Projects

Came in, slept for two hours, got awoken by the tones, then banged out three back to back calls -- a lady in rapid afib (who was in the 170-190 range, who I could only get down to the 110-140 range with two doses of Cardizem. I checked back at the hospital later and they weren't having any luck getting it down either despite even more Cardizem), an old man with cancer who felt dizzy, but wouldn't go to the hospital and was very angry at his wife for calling, and an industrial worker who got a deep gash on his leg from working with steel. I spent the afternoon working on projects. I worked on formating my abbreviated public version of this blog, ordered some books and music to get me ready for my Domincan trip, and worked on preparations for the next go around of the paramedic protocol rewrites (January 2007), now that 2005 is done.

Each day of late out here, while it has gennerally been slow, I have been banged with a late call. I am hoping to get off on time tonight. I'm not working tomorrow (as of now) and I'm looking forward to sleeping in, and spending a day cleaning and organizing my house with maybe a little r and r thrown in, along with a workout at the gym, grocery shopping. I think I will also go to the store and get Bruce Springsteen's new CD. Maybe have a steak and beer for dinner.

***

My relief is here. I only did one more call -- a high school girl with broncitis.

I just realized tonight marks 4 months of the journal. 1/3 of the way through the year.

Last Half Hour

Every Friday it seems I get a call in the last half hour of my shift. Happens today at 5:30. Motor vehicle on the avenue, where we've done countless motor vehicles before. This, like many of them, is a rush hour accident.

"Maybe it will be a refusal," I say to my partner.

"Maybe," he says.

It's not. Neck and back pain wants to go to one of the more distant hospitals. Can't talk him into going to the closer one.

I let my partner tech. I am feeling a little annoyed so it is not a good idea to tech if I can avoid it. I let my partner do it, and he is nice to the patient, a large surly man who is disgusted that his car is totaled. I am annoyed because the man was surly to me, and I am probably more annoyed because it is the last half hour of my shift and I want to get off. It isn't very professional to be annoyed at a patient for these reasons.

On the way to the hospital I hear two other calls go out in town. One at 5:45. One at 5:55. They would have gotten me either way.

I wanted to go to the gymn and get in a good workout. Instead I don't get back till seven and don't get to the gym until 7:30. The parking lot iias full so I park illegally because I really want to get in the gym. It closes at 8:00. I do some heavy squats and then some quick exercises to hit the rest of my body. No parking ticket.

Did three calls total -- a woman who fell and probably broke her hip and shoulder. I gave her 5 of morphine and she seemed comfortable on the ride, but then at the hospital when we moved her on to the hospital's bed, she started to get uncomfortable again, and I wished I had called for orders to give her more.

The other call was for a grandmother who caught her frying pan and then stove on fire with grease and nearly burned the kitchen down for the second time in a month. She had 1st and 2nd degree burns on her forehead from the heat. I also put her on a nonrebreather for all the smoke she inhaled.

A Bad Host

I stayed up too late last night watching a stupid Tv show, got too little sleep. Got to work. As soon as I walked through the door, the tones go off. Unresponsive with a UTI and fever of 102 at a nursing home. Gave him some fluid, he opened his eyes. I bought a Diet Coke. I opened my eyes.

For the second week in a row I had a paramedic student and we did nothing while she was there. I felt like a bad host. After she left we did a BLS call for a kid who cut his lip. That call came shortly before I was supposed to get off.

I spent the day working on the new protocols, typing in minor corrections found by the proofreaders. Boring and tedious and slightly frustrating.

The Grind

Seven calls in eight hours in the city. Started off with two dialysis transfers. The problem with doing my overtime shifts during the day in the city is you can get slammed with transfers. Five of our seven calls were transfers -- the other two were an MVA and lady with a rectal bleed. One of our transfers was a round trip wait and return while the patient had a quick Cat scan. She required continual suctioning. Suctioning and lung secretions are nasty. I hate having to suction.

