The corner of his eye

Two small things that bother me in the course of my day.

1)All the TVs in all the hospital and medical office waiting rooms are on Jerry Springer or soap operas, and not on CNN.

2)You can't get Diet Caffine Free soda at the kid's hospital.

***
I don't mean to complain.

***


One big thing that bothers me.

Most of my patients are not sick. Or are not as sick as they pretend.

Case of the day: Get called to doctor's office for teenager unresponsive. The kid is six two, two hundred twenty pounds of high school linebacker. He had surgery a couple weeks agao, and today started having belly pain. At the doctor's office he had blood drawn then threw up, then lay down on the exam table, closed his eyes and was all limp. The medical staff is freaking out. The kid has stable vital signs, good capillary refill, his eyelids twitch when you move your finger toward his eyes, hold his hand up over his head and let go, and he moves the hand to avoid hitting his face. He also smells like diarrhea. When you get him in the ambulance, and take out an IV, he is watching you out of the corner of his eye. He flinches when you stick him.

I have gone through this and similar scenarios hundreds of times. Okay, you're not feeling well, but you are not sick enough that you have to pretend to be unconcious.

***

Other calls: an old lady with chest pain for two days since her daughter had a stroke, a pscyh who had walked out of the ER the night before, a transfer from the hospital to a nursing home, and a prisioner hyperventilating and claiming chest pain just prior to his transfer to a tougher facility.

Day of Rest

Worked ten hours in the city and did one transfer. Sundays. I read the paper, wrote in my notebook, studied some for my personal trainer certificate, took a nap in the back of the ambulance.

Cold Beets

I'm sitting here with a small styrofoam box of cold beets that I bought at 11:30 this morning. Of course when I bought them, they were hot. We did six back to back to calls -- a lady with dementia who fell and didn't know why, a lady with a blood sugar of 24, a girl from a doctor's office who recieved some novaciane and felt dizzy and because her pressure went from 110/60 to 90/50, the doctor thought she should go to the ER even though 90/50 is no too low for a girl, particuarly one who has a steady pulse, whose skin is warm and dry and who does not look sick, but hey, he's a doctor, a lady with a bad cough for a couple days, a lady with a very tender abdomen who probably burst a cyst on her pancreous--the only call we went lights and sirens to the hospital, and a man who passed out outside a restaurant, and who I think was dehydrated. The worst part about doing these calls back to back was we'd do the call, drive back to the base, sit down and as soon as my butt hit the chair, they called us again.

We did another call earlier -- responding for a pulled chord at an elderly housing complex. In the all the years i've worked here everytime we have responded to a pulled chord at this complex there has never been a patient, but they keep sending us. No patient again today.

I mentioned I need to be vigilant when I am tired. The lady with the low blood sugar I really didn't want to take to the hospital, but her family wanted her to go, and I didn't fight them other than suggesting maybe we call the patient's doctor and see what he thinks she should do. It turns out she also had pnemonia so it was good she went. The lady with the cough got a breathing treatment at the hospital. I suppose I could have given her one, but she was walking around and talking in full sentences when we got there. Her cough wasn't any worse than mine. Eddie wanted to tech it. If I had teched I probably would have given her the breathing treatment not that she needed it right away. I mean we put her on the stretcher, gave her some oxygen and took her to the hospital. I worked up most of my other patients all the way today, did my job even though I was tired.

I was lucky that the rest of the regular season Red Sox tickets went on sale today and I was able to get tickets to two games before the calls started coming. I would have gotten more, but could never get back to the computer. Now all they have left is standing room. All those calls saved myself some money.

Except for the 90 cents I spent for the beets.

Beet. Beat. I am beat.

I look at my reflection in the window. I have terrible hat head from wearing my hat all day. It was only -10 this morning when I came in. Warmed up to the teens.

I'm going to throw the beets out. I just can't stomach the thought of eating a cold soggy beet.

Working eight hours tomorrow. I can at least sleep a little late. Don't have to go in until 9.

Eight minutes to go till crew change. Please no more calls.

Liability

-15 on the way in to work this morning. Last night the ambulance I reguarly use blew its siren so we had to use another one, which has crappy heat. We ended up having to leave the rig running outside with the heat pegged, instead of sitting in the garage.

Got called to the jail for a prisoner who claimed he swallowed cocaine in a plastic bag. He was fine -- his vitals were normal, skin warm and dry -- he was laughing while I was checking him out -- so I got a refusal, but then he was acting up again a couple hours later, so we took him in. I had talked the case over with an MD and he said if the guy said he swalloewed a bag of cocaine and was complaining of abdominal pain, I pretty much had to take him in whether it was BS or not. It wasBS. Complete Bullshit. The guy just didn't want to sit in jail.

I heard later one of the officers was upset that I said he had to go to the hospital the second time.

Here's the thing: they call me to check a guy out because he is complaining of being sick. Prisoners complain all the time of being sick to get get out of their tiny cells. I usually always get a refusal. If I think its BS, I tell them I've checked them out and they check out okay and I hand them the refusal and say sign here. And I tell them if they get worse, to feel free to call back. They usually always sign the refusal. But if I get called back twice, then I usually take them. The cops cover themselves by calling me. I am willing to get a refusal the first time, but if the person turns out to be really sick, then its on me. If they call twice, they are going to the hospital. I'm sorry if it takes an officer to go with them. I can't refuse them if they ask to be seen at the hospital. The cops can't expect me to take their liability. If they don't want to send an officer to the hospital, don't call me, and certainly don't call me twice.

