fine, unhurt and refused transport.

My preceptee is on today so we did a fake code using manaquins. The preceptee and the crew wheel the stretcher and gear into the back room, where I am pretending to have chest pain. As they treat me, I keel over and then they have to turn their attention to the manequins -- a mannequin head that can be intubated and a CPR manequin. The preceptee intubates the mannequin, while the kid does compressions on the other manequin. The medic puts an EJ in the mannequin's neck where I have taped a sponge in a plastic bag to serve as the vein. He pushes drugs and reads the monitor, and eventually they load the patient, and cart him out to the ambulance. This is a pretty straight forward code -- a simple asystole. In the past, I have done full v-fib arrests, complete with angry relatives, drug dealer pals, and crying spouses trying to distract the preceptee. He's getting his routine down pretty well now.

Once the patient is loaded, another crew member then drives around the block a few times, while they continue care. The kid is working up a sweat doing CPR. "How's the back?" I ask.

"Good," he says, "Holding up."

He is concentrating on his CPR. No counting, just pounding away, strong compressions.

"Good work," I say.

The driver backs the ambulance back into the bay, and they unload and wheel the mock patient into our fake ER, where I, the realist doctor, recieve their report, check tube placement, then look at my watch and say, "2:30. Rest in Peace."

I look at the kid. "You killed another one. Two for two."

He hangs his head.

"Hey, they usually always die. Nice job on the CPR. We'll get him next time."

And he smiles.

"You did well," the preceptee says to the kid.

He's positively grinning now.

When the day is over, the kid says goodbye and then says, "Thank you."

"You're welcome," I say. "We'll see you next week."

I still feel bad about yelling at him.

49 Years

The man is breathing like a fish cast up on land. He is quiet, then with all the effort of his chest, he gasps. He's quiet, then he gasps again. His wife says he started losing conciousness an hour ago. He has terminal lung cancer. It has all been very quick. It started with back pain a month ago.

I tell her she can come with us, but she'll have to ride in the front. She says we've let her ride in the back before. Okay, I say.

We put him on oxygen by nonrebreather. My preceptee puts in an IV. He looks at me and says, "I'm thinking he needs to be intubated."

I ask the wife if she has discussed what measures they want taken. She looks like she isn't certain she understands.

Your husband's breathing is getting to the point where we may need to put a tube down his throat to help him breathe. I don't know for certain, but from his pattern of breathing, he may close to the end. Did you want everything done?

No, no, she says. He has suffered enough.

Do you have a DNR ? Do not resucitate order?

She shakes her head.

Have you discussed it with a doctor?

Yes, she says. He was going to put an order in his chart, but its been so quick.

When we get to the hospital, I say, they are going to need to know how you feel about this.

She nods.

When we get there, I will introduce you to the doctor, and you are going to need to tell him how you and your husband feel, and the name of the doctor you've discussed this with.

I tell my preceptee to call the hospital and explain the situation. Man with agonal respirations, terminal cancer, no DNR, but wife doesn't want advanced measures. We're holding off on intubation.

When we get to the hospital, we go to the critical care area of the ER. As we move him into the room with its space aged medical equipment and waiting medical staff, the wife bursts into tears. A family services worker puts her arm around her and leads her away. While my preceptee gives his report, I excuse myself and walk quickly down the hall after them.

She needs to talk to the doctor, I tell the aide, and turn them around and bring them back to the room.

I catch the doctor's eye and introduce her as the patient's wife, and tell him they have discussed measures with his physician. He nods and then talks quietly with her. The medical staff has the intubation tray out, and is waiting on the doctor.

The doctor and the wife speak for several minutes, then the doctor tells the staff to give the man morphine and some ativan.

"No intubation?"

He shakes his head. "Supportive measures. Let's at least make him comfortable."

The wife turns to me. "We've been married for forty-nine years," she says, her voice breaking. I put my arms around her. Her chest heaves as she sobbs.

Credit

I'm precepting a nice young man who is very on the ball. He knows his protocols better than I do. I ask him the dose for Cardizem. He rattles it out. .25mg/kg first dose. .35mg/kg second dose after fifteen minutes if the first dose didn't work. Once the rate slows, you run a drip at 5-15/mccg/min. I glance down at my cheat sheet. "Yeah, that's right. Very good," I say.

He is as advanced as anyone I have precepted. He hits all his IVs the first week, runs the calls smooth as can be. I mean we are not doing codes, but still, he handles the routine ALS like a pro. In the second week, I bail him out on two IVs, but at least as far as treatment goes, he is still right on the ball, and the IVs were hard ones. I was lucky to get them myself.

"You know you're going to have a puckercall one of these times," I say. "Don't get too comfortable. Things don't go this smoothly."

"I know," he says. "I'm waiting for it."

We get called for difficulty breathing. When we pull up, we see the garage door is open. A cop comes out of the door in the garage and says, "Bring it in here. She's a little short of breath. Feels a little dizzy. I've got her on O2."

I let my preceptee go in to assess the patient while I help our other crew member try to manuever the stretcher in. We take the moniter and bag off the stretcher and set it down on the concrete floor.

The woman doesn't appear too badly off. She doesn't want to go to the hospital. She says she just passed out, and doesn't know why, but she is all right now. She appears extremely anxious about leaving her home.

My preceptee is persistent and gets her to agree to go. We get her into a johnny-top and while our crew member folds her clothes and tells her she will bring them with us to the hospital, the woman gets anxious again, and says she needs clean clothes, so we have to help her get clean clothes from the dresser by the door. We finally get her on the stretcher, and she is now worried about locking the house.

