Last Supper

85-year-old drives his Plymouth to the diner out by the highway every night at seven where he eats his dinner, then walks back out the door and gets in his car to head home.

I stand by the open driver’s door and look at the man, who stares at me vacantly. His skin is cool and diaphoretic. “We may have a diabetic,” I say to my partner.

“He’s not a diabetic,” the waitress says. She stands by the front bumper smoking a cigarette. “Jolene, you ever hear him talk about being a diabetic?”

“No,” the other waitress says. “I’m a diabetic and he never said a thing to me about it. Besides, he just ate.”

“Good point,” I say, “Thanks.” To my partner, I say, “Let’s get him on the stretcher.”

We lift him out and set him down. While we strap him in, I ask the waitress if she noticed anything unusual about him tonight.

“He ate diner here like he does every night, steak, eggs and toast. He was his normal self, polite, small talk. He walked out to the car, and then we noticed he was still out here, so we come out to see if he was okay. He was just sitting there not responding to us so we called you.”

“So 15 minutes ago he was last seen at his norm?”

“That’s right.”

On the way to the hospital, I check his sugar (it’s part of our protocol) and of course it is fine. His right side is now flaccid. I call in a stroke alert and do my best to manage his airway when he throws up his dinner.

Later the doctor shows me the Cat Scan. It is not subtle. You can see the huge white lake on one side of the brain. The ED has a hard time finding out if the man has any family. They do reach his personal physician who relates the man has been estranged from his children for many years. Finally a message is left with a son in California.

After work, I think about heading out to the diner to let the waitresses there know how he is doing. I go home instead and sit down in the living room with a beer and close my eyes and let my head fill with the sounds of my family about me. 

The Heart of Health Care

Last week, as I stood in an ED room for the first time in many years getting ready to take a patient out instead of bringing a patient in, the nurse walked in to say goodbye to the elderly patient as we spread out a clean white sheet on our stretcher.

The nurse said, "Well, good luck Mr. Jones. I hope you are feeling better."

"Thank you, Joe," the old man said to the nurse. "You were very nice to me. You have a comforting bedside manner. You are a good guy, and I appreciate it."

You have these moments in life. Sometimes you see something for the first time. Other times you are just reminded of basic truths. This was such a moment for me when you see the world very clearly.

I spoke up then, and said to the nurse. "What a high compliment he just gave you. You should be very proud of that."

The nurse blushed and lowered his eyes and said, "Thank you, most people think I tell bad jokes."

***

So we put the man on our stretcher, fluffed his pillow and wrapped him against the cold, and we drove him through the city streets to the highway, where we headed north to his town. When we found his small house on a quiet residential street, we backed into the drive, and then went and got the door open and ready before we took him out of the back, where the heat was keeping him warm. We carried him into the house on our stretcher and then went out and got the stair chair and carried him up the stairs to his bedroom, where his wife of fifty-three years was preparing his room. "This beautiful woman can't possibly be your wife," I said, "Unless of course you are a lucky man, which I now see you are." The wife smiled broadly and the man laughed and they looked at each other in the way people do who have spent their lives together through good and bad, and know they have never lost their faith or their sense of humor. We got him settled into bed and and we joked some more and exchanged well wishes with them. And then the man and his wife thanked us again for helping them.

And my partner and I left and drove back to the city.

***

I mentioned in my last post I am reading this book called Outliers: The Road to Success. The book examines the lives of people like Bill Gates, and professional hockey players, concert violinists, top Wall Street lawyers and children from disadvantaged neighborhoods who have gone on to be the first member of their family to go to college and others who have risen to the top of their fields. The one overriding theme in all of their lives is that effort equals reward. People who are most satisfied with their work and lives are those in fields where they can see the result of their labor.

What I like about EMS and health care is that if you view the work not as about saving lives, but as about treating people well, then on a day to day basis, your effort will be rewarded. And the reward is more than a check that is good at the bank at the end of the week, it is the simple feeling about being happy with your life's work -- taking care of people. This is not a thankless job. The people who matter -- our patients (most of them anyway) -- appreciate what we do. And of course, we get to tell bad jokes. 

Part One:

Picture this: One of those walk bridges over a canyon. You know the kind that sways when you walk on it, and has missing boards, and all you can hold on to is the fraying rope, and you are suspended 1000 feet up over rocks and a raging river. Well, it wasn’t quite like that, but if I tell the story enough that’s where it will end up.

Let me begin. Picture this. It is a nasty winter day. You are at work at your EMS job. You’re sitting back in your warm recliner, feet propped up, eating a hot meatball sub, watching Die Hard on the wide screen TV as the sleet clatters off the windows. One partner is snoring, the other is laughing manically as he texts on his Blackberry.

Got it.

Now picture this. A man arrives at the home he shares with his brother who he last saw this morning. The man does not have his key, so he knocks on the door, but no one comes, so he walks around the house through the deep snow peering in the windows. In the living room, he sees the TV on – Die Hard perhaps -- and he sees his brother sitting in his chair. His head is slumped down. The brother knocks hard on the window, but his brother does not respond. He is dead motionless. The brother in the snow shouts and bangs again and again. No response. He takes out his cell phone and dials 911.