The only other call was for a very sick old woman with multiple diseases, who was unresponsive and breathing irreguarly. The visiting nurse was all freaked out, but the woman's vital signs weren't too bad. I gave her some 02 and took her in on a non-priority.

Eight minutes before crew change, we get sent for a code three, lights and sirens MVA, and no relief in yet. But we ended up getting canceled before we got there, so I didn't get out of work too late.

Six Minutes To

After busting it for the last three days in the city, I get my suburb shift and do nothing all day......until six minutes to go in my shift.

Diabetic with low blood sugar at a local industry. I give her 25 grams of D50 IV, get her back to normal, and say, "Would you like us to take you to the hospital?"

"Yes," she says.

"OR," I say, "You could eat a sandwich and have someone watch you and if you start to feel badly again, then call us back and we'll take you to the hospital then."

"Okay," she says.

All right.

Now, it wasn't that it was after my crew change that I took the refusal. If she really needed to go to the hospital, I would have insisted. But I have felt lately, a little creep in my standards as the clock approaches the going home hour, particuarly with all the hours I've been working. I want to get home.

But I need to stay vigilant.

TreadMill

And it continues. We signed on at a few minutes after eight. Dispatch sent us through the snowstorm from one end of town to the other for the cardiac arrest, which -- no surprise -- turned out not to be. The nursing home said the person was a cardiac case who was a full code. Translation, the patient has a heart related ailiment and in the event they were to stop breathing, they should recieve CPR. Our calltakers translated it to mean the patient was in cardiac arrest. Instead our patient turned out to be an old Russian speaking lady with shortness of breath.

We did a nursing home call for an old guy who had a syncopal vagal episode, but was fine by the time we arrived.

A lady with chest pain. I gave her a nitro and some 02 and her chest pain went away.

A psych, which turned out to be a girlfriend who wanted to evict her boyfriend by claiming he was crazy. "I can take it anymore," she said. "He all the time accusing me of stealing his money!"

"BUt you took my twenty dollars," he protested.

"You owed me that money and the only reason I gave it back to you was to shut you up cause you was acting crazy!"

"I got to hide my money in the mattress from her," he said, "But she even go into my mattress. No place is safe from her thieving hands!"

"Just get him out of here. Take him to the crazy hospital, put him in a shelter, lock him up or throw his ass on the street. I don't care. I'm tired of living with this crazy motherfucker. A girl need peace."

We ended up being cleared by the police, no medical emergency.

We drove through the snowstorm to a nursing home in an outlaying town only to be canceled on our arrival.

We took a man discharged from the hospital from hip surgery and open heart surgery to a nursing facility for rehab.

We were called to a commercial building for the unconcious and arrived to find a man standing in a doorway with his dick out, taking a pee. He was hammered, but he knew his name and the date so we couldn't take him, and because it was just us and the fire department we couldn't arrest him. He looked like he was on the bad end of a week long bender, his face all purple and swollen, unshaven. We talked to a lady who was the landlord of the building, and she said the guy worked for a guy who rented the office space, which was some sort of computer training center, and he must have fallen off the wagon. She had tried to wake him up, but couldn't. He was sleeping in there on the floor with all the lights out except the computer monitors. I guess the urge to pee had done the job. A couple hours later we heard another ambulance called back to that address for a drunk. It didn't occur to me until I went home that it was the same guy the fire department had pulled out of a smoke filled apartment when he'd fallen asleep smoking a cigarette and caught his mattress on fire. He was hammered then too. I remembered he told me he worked with computers.

We took a diaylsis patient back to the nursing home from the diaylsis center.

A lady with a bone infection having chest pain that her doctor thought might be a pulmonary embolisim.

The call of the day was an eighty year old lady who got on her husband's treadmill and it started going to fast for her, sort of like the treadmills do in the cartoons, and she went flying off it, and dislocated her shoulder and maybe broke her arm too. I gave her morphine and phernergan when the morphine made her nauseaous. I felt bad for her and her husband.

One good thing about busy days is the ten hours goes fast, but I will say, today was cold, and it seemed like all we were doing was sliding patients from beds to our stretcher, or from our stretcher to beds, and they were all heavy and my back was kind of tight by the end of it.

Hammered

Getting hammered in the city. The last two days it has been sign on, get a call, sign back on, they are holding two. Did a lot of BS again today too.

A guy who fell eight days ago, and today his legs started hurting. No deformity. We had to carry him down three flights of stairs.

We had a lady feeling weak for a week.

A 22-year old feeling weak because he hadn't eaten all day.

A teenage girl hyperventilating at school, who had the nurses running around like headless hens when she started arching her back and rolling her eyes. Then when we went to the hospital one of the nurses wondered if she was having a dystonic reaction. I wondered if she had ever seen a dystonic reaction. It turns out someone had written the girl a nasty note earlier in the day.

We responded to a 22 year old feeling light-headed who said he hadn't eaten all day. We did a two month old who got temprarily short of breath according to his mom when she brought him to the state welfare office. The person at the welfare office wanted me to investigate why the baby hadn't recieved any medicine when she was brought to the doctor the day before. I felt like saying maybe because the baby wasn't sick.

We did a drunk on Main Street.

The most interesting call was for a girl who'd had gastric bypass a year and a half ago and who suddenlt today started vomiting and shitting dark brown blood. She was very pale and clammy when we got there, but after some oxygen and a liter of fluid was looking a little better. When I patched to the hospital, I told them she was alert and oriented. The nurse on the other end of the radio asked, "What's the patient's GCS (Glaskow Comma Score). I responded, "Well, she's alert and oriented -- that would be a 15." Its like asking is the patient breathing after I say, the patient says she is in pain.

