American Summer

It’s been over ten years I’ve been working in the city. Driving around in the ambulance, you can see the changes. None of the book stores I used to stop at are still in business. The barbeque place in the north end where they sold cornbread muffins for twenty-five cents is gone. The Lion’s Den – the Jamaican vegetarian restaurant -- where you could smell the marijuana smoke coming from the backroom when you went in to buy soy patties – burned to the ground and was demolished. One of the city hospitals closed. The nursing homes all have new names. People still shoot each other and do heroin and call the ambulance for dumb things. There are still a lot of drunks, but none of the old ones are left. We don’t respond in the south end anymore – another company does. The fire department is a first responder now instead of the police who rarely ever came in the first place. Instead of navy blue uniforms we wear light blue shirts. There are more medics on the road these days where before there were just a few of us. We never did transfers unless they were ALS; now transfers are a regular part of the day. I’m as apt to be doing a dialysis run as I am responding to a motor vehicle.

I ‘m working with a guy who has been around almost as long as me, and we are talking about how some girls who were pretty when we started are now on the heavy side, how some medics who were sparks are now burnt out, how some new stuff is good – like all the overtime -- and some is bad – like how the out-of-town dispatchers don’t know the streets. We talk about how you can never rely on anything to stay the same. All you can do is try to do your job and treat your patients decently. The seasons come, the seasons go.

The afternoon is slow. We are posted in an area near the edge of town. Instead of posting on the specific street corner that represents the area we are covering, we are about a quarter of a mile away at the maintenance entrance of a park, right next to a small pond. It is a beautiful August day – blue sky, a slight cooling breeze. We shut the engine off. I open the door and stretch my legs out. My partner goes over and sits on a bench. We are the only ones there. Five minutes later we get a page. Effective immediately per the PD we are to move to the assigned area. We look around and don’t see anyone. I look at the maintenance building, at the windows to see if anyone on a phone is looking out at us. Someone obviously complained to the police about us being in the park.

We get in the ambulance and drive up the road to the posting location and park on the asphalt in the sun. The AC is running, but we are in an old car and the engine is really loud. I try to do the crossword puzzle in the morning paper, but it’s late in the week and as you get toward Friday, it gets much harder. I don’t make much progress.

We go on a couple calls. On a motor vehicle, as we arrive lights and sirens, the cops give us the cut sign. They say they canceled us – it just never made it through the dispatchers. Then we get the dispatch. We’re canceled.

Dispatch sends us over to Main Street for an ETOH. The man who called leans out from a third floor window under a flag of Puerto Rico and points across the street to the baseball field and says, “He’s over there under the tree. He drinks too much. You need to take him to detox.”

We get back in the ambulance and drive over to the field, get out walk along the tree-lined fence, until we come to the entrance, and then walk over to where we see a man in a Yankees tee-shirt sitting with three forty ounce beers. He’s a got a big grin on his face. He’s just cracked open the first one and has two full ones sticking out of a paper bag.

“What’s up?” I ask.

“Drinking beer in the park,” he says.

“You know why we’re here?”

“Cause I’m not supposed to drink in the park?”

“No, that’s not our business. We’re here to see if you’re okay, if you’d like to go to the hospital. Do you need detox?”

“No, I just want to drink my beer. Did my uncle call you?”

“Is he the guy in the third floor window?”

“Yeah. He kicked me out of his apartment. He drinks more beer than I do.”

“Well, just because he wants you to go to detox, we can’t take you against you will, but you realize, if you pass out, we can come and take you.”

“I understand.” He smiles. He sees we are no danger to him.

I’m looking around at the lush green field, the beautiful August day, the beer which is cold right from the store. I look at my partner and I know he’s thinking the same thing I am. “If we weren’t on the clock,” I say, “We’d love to join you. You have a good afternoon. Don’t outdo yourself, and if you ever aren’t feeling well and need to go to the hospital or want detox, just give us a call. And if you do pass out and your uncle calls, we’ll have to take you in. Understand?”

He smiles again, and extends his hand. “You guys are alright,” he says. “It’s a deal.”

We walk back to the ambulance, get in, and then drive back to the apartment building where we call up to the guy in the window. “We can’t take him,” I say. “It’s America. He’s alert and oriented. He’s got rights.”

The man, who we can see has a long-necked bottle of beer of his own in his hand, shrugs and thanks us for trying.

“He passes out, you call us back, and then we’ll come and get him.”

He waves, and sticks his head back inside.

I don’t know about my partner, but when I get home I have a few cold ones myself and sit out in my back yard and enjoy the summer evening.

Time passes. Sometimes you need to stop and enjoy the seasons.

Thoughts on Blogging

Hello Everyone. I hope you are all having great summers. I am writing this entry today because I lack the energy to write well about a funny call I did recently.

I have been working quite a lot -- 84 hours in seven days this past week --and am finding it hard to keep up the quality of this blog and my daily blog at Paramedic: A Year on the Streets. I am not yet ready to give up. I am hoping this is just a lull and I will catch a second wind. It has been almost two years since I have been blogging here, and 20 months at the daily blog. During that time I have noticed some of the bloggers that I have been following have disappeared off the internet. I don't know if they got burned out, or had complaints or if they left the field.

I like blogging in that it captures my day and events I might forget about or not remember as clearly. But to do that well I need to be able to see freshly every day. A problem that I think comes with working so much is I tend to just want to get through to the next call to the end of the day, and to the next day and to pay day when I spend probably too much time looking at my check.