With me still? Nothing really unusual here. You could change the scenario to any potentially serious 911 call. A car off the road. A man down in the snow. A baby not breathing. And as for the responders, you could change that up to. Maybe instead of the big screen TV, it is a scratchy old set dug out of the trash with tin foil on the antenna. Maybe instead of Die Hard, it is American Pie. Pizza instead of a meatball grinder. Maybe the crew is sitting in an ambulance on a street corner watching the movie on a portable DVD or an I-phone. One partner – snoring or texting – instead of two.

Nothing unusual here. Either way -- the tones go off, they call your number over the radio or your pager vibrates. One way or another, you get up – leaving John McClain to fend for himself – and soon your sirens are wailing and you are on your way to another run.

Now you have been lucky so far during this storm. All your calls have been at nursing homes or doctor’s offices and all the hospitals you have transported to have had covered awnings. You have barely gotten your boots wet. But you know this won't last.

The address is in the mountains. You partner thinks he has been there before. Thinks it is a regular, but the address does not seem familiar. You know the road, but the street number doesn’t recall anything. The CMED dispatcher has no information for you. You wait to hear if the cops are out, but nothing comes over the radio. A part of you is expecting to hear them put out and a minute later (after they have kicked in the door) hear “CPR in progress,” but nothing.

When you get on the road, you see the cops patrolling looking for the number. One cop turns around realizing he has just passed it. “I guess I haven’t been here before,” your partner says. The driveway you discover is barely visible. It is likely a dirt road, but who can tell with all the snow. There is brush on either side of the road, barely passable for a police car. No way for the ambulance.

You get out and walk. No house in sight. The road is like an ice rink that hasn’t been cleaned by a Zamboni. It’s a good thing you are wearing your Fort Smith Boots in this sleet storm because the water and freezing slush and ice are treacherous. You walk carefully. The last thing you need is for you or your partner to go feet up in the air, head and butt slamming to the ground. Talk about a call from frozen over hell. Over the radio you hear one of the officers say he will come back and get you, but no car appears. You hear now his cruiser is stuck. Still no word from the other officer who is surely trying to gain access to the house that likely holds a cardiac arrest to test you and your crew's mettle. You start to think about how once you get there -- if you get there -- you are going to get the patient out. You picture your crew doing CPR in the sleet all the way back to the ambulance here on this wild frozen trail in this first episode of a new reality TV show "Ice Road Paramedics."

Finally at the end of a bend, the road drops down a hill where you see the two cruisers. There is a small turn-around but the road is sheer ice. You consider throwing your house bag down and using it as a sled to get down the hill, but you are worried that you will not be able to stop, only to shoot off the end of the land and into the raging rapids in the gorge below. That's right -- icy, churning rapids. The house which you now see is on the other side of the raging river (I am exaggerating slightly -- it is more a raging mountain stream).

You make your way down through the snow on the side of the road. It is there that you first see the bridge -- a ricketedy wooden foot bridge -- thirty feet above that insane niagrous Artic megastream. You can’t believe what you have discovered. You think you know your town, but you have never been here before, never knew this place existed. The house is in fact on an island, completely surrounded by moving water.

And on the other side, a man inside a still locked house, slumped down in his chair. You can make out now the shape of a police man standing by the front door, raising a crow bar and smashing it against the door that will not open. Bang, Bang Bang!

And now you must make the crossing... 

So there I was (ala Commander McBragg) thirty feet about the frigid raging waters, having traversed an icy treacherous roadway on foot. My MediC Stat pack on my back, my hands out holding the sides of the narrow wooden foot bridge for balance, trying not to look down at certain death below (should the rickety boards below me give out). And ahead of me, the house on that rock island, the house surrounded by deep snow drifts, the house whose front door was being pummeled by an axe-swinging (again I exaggerate -- crow bar banging) police officer, and somewhere inside slumped in a chair is what I believe to be a dead or dying man.

I think -- if he is departed and beyond resucitation, let him be cold and stiff by a warm fire. Let there be no grey in the decision to work or not to work his body. And while I am praying, please don't let me slip and fall -- I am already halfway across -- please I do not wish to plummet to my icy death or to land on the jagged rocks at the river's edge. If the bridge is to give out, let it break first at the far side and go one board at a time like in the cartoons and let me run fast, one board ahead of disaster. Please no Wyle Coyote falls for me.

One by one we -- my crew -- make it across, and then step through the deep snow to the doorway, where the door, deadbolted has still not given way, despite the Paul Bunyonesque slams of the officer's mighty crow bar (He was actually prying, banging in the appropriate manner). I ask the quiet and worried brother standing with us when he last saw his older brother, who he tells me is in his 80's. He last saw him at sunrise, many hours ago now. He is dead, I am convinced of it, but I say nothing, just nodd.

The officer runs at the door now with his shoulder, and light from inside now shines through. Another ram and a kick and the door is open and we dash in. Through the foyer, and through the kitchen, down a hall, and through a dining room we go. Ahead I see the living room and hear the TV, now in sight -- Let's Make a Deal is on. I see the man now -- his back is to me -- slumped in his chair. I simultaneously see a grey pale face and a large hearing aide behind his left ear. The officer shouts as I reach for the man expecting another icy surface.