We got sent for a person in a wheel chair hit by a car. Another ambulance on the way to a sprain was passing by and stopped to treat the patient. Our dispatcher told us to continue there and take over care so that the other crew could go on to their call. We got there and they had the call well in hand. I told them to just go ahead and do the call -- their ambulance was even pointed in the right direction -- they were only a couple blocks from the hospital. So we went on to their call, which we should have been sent to when they came upon our call. By the time we got to it -- a strained thumb from an assault, the patient had already gotten a ride to the hospital.

Our last call was for an old woman who had been on the city bus earlier when the bus was in an accident. The cop who checked the accident out, asked her if she was okay, she said she didn't think she was hurt, but then when she got off the bus and started walking home, her back started to hurt. So she called for an ambulance a couple hours later. When we got to the hospital, her son met us outside and started yelling at me about what where they going to do, how were they going to handle it, her being hurt on the bus like it was our fault. I tried to tell him we had nothing to do with the bus and that was a matter for the police, we were just taking his mother in to have the doctors look at her, but he was not happy. Then when we moved her over on to the hospital bed, she groaned, and he started shouting at us that we were abusing his mother and we were too rough. He yelling this out to the whole ER like a man who had witnessed a robbery and was trying to call for help. I apologized and said, we had not intended to cause her pain. Then he accused me of treating all black people that way. I told him he shouldn't make assumptions. His mother apologized for his behavior, and thanked us for treating her well.

That was my day.

***

The other interesting thing that happened was one of our calls was to the headquarters of the city paper. We approached the call from the south, the fire department came from the north. They got stuck at the train tracks as a long frieght train came through. So we got there way ahead of them. I have no problem with the fire department, but the paper has been way pro-fire and way anti- ambulance*, so it is always nice to go to the paper and beat fire there.

*When I first started in the city, the fire department only responded to motor vehicle calls that required extrication. The police department was the first responder. The problem was the police were too busy to go to many of the calls, and when they did go to a call, they were reluctant to get too hands on. A few years ago the fire department after lengthy internal debate between the old school(we only fight fires" and new school "we need to justify our jobs because there aren't that many fires anymore" members decided to become the first responders. The best part about having them respond is we no longer have to look for the house or building numbers, we just look for the red fire truck(if they beat us). They are also very helpful with carrying equipment and are genuinely pleasant helpful people. Sometimes they even get to cardiac arrests before us and their CPR makes a difference in patient outcome. The bad part is they get all the good press and we get none. The paper, which bashes us constantly, reccomended that the fire department crosstrain its firefighers as paramedics and then take over all of EMS in the city. My problem with that is it assumes that anyone can be a paramedic as if being a paramedic is as simple as going to a few classes. Don't get me wrong. I would love to have a city pension, but I think paramedics should be first and foremost paramedics.

Dirt and Slush

Busy day. From the moment we signed on, we were always on a call. They sent us for a drunk, who'd fallen a few days ago, and now his arm was all swollen and bruised. As soon as we cleared the hospital, we were sent for a man with dehydration, then for an unconcious in an apartment building, who turned out to be a man who fell, got up, walked to his apartment, then slammed the door in our face after telling us to leave him alone, then an abdonomal pain at a doctor's office, then a drunk outside a homeless shelter, then a diaylsis transfer, then a respiratory distress that resulted in a refusal. The man said he'd just had a coughing fit. Seven calls in eight hours.

***

Today was the kind of day when the ambulances were all dirty, and we tracked slush everywhere we went from walking in snowbanks all day. Walking down the hall of the hospital, I always feel like the custodians hate me. They have just mopped the floor, and then I walk by, tacking in all the dirt and slush. I feel so bad. All day long. Here I come again. Sorry, man.

Back to Sleep

Spent the night at the ambulance barn so I wouldn't have to drive to work in the morning. About ten o'clock last night I was sound asleep when the radio identifier went off, then I heard the dispatcher call us.

I swore and started to get up, and then realized. Wait a minute, I'm not on duty. I don't have to go anywehere. The on duty crew had to get up and go out into the blizzard for a bleeding penis. A couple hours later, they went out again for a bleeding rear end. I slept like a baby.

The observer who was on with us yesterday was in when I got up. Somehow he convinced his father to drive him through the blizzard so he could ride with us. The roads were pretty bad he said.

So far we've only gone out once today for a lady feeling dizzy. We were lucky she was young and able to walk well, so we helped out through the snow drifts. Hopefully we won't have to do any bad calls that require the stretcher. Not many drives or walks are plowed. About 16 inches have fallen according to the weather.

***

Ended the shift with only two calls. We did an unconcious diabetic with a sugar of 20. She woke up with an amp of D50. She'd been having trouble over the last few days with hypoglycemic episodes with no explanation, so we had to take her in. We were just about to start carrying her across the snowcovered yard when their plough driver showed up and plowed the drive.

I spent the rest of the afternoon sleeping in front of the TV, semi-watching the Eagles-Falcons NFC Championship game.

An Encounter

BLIZZARD!

That's the word on the weather street anyway. It started snowing around three-thirty-four o'clock and it's now almost seven, maybe three inches down. Expected to get 20. I'm lucky I managed to park my car in the garage, squeezing it between the two ambulances. I was supposed to work in the city tomorrow, but the suburban day medic just booked, and they let me swap into his shift. So I'll be on the clock here till 10 tonight, then get an eight hour break -- I'll crash in the back bedroom, then back on at six A to 6 P. With luck I'll get to watch the football games on TV tomorrow.

***

It was very busy this morning as anyone who even thought they might be getting sick, wanted to go to the ER.