When I started as a medic I told myself I would never let myself get to the point where I needed to work overtime to get by. Well, so much for the that. It's what a house and a divorce and a will to see the world before you croak will do to you.

I have been spending a lot of my time lately on my Capnography blog at Capnography for Paramedics. What started out as just a place to put the information I had found on my own has become a near obsession. My physiology background is shamefully weak so I have been struggling to get a handle on everything and then put it into simple language. I agreed to teach a class on Capnography this coming September when I knew very little about Capnography, but knew if I agreed to teach the class I would have to become an expert. I have enjoyed learning. Everyday I hope to get a new capnography strip or story or read about a new study. I am working hard on my powerpoint presentation.

I have also been working more on one of my novels that I excerpted recently. I will probably post more chapters soon. Unfortunately it has taken a back seat to the capnography which is under deadline.

Recently the ambulance service where I work as the contract medic opened its EMS Commander position. I thought about applying. The pay isn't what I make in overtime, but it was decent for a salaried job. And it was a way off the street in the daily grind sense. It was a job I could do when I am older or if I get hurt. I have lots of ideas about how to make the EMS system better, and it would have been fun to have a playground to try them out on.

But I didn't apply. Mainly because I love being a paramedic, and in the new job I don't know how much I would have been able to work -- maybe only in a supplemental way. And I would have had to have quit the company I work for now due to conflict of interest provisions. Also, not being able to work overtime I would see a decline in income. And you can't overrate the ability to have the time be your own when you are not responding to calls. I mean right now I'm at work, I'm on the clock and I'm sitting here working on my blog. How good is that!

Maybe some time down the line I'll be ready for a step off the street, but now I want to stay here.

Thanks for reading my blog and I hope I will try to get to that funny story soon.

Podcast

I want to apologize for a slowing number of EMS scene call posts in the recent past. I have been very busy working on several projects in addition to working mega hours. I think I am so tired that I am losing my fresh look at each scene and the energy to write about it fully. Maybe I am working too much. I hope that I will soon regain my energy or have some calls that will spark my muse. In the meantime, I am going to highlight some alternative EMS sites that people may want to check out.

Today, I'm recommending The Medic Cast -- an EMS podcast done by a Maryland paramedic named Jamie Davis. When I first heard the term podcast, I thought you needed an IPOD to be able to listen, but I soon found out all you need is a computer. Jamie puts out a biweekly show of 20-30 minutes covering a variety of EMS topics, trends and treatments. His accompanying web page also has interesting and relevant links. I often put the show on and listen while working on my projects. I highly recommend you give his podcasts a try.

Here's the link:

The Medic Cast

New Frontier

They said she was vomiting and nauseous and having seizures. I asked what the seizures looked like and the patient’s friend who had witnessed them, said the patient shook all over with her arms and legs out. It didn’t sound like a seizure. She said they had done all kinds of tests, but hadn’t been able to diagnose anything. In the ambulance, I was putting in an IV when all of a sudden her head goes to the left, her arms and legs go out straight and she starts shaking. I am not impressed. “Knock it off,” I say. She stops. She is fully coherent. There is no postictal state. She didn’t pee herself or bite her tongue. She demonstrated complete control of her muscles in the way she was flapping. “What were you thinking about what just now?” I ask. “I wasn’t thinking about anything,” she says. “Why were you shaking?” “I don’t know.” “Is that what happened to you before when you had your seizures?” “Yes,” she says.

I have seen many seizures over the years and many fake seizures. I remember when I was a new medic and how this girl had arched her back and started shaking and foaming at the mouth, and how I told them breathlessly at the hospital triage how she had seized. The nurse looked at me like I was an idiot and told me to take her to the waiting room. She was a regular – always looking to fool new medics and new doctors into giving her valium, which is what we gave in those days. Some people fake seizures for drugs, others for attention, others I don’t know why.

I get an idea then. I reach into my backpack and take out my small digital camera. I use it at traffic accident scenes to take a picture to show mechanism of injury at the hospital. The trauma team loves seeing the pictures. The camera is so small it fits right into my pocket. Often I don’t even know I am carrying it. There is a motion picture feature on it. I think if she has another one of her fits, I can record it to show the doctors. Maybe then they won’t need to do any more expensive tests.

But then I think, hold on. There might be some patient privacy rights going on here. I am almost certain there is a rule about filming patients. Probably even if filming their seizure might be of great benefit to the doctor’s. I put the camera away.

The next day I get called for a woman with vaginal bleeding. There is blood all over the floor, in the bathroom, in the bedroom. I see some big clumps that look like maybe they might hold a tiny fetus. I need to focus my attention on the patient and not the clumps. She says all her periods have been regular and there is no way she is pregnant. I’m thinking miscarriage. I have my camera in my pocket. I could snap a few quick shots of the gore – to show them at the hospital. It would tell a better story than my just saying, it was really bloody there. Still, this is new territory and I am not really certain I want to be on the end of “Report at once to the Supervisor” pages.

I seem to remember getting some type of memo about digital cameras, but I can’t remember exactly what was in it. I know it was don’t do the obvious wrong stuff, but I don’t know if it covered the grey areas. I don’t want to chance it.

It is new territory, maybe territory that needs some addressing. There surely is a possibility for abuse, but also a possibility for some good. Cops videotape all their encounters on traffic stops. I’ve heard talk of cameras being put in the back of ambulances. How will this all shake out in the future? I wonder.

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).