The dead man raises his head. "Oh, good day," he says with a smile.

***

Not the first time that has happened.

***

A hour later after much time in the snow and ice helping free trapped vehicles and get them up the hill, and then making that long ice road journey back to our ambulance parked on the road, we are again in our warm quarters. I -- in the recliner -- hold the TV remote. Click, click, click and we are back to Die Hard which seems to always be on one channel or another.

Memory

 The man has dementia to the point he forgets that he called us. He forgets that he went to the hospital yesterday for the same complaint, forgets that they saw him and sent him home, forgets what they told him about it. “You were the one who called them,” his wife says, after he demands to know why we are in his bedroom.

He looks confused, but doesn’t deny that he might have called. It is as if he has some recollection of it, and is not certain enough to swear he didn’t.

“Is there anything wrong?” I ask.

“Me got pain here,” and he points below his belly button, same as yesterday. “Bothering me all night,” he says.

The house is disorderly. Yesterday I made the decision to put the man in a wheel chair and wheel him out to the breezeway where we had the stretcher set up. That way we didn't have to move furniture and could maneuver well enough through the obstacles.

And so yesterday I wheeled him right to the door, leaving space to open it. I set the brake, opened the door and stepped into the breezeway. My plan was to help him step down, and then I could pivot him onto the stretcher. But before I could react, he felt the cold blast of air, and tried to kick the door shut. "COOOOLD!" he shouted. "YA trying to FREEEZE Me! Get out of Me House! Get out of Me House Now!"

And so ensued a struggle to keep him from locking us out while we braced the door against his kicks and negotiated to get back in the house and the whole time he was yelling at us like we were bandits come to rob him and then leave him out in the cold.

Today I say to my different partner, I want the stretcher brought into the bedroom. He looks at me like I am crazy. I acknowledge that we will have to move some furniture to get the stretcher in to the bedroom, but that is what we will need to do.

Memory.

The furniture moved, the patient wrapped tightly with thick blankets and our trademark towell around his head like a babushka, we carry out though the porch and then outside across the snow to our ambulance.

"Cold out," he says rather calmly.

Old Paramedics

 I have been getting in and out of ambulances for over 20 years now. That means just what it does. Twenty years ago my knees and back and all my bones and joints were twenty years younger than they are today. I’m in good shape, but still, I find now when I get out of the back of the ambulance when we arrive at the hospital my partners tend to offer me their hand to help me down. I ignore their help of course, but I do admit I’m not jumping down as spryly as I used to.

I read this article -- As Doctors Age, Worries About Their Ability Grow in the New York Times this week and it made me think for a moment in the same way I think for a moment when I read the “Will you have enough Money for Retirement?” articles. I think I can put worrying about this off for awhile longer, but I sense that someday these articles will be my front page stories. Just not yet.

The physical deterioration of these years is slow, but undeniable. When I went to nursing school a couple years ago, I found I had to buy a pair of reading glasses so I could see the fine markings on the insulin syringe so I could draw up just the exact amount before handing it to my examiner to verify. On calls now, sometimes I squint to see the tiny vein I am trying to thread a 24 into in. A month or so go when I intubated a patient, I, for a moment saw two sets of vocal chords side by side. During cardiac arrests now I have learned not to relay on my view of the monitor beyond two arms length. What may look like asystole, if examined may actually be a defined rhythm with low voltage. I make it a practice now to print or have the strip printed out and handed to me so I can verify it.

When it comes to hearing, I have always been annoyed with patients who don’t speak up when I ask them questions, but lately I have found myself saying “Huh?" and “What?” more often than before, and finally asking them to please speak up blaming my difficulty hearing on the noise of the engine.

I used to love breaking into locked homes to rescue patients unable to get to their doors to let us in,. I'd divehead first into windows (while getting a boost from my partner) or climb up onto roofs to access second story bedrooms. Now, just as with carrying our heavier equipment, I sometimes defer to stronger more agile partners or responders on scene.

A few times I have seen a tremble in my hand and asked, is this the first hint of a condition that will change my life or am I merely suffering from lack of sleep or caffeine withdrawal? (A reassurance, I just checked both hands, and today as I sit in front of the computer, each hand is as steady as a gunfighter’s, although quite lacking the gunfighter’s speed).

One of my partners is ten years older than I am. Sometimes his slow deliberate way is frustrating to me. His scene clock is slower than mine, but then when I work with younger people, I sense they may feel the same about my pace. I like to think that I move quickly when I have to, but as in a game of softball, I no longer have the reflexes to snare a blazing line drive in the infield.

A few years back I came on the scene of a rollover, a car on its side with a women still in there, although with only minor injuries. While I pondered what to do, considering the best approach, another medic arrived on the scene, and was in the car before I could even say “good day” to him.

I like to think my approach was mature, deliberate and proper, but I do wonder if someday it will tick past the mature deliberate safe response and into the doddering greys of early dementia.

My hearing is not so bad that I can’t at a distance hear the tick tick tick of the finite clock that beats for all of us.