So far today we've taken in a cancer patient feeling faint, a nursing home patient having a stroke, a man with bronchitis whose daughter was worried he might stop breathing during the blizzard, and another man from a nursing home with a fever. We also did a refusal on a man with a syncople episode at dinner. I would have liked to have taken him in, but he didn't want to go, and he agreed to be seen by the nurse at his retirement facility and to call back if she convinced him to go or if he felt worse. Other than a slight orthostatic change in BP from sitting to standing from 104 to 96 systolic, he looked good, good color, good pulse. Still, all syncopes should go to the hospital.

Both hospitals were packed earlier. While we were doing our calls, our second ambulance did another 4 calls.

I just went out to get a pizza. Now pizza isn't on my diet, but blizzards let you break the rules. I needed something hot and filling in my stomach.

***

At the pizza shop, I noticed a grey faced woman say hello to me as I went in the door, then when I came out she was lingering in the heavy snowfall.

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

"You're welcome. Thank you for saying that," I said. "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.


***

Only went out once more -- a lady from a retirement community who possibly broke her foot when a closet door came unhinged and landed on her foot.

My partner was funny with her. She was all upset at the retirement community people -- the nurse, nurse's aid and security man, and insiting that the retirement community pay for the damage. She was very demanding, telling us to bundle her up. My partner who has a shaved head and tatoos on his arms and bad teeth, was smiling at her and sweet talking and charming her. "Just hold on a minute, give us a chance to do our stuff. We're going to have all bundled up, warm and comortable as can be, you won't want to get off our stretcher. I'm just going to tuck those tootsies of yours up right now in out special blanket. There how's that? I knew you'd like that. Now let me fluff that pillow and sit you up just a little bit more, there, more comfortable. I thought so."

No RBI

Cold day. temperature only a couple of degrees. Got two hours of sleep to start the shift, then went to a totally BS chest pain at an address where about ten people live and their family uses as like a neighborhood taxi service to take them down to the hospital to get every little ache and pain checked out. 50 year old lady felt a twinge when she bent down after vaccuming. Only lasted a minute. Warm, dry, ambulatory, the works.

Then we did an elderly lady with a high fever, and then as we were clearing that call, we heard the cops being sent to a local nursing home for a code, a city ambulance already in route. So they sent us to back the city rig up. We had to put on masks to enter the room. The lady had MRSA in her sputum. I asked the city medic how I could assist her. She said she couldn't get the tube, maybe I could try. The lady's neck was completely stiff. She was asystole, but they said she was always sort of stiff. I tried a couple times to get the tube. There was no play at all in her neck. I couldn't see the chords, so I tried the bougie, but I went in the esophagus. The mouth was full of crap. I tried to look in using the ice pick method, but couldn't see anything, then tried to do it digitally, but couldn't get my hand in. Another city medic showed up and he ended up getting the tube. I got an EJ and we did three cycles of drugs with no effect, then called her dead.

I admit to being a little disappointed I didn't get the tube. I always get the tube. Its a point of pride. I probably would have gotten it eventually if I was on my own, but when other medics are there you have to take your shot then pass the scope. I know what I did too. I should have lifted higher to the right and knelt down lower, then maybe I might have seen the chords. I'd like to try again.

It's the first tube I haven't gotten in years so I guess I was due to have trouble. The fact of the matter is I just don't get enough intubation attempts to have the proficiency I would like. I average 12 tubes a year. Last year I only got 8. I got all the tubes I tried, but you really should be doing 20 or more a year.

I'm much better than when I first started. Or maybe I've just had easy tubes. No, I've tough ones and I've managed to get them -- not always on the first try. But not this one. I feel like a ballplayer who failed to drive in the run.

***

There was a big article in the latest Journal of the American Medical Association about the poor quality of CPR being done, and I have to admit I've seen my share of codes where people forget to do continuous chest sompressions. Sometimes even when they are doing them, they are doing them poorly.

Here's the link to the article:

http://jama.ama-assn.org/cgi/content/full/293/3/299

***

Last call of the day was a guy with abd pain from a doctor's office.

Working tomorrow. A blizzard is on the way.

Chase

Got to work, checked out my gear, then lay down in bed. On the cop frequency, they had a car chase going on the city/town line. Everytime the car headed south I cheered. When he headed north I booed. I figured if it ended up in town, I was going to end up seeing him at some point and I was comfortable right where I was. The guy ended up ramming a couple cars, then bailed and the town cops finally tackled him. Lots of breathless shouting all throughout the chase.

Five minutes later they are calling us on a Priority to come down to the PD. The bad guy or bad kid is now handcuffed and writhing on the ground. He says his neck hurts and he feels like he might pass out, he then goes into an oscar award winning seizure flop, which fails to elict much of a reaction from me, particuarly on account of having seen the real thing so vividly just the day before. We took him down to the hospital where he soon got a clean bill of health.

***

Busy day early. We did a major anxiety attack where the woman was complaining of difficulty breathing and chest pain. Forty-year old lady. She was freaking out. Hyperventilating. Her twelve lead was perfect. 100 % Sat on room air, great vitals. Skin warm and dry. I should have called for some Ativan for her.

Then we did an old lady with bleeding gums and a foul foul odor coming out of her mouth.

Last call was a old guy feeling light headed.We took him to the hospital. When we got out at the ER entrance-- this hospital is built on top of a mountain, a gust of wind came up and blew my 12-leads up into the sky and swirled them around. I chased them across the parking lot, but they got away, and blew out over the valley. Gone.