Working in the city has really changed from when I started. Back then, there were far fewer medics than there are now. Some days there were only one or two of us on. For a medic to do a routine transfer was unheard of. Even being sent to an ETOH was considered an insult. Every day you did at least one intercept with a basic unit who was screaming for a medic. Gradually as more medics were hired, and the company changed hands, transfers became more common. Now there are so many medics on -- intercepts are extremely rare and transfers are an everyday fact of the job. We all do transfers. Sometimes I actually prefer the transfers -- they are easy and make the day go by. A rainy day, I'd rather be doing transfers than getting soaked at an MVA. The only time it bothers me is when I'm sent on a transfer and a basic car is kept available, then the basic car gets sent to a chest pain, and they end up calling for a medic and there are no medics available.

I mention the transfers as away of introducing the topic of "dogging it." Because I don't have a regular partner for my overtime shifts, I get to work with many people, and they all have different attitudes about the job. And they all work at different speeds. One of my old partners used to kid me that I was the only one who sped back to the city from out-of-town trips, and that I would always clear when they needed a car. And when I'd clear, they'd just slam me with a transfer. I used to joke that I was a "company man." I meant that in the generic way that I took pride in getting to work on time, doing my job the way a job should be done.

There are different speeds at which you can work. No one can work at 110 all the time. I have found many of the people I work with slow down when they feel they are getting, in our parlance, "bent over," getting slammed with one transfer after another. So they slow down. They do their call, they write their paperwork, they hit the can, wash their hands, get something to eat, smoke if they smoke, say hi to someone they know, catch up a little, then they clear and do it all again.

The reality is a medic is a medic is a medic. You don't send the best medic, you send the closest one. I know some medics who have been on the streets longer than me -- good medics, the kind of people who you want coming in your house when you are sick -- and it seems sort of a waste to see them humping transfers all day while brand spanking new medics are sent to "the big bad one." (It's even worse when a basic unit is sent.) But how are brand spanking new medics going to learn if they don't get experience?

For some the day comes where what brought them to the job is no longer there. They don't feel respected for their ability and their don't get a chance to use what they know so they move on. Or maybe just when they are ready to hang it up, the good call comes in and they matter again, and that keeps them interested and satisfied. They feel the adrenaline again. They feel needed.

Me, I'm lucky, I have a suburban shift for my main post so that combined with the fact I work six days a week, I get enought "good" calls to keep me interested. In the suburbs, I am spared transfers, although I still do a lot of "emergifers", which are basically routine transfers from a nursing home to an ER that come in through the 911 system.

Sometimes it seems like a grind, but I still love my job. And as long as my check is good at the bank(and I still need it -- I do), I really can't complain too much.

Dizzy

Dizzy

We get called to a doctor's office for a person feeling dizzy. We're in the absolutely loudest ambulance in the company. When you step on the gas, the diessel is so loud it completely drowns out the radios, so you have to have the radios up, which just increases the racket. The address isn't that far away and traffic is moving well, so I tell me partner to ease back on the siren. "I can't take the noise. It's killing me," I say. "I am going deaf." And you figure how bad can someone be if they could make it to their doctor's office on their own. We arrive a few minutes after dispatch with no delay from traffic.

The doctor tells me the woman came in to have her foot examined, but she has been feeling dizzy and they can't get a blood pressure. She is also a diabetic and her blood sugar is critically high. She is alert, but looks a little pale.

I put her on 02 and run a quick strip. The quality of the tracing is poor -- only lead two comes out, but I can see it's a normal sinus. We get her on the stretcher, and get her out to the ambulance where her blood pressure is 84/50. Her heart rate 60 -- she's on a beta blocker. She is obese with poor IV access. I am lucky to get a 22 in right forearm in a thin superficial vein, but at least it was visible and it runs the Iv fluid well. I reconfirm the blood sugar is high. At least over 600 as my machine reads only HI.