She tells me I need to hit the garage door button on the inside of the garage door, then go out through the front door. I tell her not to worry about it, I'll take care of it.

As they wheel her out into the garage and then out onto the drive where the ambulance is parked, I hit the button that closes the garage door, then I go upstairs and out through the front door, making certain it is locked behind me.

I open up the back doors of the ambulance to see how everything is going. "Where's my gear?" my preceptee says frantically.

"Ahh, You don't have it?"

"No, I thought you had it."

"I don't have it."

We look back at the garage door that is closed. I walk over to it and peer in through the window. There is the monitor and gear pack that holds all our medicine and ET supplies. I lean down to try to lift the garage door up. It doesn't budge. I walk over to the front door. I try to turn the knob. Locked. I walk back to the ambulance.

"They're in the garage. It's locked. Does she have a key?"

She doesn't have a key. Who does? Her daughter. They can't reach her on the phone. The cop has left the scene to respond to a car chase in progress. I look at the patient. She is definately short of breath despite the oxygen. My preceptee looks panicked.

"Let me check the windows," I say.

I am pretty good about holding off panic. Not admiting trouble. Besides, I tell myself, I didn't leave the gear. But then I think, well I am sort of responsible. I was the one who locked the doors and I am the preceptor.

The windows are all locked. There is no key under the flower plants. I try the doors again. Locked. I stare at the front door. I take my wallet out and take out a credit card. Well actually my plastic Wampum card from the local casino. I try to credit card the door.

There is no deadlock and there is just a little give in the door. I have credit carded outside apartment doors before, but never a front door. As I sit there working the door, I feel sort of foolish like what kind of idiot am I banging up my wampum card trying to open an obviously locked door. The door opens.

Whoo-hoo! I walk right in, go down the stairs, into the garage, pick up the monitor and gear bag, go back up the stairs and out, locking the door behind me.

"You're lucky you have a resourceful preceptor," I tell me preceptee, as I hand him the monitor.

He looks enourmously relieved.

"How did you manage that?" my crew member asks.

I wave the wampum card. "Let's just say I am well read in many fields. Someday I'll teach you how to pick the lock on the narc box with the clothespons from the triangular bandage package."

I am very proud of myself obviously.

"Why don't you get in front and drive now. We've been here long enough," I say, then to my preceptee. "How's it going?"

He is dripping sweat. "I can't get an IV," he says. "If you can, I'll consider you a god."

Naturally I take him up on the challenge. As we hurtle to the hospital, I inspect her arms. "There's a little one right here," I say, pointing to her hand. "I think I can get a 22 in here."

Aside from my growing interest in cat burglary, my secret pride is my IV skills. I am a good paramedic -- not a neccessarily great one, but I am a great IV tech. My goal is to put an IV in a stone. But as I rub an alcohol wipe over the woman's hand, and look at the flimsy little vein, I am starting to doubt myself. But no, I think, I just credit carded a door. I can do no wrong.

Bottom line. You got it. I missed.

Not a god today.

"I feel better about missing now," my preceptee says.

"Just don't leave your gear behind again," I say.

Ruby

We're called for a fall at a private home. When we pull up my partner says he's been here before. He gets on the radio and cancels the district car.

"What if she's a big lady and we need a lift?"

"She's a little thing," he says.

We go to the front door. It's locked.

Darren swears. "She lives alone," he says, "its normally unlocked." He starts to radio for the cop to continue, but then I pull out my wallet and take out a credit card.

A minute later we're in.

Ruby is in bed. She is 89 years old and crazy as a bat. "What nice tall men," she says, "What are you doing in my house?"

"You called us? Is something the matter?"

She thinks a moment, then says, "Yes, I need help getting to the commode."

There is a portable comode by her bed.

"How do you normally get around?" I ask.

"Oh, I walk. I walk."

"Why do you need us to help you then?"

"Well, I hurt my foot. I can't stand."

I look at her ankle. It is swollen and deformed. I touch it, and she flinches.

"How did you do that?"

"I don't know. I don't recall."

"Did you fall?"

"Beats me. What tall good looking men you are."

"Thank you. We should probably take you to the hospital. You may have broken your ankle."

"Do you think?"

"You need an xray."

We are unable to get the stretcher into her bedroom due to the layout of the hallway and furniture, so I pick her up in my arms and carry her out to the living room where Darren has the stretcher set up.

"Oh, this is quite my day, isn't it. To be swept away. Where are you taking me?"

"To the hospital. You may have broken your foot."

"How did I do that?"

"Beats me," I say, "But its swollen."

Her name is Ruby and we talk as we drive her to the hospital.

"Are you the Ruby they wrote the song about?" I ask. I sing a few lines. "Ruby, Ruby, Ruby, Will you be mine?"

"No, no, I don't belive so," she says.

"Are you sure? I can imagine a young man singing that song to you once."

"Well, maybe. Where are we going?"

"The hospital. You may have broken your foot."

At the hospital, when I drop my paperwork off, she looks up at me like she has never seen me before in my life. "What nice handsome tall men. Where are all these good looking tall men coming from? They seem to be everywhere. Here comes another one."

A male nurse has entered the room. He looks at the paperwork. "Ruby," he says. "Are you the Ruby they wrote the song about?"

"Yes, yes, I believe I am," she says. "That's what they tell me."