Bleeds

Worked ten hours in the city today. Busy. Started off with a 92 year old lady from an assisted living center who's eyes were deviated to the left and she was seizing. gave her some Ativan. Turns out she had a major bleed.

Later in the day we went to a fall. The woman in her forties went down a few steps hit her head. No loss of conciousness. She was alert when we got there, no amnesia of the event, asked where her pocket book was. No one described an seizure activity. A family member said she had a history of recent falls, including one last night down some stairs. The family member said she panicked on stairs and often went limp. There was some phycsh history there.

We boarded and collared her, and went to the hospital BLS, although I teched the call. I was asking her questions on the way. She said sometimes she got the shakes, and she thinks that was what happened on the stairs. Just as we pulled into the ER drive, she had a violent gran mal seizure, biting her tongue so hard she bled from both sides of the mouth. I popped in a quick IV, but stopped seizing before I could open the Ativan. She was out cold for a couple minutes, then woke up as I tried to put a nasal trumpet in her nostril. We talked for a little bit. I asked her if she knew what happened. She was still postictal. I checked her pupils again. Equal and reactive.

We get her in to triage. Bam! She starts seizing again. Even more violently. Lasts about forty-five seconds then she's out cold. They cat scan her and it turns out she has a subdural hemotoma. Whether that was from this fall or the one last night or something going on in the last couple days, they don't know.

***

We did a patient who had been vomiting and with fever at one of the physciatric hospitals. This one place -- well, in my experience many of the pscyh hospitals, it is hard to tell the patients from the staff members. Its like owners who look like their dogs or dogs who look like their owners after awhile. We go in the door, a staff member/inmate lets us in the locked entrance. Then once in the entrance, I heard someone banging on the outside door. I open it thinking its a staff member. In walks this big guy. He stares at me, looks at the oxygen tank on the stretcher demands? "Is that an Oxygen tank?"

I nodd.

"Take it off!" he shouts.

I just stand there.

He starts down the hall, gets maybe forty yards down the long hall, then turns and shouts, "You want to get it on punk ass bitch. You want to get it on?"

I'm still just standing there, thinking how bizzare this is.

"I didn't think so," he says, then turns and continues away.

Another staff member/inmate takes us up the elevator. He has a cigarette behind his ear.

The nurse in the locked unit, tells us our patient is orthostatic, dizzy on standing with no blood pressure or palpable pulse. He is so pale, you can almost see through him, she says.

"Where is he?"

"He's getting dressed," she says.

He comes walking down the hall. He is as pale as she says.

"Let's lay you down," I say.

I can't feel a pulse or hear a blood pressure either. On the monitor, his pressure is 80/50. His heart rate is 160. And they had him walking around.

Also did a chest pain, a couple transfers and a motor vehicle.

Singing

I worked with another ten year plus medic today. People saw us and commented on what a high priced car we were. My partner has been here even longer than I have. We both work in the suburbs and do lots of overtime in the city.

We were talking today about changing jobs. People wonder why we have stayed so long in a job with limited retirement possibilities. Both of us make big salaries because of the hours we work. My partner always makes right around $80K. We both contribute to 401ks and IRAs and try to manage our money right.

The bottom line though is we recognize a good thing. We love our jobs, believe we are respected, have the benefit of being assigned in the the suburbs. Alan works the nights so can sleep a good part of the shift. We can work three days a week if we want to get our forty hours, or we can bust and work 6-7 days a week. All depending on need.

Today we did a call in an insurance company and wandering through the maze of cubicals, it occured to me just why I am still out here. i have worked other jobs. I know what its like to have to kiss a boss's butt all the time, what it is like to have to deal with heavy office politicis, and climbers, what it is like to never be able to leave work at home, always having a project fdue for work, what it is like to have to make a sale to get paid, what it is like to drive through rush hour traffic for an hour everyday. It sucks.

Today I found myself singing as we wheeled down the cotrridor of a nursing home. I realized I always sing on the job. I sing everything from "Johnny B Goode" to "Jimmy Crack Corn." I sing "Santa Claus and His Old Lady." "Mamamamama-cita, donde esta Santa Claus, the cat with the hair on his jaws..." I sing country. "I don't want to have to chop no wood. I can be bad, I can be good, I can be anyone that I please one of these days..." I sing gospel. "Precious Lord, take my hand. Lead me on, help me stand..." I'm a singing fool.

Sure there is stress in this job, but I don't think I show it in my face. I look young for being middle-aged.

Most days the job is routine in the sort of way that it all flows easily. In the course of a day, you see lots of people you know, you smile a lot and say high and joke. You do your job well for the most part.

For better or worse this is my place in the world and I am comfortable in it.

We did five calls. An old lady with colds and flu, a man from a nursing home who had been vomiting and was lethargic, a woman with chest pain when she breathed at work, who the work nurse practioner's gave several nitro to, causing her to pass out, an elderly man who fripped on the sidewalk and cut his forehead and nose, and another nursing home patient who had abnormal lab values. Nothing too exciting. the nurse practioners giving the lady nitro provided a chuckle for us. It reminded me of the time I got called for an allergic reaction at one of the insurance companies. The nurse had given a young male employee a flu shot and he passed out immediately, so she gave him a shot of epinephrine thinking he was having an allergic reaction to the flu shot. Not. He was having a reaction to seeing a needle. When we got there he was up and looked like he'd just drank ten cups of coffee.

My preceptee got cut loose. I didn't get to talk to him, but it was announced on the air, and we all got to congratulate over the radio which is tradition. He'll be a fine medic.

Tomorrow I'm off for personal business.