She says her chest hurts so I give her some aspirin and do a 12 lead. I get a nice tracing this time, and have to do a double take. It is not the huge punch you in the face ST elevation, but there is small but noticable elevation in the inferior leads, particuarly Lead II, and AVF. Increasing my concern is the invervse ST in VII and VIII, that combined with the elevation in the inferior leads, suggest an inferiorposterior MI. We go immediately on a priority to the hospital. I patch in with an MI alert on the way. At the hospital, I alert the doctor, and she brings up an old ECG for the patient, and it is clear what we are seeing now is acute. She is on the phone to the cath lab. Shortly after the woman is whisked up there. Still waiting for an update.

A couple lessons. 1) Anything can be an emergency 2) Make sure you get a good initial tracing and look at it, not just glance at it.

But even though I made a small initial mistake, I feel like I rocked the call. I picked up on the MI and I pushed her through the system. I called in an MI alert, told the triage nurse, I thought she was having an MI, when I got in the room, told the nurse to get the doctor because I thought this lady was having an MI, and showed my 12 lead to the MD, and told her why I thought it was an MI, and asked her if she thought the ECG was a ticket to the cath lab.

I much prefer cardiac calls to respiratory because while the cardiac can be just as sick, the patient is usually a little calmer and easier to manage, then someone gasping for breath.

Later did a dsypnea at a nursing home on their psych ward. The patient was SAting at 88 on a cannula, up to 100 on a nonrebreather. I couldn't hear any lung sounds. At first I thought my stethescope was turned off, then I switched it a couple times on and off, but I still wasn't hearing much. I tried my partner's scope and while I couldn't hear much I could at least hear something. Time for a new stethescope. The patient was either in CHF or had pnemonia. When he coughed, it sounded like a washing machine, but when he wasn't coughing like I said, I couldn't hear much. He had a good amount of edema, but he was also extremely lethargic, but not lethargy from huffing and puffing. It was like he was severely overmedicated. He was on about seven psych meds and the nursing home he stays at is more like a halfway house than a true nursing home. Many of the patients are just psychs who come and go. His pupils were constricted, and I thought about giving him some narcan, but as long as he was SATing at 100 and wasn't huffing and puffing too bad, I thought let him sleep. He's another one I need to check back on. The doctor wasn't certain what the deal was with him either, or at least on first impressions.

Also did a long wait and return transfer and another transfer. Got out too late to pick up my prescriptions for my trip to the Domincan Republic, along with the special mosquito reppellent. This morning I went to the Travel Clinic and got three shots -- two in my right arm, one in the left.

Eight Hours

Eight hours in the city goes by fast. Did four calls, nothing interesting. Caught a little nap in the back of the rig this morning which I needed because my morning workout beat me down.

A Maternity, a diaylsis transfer, a woman with vertigo, and an MVA.

Your Honor

There's an article in the paper this morning about a family suing an ambulance company because the ambulance allegedly got stuck in the mud while at the scene where a family member -- a previously healthy young man had collapsed while in training. The article also reports that the ambulance arrived within minutes of the collapse and the patient was still brought to the hospital within seven minutes.

I have no details of the case. But just reading it, you want to shout out "Shit Happens!"

I've gotten the ambulance stuck before -- not on purpose, and not really through carelessness. I've been stuck in a snowbank and my partner once got us stuck in mud -- both times we got out. When it came to the snowbank we got out with an assist from the patient who helped push us out. (He really wasn't that sick -- he just wanted a ride to get his prescription refilled.)

I have dropped patients. Again, not on purpose. Once it happened on ice. The wheels went up, the patient went down. Believe me I felt bad about it. I felt like an idiot.

Another time I did a call once at a nursing home where we found this big fat woman who wasn't feeling well. Her family wanted her transported, even though the staff felt she was fine. She is on one of these big double wide beds, so we push our stretcher over next to the bed, then instead of sliding her all the way over in one pull/push, we decide to go to the edge first. My partner is on the stretcher side, doing the pulling. I'm on the bed side doing the pushing. We go to the edge. I am now up kneeling on the bed, holding the sheet we're using to move her. Then it happens.