Watching Football

Last day working with my preceptee. Started out with two quick calls. A seizure and a chest pain that turned out to be a young female security guard with the flu. Later we did a kid who suppossedly ate a whole bottle of tylenol. We arrived to find him playing merrily with his siblings. He went to Children's where they probably pumped his stomach. Our last call of the day was a fall in a homeless shelter. We later got a call for a shooting, that was updated to two people shot, one in the neck, but when we got there, there were no victims, and the cops cleared us. We ended up sitting outsdie the Athletic Cafe watching the NFL Playoff game through the window till they called us in.

My preceptee rides with the chief paramedic tomorrow to get cut loose. He should do fine. As for me, its back to working, doing the calls myself.

Working 9-5 tomorrow in the city. Its Martin Luther King Day, so its double time and a half.

Choking

Sixteen hours in the suburbs. Didn't do a whole lot interesting. We were canceled on a fall that the police helped up. We were sent to a nursing home on a priority for a choking, only to be updated that the patient only choked when they tried to fed her. Once we got there, they said she'd been disoriented. Turned out she was hypoglycemic. I got a 24 in under her wrist and slowly pushed in the Dextrose and got her back to alert.

Later, we did a kid who fell playing basketball and got the wind knocked out of him, and a refusal for a man on portable 02 who was running low on 02 and thought we could give him a new tank. Last call of the night -- two minutes before I was due to get off -- was an asthma that got a breathing treatment.

Allergic to Handcuffs

I had to take half a day off today for personal business. Came in at noon. Did three BS calls. We checked on a prisioner who claimed he was allergic to handcuffs, did a back pain at a local wharehouse that has featured an epidemic of falls and back pains lately -- most I suspect related to their three paid days off policy for falls or back injuries on the job, and a nursing home patient with a TBI whose mother claimed she was leaning to the left. The staff said this was the patient's norm. The mother appeared to be somewhat irrational, mumbling to herself.

DNRs

Cold, rainy, foggy day. Only did two calls. One at an MD's office for a man who came in feeling dizzy, and who was found to be in a new onset of rapid afib. My preceptee gave the man Cardizem, which brought the rate down from the 140's-150's to the 80's and then started a Cardizem drip.

Later in the day, we did an unresponsive, which turned out to be a nursing home patient, who'd just had his DNR signed, and none to soon. Agonal resps, no BP, 20 on the monitor. This is the second time my preceptee has had a patient he could tube, but had to hold off. At the hospital, they just tried to make him comfortable.

I was sort of ticked at the nursing home. They always try to ship their DNR's off just before they croak.

Overnight

Went to bed at eleven, woke up at seven thirty. That's a good overnight. I needed the rest.

They called our number for the first time at quarter to eight. A COPD at an elderly housing complex. We got back, sat around for an hour or two, then did three back to back calls, a fractured hip, bad pnemonia and syncopla episode. Three of our calls were all at the same elderly housing complex.

It was a damp, dirty day, the kind you need to hose the ambulance down after every call. When got back from the hospital, you couldn't see out any of the back windows.

We gave the guy with the fractured hip 5 mg of Morphine and he slept all the way to the hospital.

Retirement

I'm in for a 16 hour shift. Its snowing, three or four inches down already. This afternoon I went to my monthly regional metings. After the first meeting we were taking about how people in the field are underpaid and some were arguing if there were no volunteers, people could make a decent living because towns would be forced to pay to retain people. They were asking about what people made and were shocked when I told them I made over $80,000 as a medic last year. But that's working six days a week, having no life and having to save for my retirement. The company has a 401 K plan in which they contribute 3% of your pay. So all they gave me was $2460. So if I work for 20 years six days a week, they will have given me $49,200. There are police and firefighters who will recieve that much every year for the rest of their lives as part of their pension plan. $49,200 in the bank produces an income of $47 a week.

Why don't I quit whinning and get a real job?

Because I love this one.

Short Term Memory

Worked 12 hours with my preceptee and one of my old regular partners. I think we did five or six calls. Nothing memorable at all. Let's see -- a Hispanic lady with abdominal pain, a disturbed juvenile pscych patient who tried to stab herself with a pencil, a lady with a blood sugar of 500, a pschy transfer back to the nursing home, and another nursing home patient who had a slight fever.

My old partner delighted in telling the preceptee some stories of our old days working together, but when I remembered a great call Wendell and I did a year ago -- a guy who went into v-tack in the back, who I shocked into arrest, then tubed in like 30 seconds, and then after we brought him into the ER and the doctor called him dead, he started breathing again, and then he stopped and the doctor called him dead again and then he started breathing again, hel couldn't remember it. He says his short term memory is going.

The highlight of my preceptee's day was getting a 24 in the arm of the diabetic lady who was close to 400 pounds.

My cold is better.

Beets

Did eight hours in the city. They let my preceptee and me rove the city looking for calls for him. It was a slow day. We only did two, both came in as unconsious, a patient who took too much pain medicine on an empty stomach and nearly passed out and one who had the flu and passed out in church.

Got a good hot lunch at City today, roast pork, green beans and red beets. Hmmm, love those beets.

Cold and rainy

Ten minutes to go till my 16 hour day is over. Cold and rainy and icy. Fortunately we only went out twice -- two nursing home calls -- a dehydration and an unresponsive, which was more like the lady was just in a deep sleep. She woke up and smiled when we moved her onto our stretcher, and yawned.

I was lucky it was an easy day becasue my cold is still beating me down.

National Scope of Practice

I attended the National Scope of Practice presentation at City today. Very interesting. The idea behind it is to have national standards and education and a scope of practice so that a medic can go to any state and be certified or licsensed there. It would not require states to follow the guidelines exactly, but would encourage them too.

Here's the link:

www.emsscopeofpractice.com

They envision a new level called Advanced Practice Paramedic, which would require a batchelor's degree in paramedicine, and enable the practicitoner to do things such as suturing, dislocation reduction, treat and release, etc.

My initial read was that you would not getting this level in this state, but now I think maybe you could. It all depends of developing a mechanism for reimbursement and the willingness of medical control to sponsor the medics.

The one question I asked had to do with whether or not the scope addressed the increasing role of paramedics in ED's. The presenter said, it did, but I don't see it in the document. I think I may send in a comment, encouraging to detail more fully that the areas a medic may practice extend beyond an ambulance.

****

I was hacking up quite a storm in the back of the room. I saw a bunch of people I had seen in a long time, and I warned them, "We're going to have to do a virtual handshake. I'm sick."

And they all said, "Get out of here, I shake hands with sick people all day," and they'd give me big solid how are you good to see you, you're my friend handshakes. So at the end, I go up to this doctor I know and he turns and looks at me, and I put my hand out to shake, and he looks at me and says, "I'm not shaking your hand. I heard you coughing, you're sick."

All right, fine.

14 mgs of MS

It was cold snowy, icy, rainy miserable day. We did a refusal for a woman choked by her boyfriend, a cancelled MVA, a broken tib-fib from a fall on ice and an abd pain.

The tib fib was a good call for the preceptee. He ended up giving the guy 14 mg of morphine. 5 IM to start because he couldn't get an IV, then when he still couldn't get an IV, he called medical control for another 5 IM. I finally got a 24 in the guy's bicept and then he called and got an additional 4 mg Iv. It certainly took the edge off for the guy who was a big man -- 250 lbs with a severely angulated tib/fib. He was singing when they wheeled him into x-ray.

I'm coming down with a bad cold. I'm wondering if the flu shot I got last week lowered my immunity. I've been pretrty healthy lately. Now I'm all doped up.

I'm off tomorrow, but am planning to go to attend the new National Scope of Practice presentation.

Photo

The morning paper had a picture of us at the accident scene in the state section. All you can see is my back side, standing with the board and stretcher, while my preceptee directs the extrication, just after the fire department has peeled the roof off.

Today we did an old woman who passed out in the bathroom, a unresponsive diabetic with a blood sugar of 39 who my preceptee woke up with an amp of D50 IV and then got a refusal, a chest pain, a four hundred pound lady who was vomiting and two calls where no patient was found. In one, the fire department had to break the double locked door down only to find no one inside. It happens all the time.

Wreck

My preceptee got his trauma today. A good wreck on the highway. A truck plowed into the back of a stopped car and drove the bumper almost into the front seat. Fortunately no one was in the back seat or they would have been called dead on the scene. It took the fire department fifteen minutes to cut the driver out. They ended up taking both doors and the roof off. As we wheeled our boarded and collared patient to the ambulance, he detailed his game plan. Instead, I told him to tell our partner to drive lights and sirens as soon as she got behind the wheel, and that his job en route to the hospital was to cut off all the patient's clothes, get vitals and do a full assessment. Only then if he had time, could he try an IV. He got a 16 in so he was happy. He did a good job, and the patient did okay.

We only did three calls today, a chest pain anxiety that we took all the way to the hospital, the wreck, and a lady who fell and was bleeding profusely from under the chin. The blood was pulsing out, and it took quite a bit of pressure to control it.

Ammonia

Worked eight hours in the city today. Another medic needed a partner so they let my preceptee and me work as a two man crew. We got permission to let him tech calls in the back without me driving (provided I had a good comfort level with the call.) We did five "jobs" as he calls them. Nothing too exciting, a pseudoseizure, a chest pain, a man down, who turned out to be a drunk who got up and walked away, a man with suicidal thoughts, and a nursing home infection call that cleared my sinuses out like someone had shoved two ammonia inhalants up my nose. My boots were sticky on the floor. The guy must have spilled his urinal several hours earlier. He had pissed and shit himself or his makeshift diaper which was loose, and he was three hundred plus pounds and his feet were full of blistering yellow pussy sores, and he was sort of a surly guy to go along with it. I drove to the hospital with the windows down.

I was thinking afterwards, it must be hell to work in a nursing home. I deal with this guy ten minutes and can't breath, and admitedly was sort of grossed out by him. Then I drop him off, and I'm done with him, other than the lingering amonia scent in the nares of my nose. But if you work in the nursing home, this is a guy you are going to have to deal with everyday you work for maybe a year, maybe twenty years if he lives that long and you work there that long.

We talked to the chief paramedic today and he is going to ride with my preceptee the week after next. He done well, but he hasn't really been tested yet. Some preceptorships are like that. The day they are cut loose, they start getting horrendous calls. He's smart though and knows more than I did when I started.

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 and talked to the 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 was yelling at 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 yelled at 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."

"Its 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..." Amnd 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!" I almost added, "You're driving me nuts with that counting."

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

He still walked out with his head hanging.

He's supposed to come in this morning at 8:00, which is twelve minutes from now. I hope he shows. I will try to be nice to him today. I feel really bad about yesterday.

***

8:00 A.M. on the dime, 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 down at his shoes.

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

He nods and smiles.

"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.

Yogi backs the ambulance back into the bay, and they unload and wheel him into our fake Er, where I the 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.

And the smile gets even bigger.

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

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

I still feel bad about yelling at him.

At least he came back.

Sad Day

New Year's Day.

I went to work as usual at 6:00. First thing I did even before checking out my truck was to read the story on the front page of the morning paper -- about the death of a police officer the night before in a shooting at a domestic.

I guess around 10:30 P.M. on December 30th, the officer a 17-year veteran of the police department responded to a domestic call. The details are sketchy, but a woman answered the door and told them her boyfriend was in the basement. As they walked down the basement stairs, the man fired an assault rifle at them -- a rifle he had reconfigured to basically turn it into a machine gun. The officer was hit 17 times. His partner and the woman retreated. The officer got the woman out of the house, then went back to the basement door and called down to his partner. No answer. As another officer said to me today, that officer made the right tactical decision not to go down into the basement to retrieve his friend.

What followed next was a daylong standoff, where for awhile they thought that the officer was still alive and being held hostage. The standoff lasted all day with sporadic gun fire as they tried several attempts to flush the man out. I guess he had big arsenal that included a gas mask that kept the tear gas from being effective. They sent in robots and tried to gain a view with fiber optic probes. In the end, convinced the officer was dead, they flooded the basement with a water hose and the gunman shot himself in the head as the water poured in.

We watched throughout the day on TV. They had several ambulances there, from the city, from the Volunteer ambulance. Even the helicopter was there, although I don't know why. The scene was only four miles or so from the hospital, and ambulance would have a patient in the trauma room before they could load a patient onto helicopter and get the engines warmed up and off the ground. They were probably there as a gesture -- there for moral support. I'm sure it was appreciated.

This morning I saw the photo of the officer. The name had meant nothing to me. The face did -- I recognized him. I've been doing calls into that town for ten years now. He was a familiar face. Nice guy. Most cops I've found are good guys, but he struck me as being especially so. Never putting on an attitude, always friendly with us. He was a big man with a big head and big hands. He reminded me of the big kid in school who was always called upon to deal out justice to the school bully on behalf of the little kids.

Its hard to think that I saw him on a call just last week. How could you ever imagine that a week later he would be walking down some basement stairs and get ambushed, mowed down by an assault rifle. Shot 17 times.

People at the ambulance were wondering if he had on a bullet proof vest. It wouldn't have matter against a gun like that -- a virtual machine gun. The police officer I talked to said a gun like that would go through the vest and right through him.

The officer was saying how many times he's gone to domestics and walked down basement steps like that. It could happen to anyone. A couple years ago, I did a call in the city. A police officer responding to a 911 hangup. A guy jumped him and stabbed him in the neck. Fortunately he was strong enough to fight him off. Still he almost died. Another couple years before then, an officer in a neighboring city responding to a robbery, went around a corner and got shot in the head, Now there is a portion of highway named after him. I'm sure soon they'll be naming some road after this officer.

In EMS they teach scene safety, don't go in unless the scene is safe. I've been to calls for unknown medical or bloody nose and walked right into a domestic. Years ago in the city we walked into calls by ourselves all the time. There were no first responders and the cops were always so busy. A lot of the medics wear bullet proof vests. I never have. I have always figured, if they were going to shoot me, they were going to shoot me. I'm big and pretty easy going. I try not to antagonize anyone. I think of myself as one of the good guys.

That's what the officer was. One of the good guys. He couldn't have been thinking that some demented fired corrections officer was laying in wait for the first officer to come down those stairs -- be it the officer who got shot or whoever else was unlucky enough to be on that day and get that call.

I remember him from the call last week as real as right now. He met us outside, gave a quick report, and that was that. You think you could close your eyes open them again, and there he would be. But you can't.

I'm sure in the coming days there will be solemn ceremonys and a funeral procession. I still find it hard to believe he's dead.

***

I've been on fifteen hours today. Another hour to go. I get double time and a half on holidays. I've done five calls(three from nursing homes), two falls, a fever, a chest pain and a cardiac arrest. The code was a nursing home patient. The patient was asystole when we got there, the nursing home staff doing CPR, the cops had put their defib on her, but no shock was advised. I tubed her right away, but had some trouble getting the IV. Once I got it I debated just working her the twenty minutes required and calling it. Our protocol lets us presume death in an asystole arrest after 20 minutes of ACLS resucitation(which includes intubation and IV meds). But since we'd already been there a good ten minutes, and with all the staff helping us and all the patients watching from the hallway, and her being a full code and her being seen talking ten minutes before they found her not breathing, I decided to bring her to the hospital. Staying there another twenty minutes and working her and leaving her didn't seem right. Besides, I had a new EMT with us, a young high school kid, and it was a chance for him to work his first code, do CPR for the first time.

I was tired and yelled at the kid several times on the way in. His CPR needed to be stronger and he kept banging against my tube. Starting today we are required to run capnography on all intubated patients, so I was doing that for the first time, and was only getting between 8-12 as my number, which I guess is poor, though maybe norm for an unwitnessed arrest.

(Capnography measures end-tidal C02 -- the best measure of whether or not you're in the trachea. A dead person or a tube in the esophagus, which is the same as a dead person doesn't give off any C02. CPR will give off a little. The better the CPR, the better the end tidal too a point anyway.) Here's a link on capnography:

http://www.capnography.com/outside/911.htm

I kept yelling at him to put some effort into the compressions, to push and not be a wimp. I wanted excellent CPR to get my end tidal number up. He was sweating and complaining about how his back hurt. The apnea alarm kept going off because I'd stop bagging to show him how to do CPR or to push some more epi. I could have used another hand in the back.

They called the patient at the hospital. I apologized for even bringing her in. I probably should have just left her at the nursing home. Worked her twenty minutes, then called her. At least her family will feel like we did everything we could. Maybe the gesture is appreciated.