She appears to start to sink. I look up at my partner and he is very slowly moving away from me. Now she starts to sink not quite so slowly and I see now, she is falling between the bed and the stretcher, as the stretcher slides away from the bed and the hole between the two where the woman is now descending, is swallowing her up. I hold on to the sheet and quickly scramble across the bed, and do my best to control her fall. She still hits with an audible "Thud."

Oh, my God.

To hear the family and the patient go on.

Daughter: "I can't believe you dropped her."

Mother: "They dropped me, Oh Lord help me, they dropped me!"

Daughter: "I'm getting my lawyer. You dropped her. Right in front of my eyes. Right in front of my very eyes."

Mother: "Oh, put me back in bed. You ain't taking me nowhere now. You dropped me. You dropped me. Oh Lawd, have mercy!"

Daughter:"You dropped my mama. They dropped my mama!"

Me: "Sorry, sorry, sorry."

While continuing to apologize, I assessed her. I went and got the staff. Told them, what happened. Had a nursing supervisor come in and document it all, including on the W10, so the hospital could check her out for the fall as well. I documented it later on my run form. Told the hospital about it. I wrote an incident report. Etc. Etc.

The lady wasn't hurt and I heard no more about it, though who knows five years from now I may be called in to court, and find the lady wearing a neck brace, and instead of being in a double wide wheelchair, she is now in a triple wide one.

Mother: "That's him, your honor. He is the one who dropped me! I recognize that rascal anywhere!"

Daughter: "That's him. He's the one, who dropped my mama, my mama who suckled me with her own breast milk. He dropped her on the cold ground, heaven have mercy."

There are so many things that can go wrong on a call. I had no idea my partner stood on the stretcher railing whenever we moved a patient. At my height I am always on the ground, anchoring the stetcher, but I guess a lot of people stand on the rail. Things you don't know. We slide the lady a little too far over. Her weight pushed the unanchored stretcher away from the bed as she fell into the slight hole that turned into a giant opening in the earth.

***

Get a call while I am writing this. Check this out for things going wrong:

Lady with pulmonary fibrosis having severe difficulty breathing. I find her in the upstairs bedroom on home 02. Barely moving air. Heart rate in the 160's. The first responder is standing there. She's already on home 02 by cannula. I ask my crew to hook her up to the a nonrebreather.

Guess what?

Our tank is empty. We used it on the last call for about ten minutes at 2 lpm. I didn't check it. I never check it. I wrote the run form and put away my gear. My partner is supposed to put the stretcher back together and check the 02 and change the tank if it is low. Should I check on the crew? Yeah, I guess I need to. Maybe there was a leak. Maybe they didn't change it. I'm the medic. Its my responsibility and I'm the one who looks foolish.

Fortunately, the responder has a tank, and we use that.

One crew member sets up the stair chair. He's done it many times before. I've gone over it with him. He doesn't lock it. I point it out to him. You have to lock it. I make certain it holds. I get the woman on the chair, buckle her in. I say, I'm going to take the feet. I ask the first responder to take the top because he has some strength, which my crew members do not. I look for a crew member to carry the 02 and one to watch my back, but they have both disappeared.

The woman is having a really hard time breathing. I shout for my crew. They are outside. What they are doing, I don't know.

I have to enlist the woman's daughter to carry the 02 bottle behind the responder who grabs the head of the stretcher while I take the feet. I almost tumble coming down the stairs. I have no one on my back and this responder is not one who likes doing the medicals and is not really used to doing carrydowns. We make it outside where the crew is trying to figure out how to get the stretcher into the proper down position. They are having a terribly hard time working the stretcher. It seems on this call they have forgotten everything they know. (I can't say it hasn't happened to me before. My crew foregetting on me and yes, sometimes, me forgetting).

When we finally get her loaded on the stretcher, when the heavens open up and it pours rain on the poor patient and us. The ambulance has been turned off because we have a anti-terrorism policy that says you have to take the keys in the house with you and this ambulance doesn't not have the system installed that lets the car stay running without the keys. I always tell my partners to leave the keys in and the truck running, particuarly in the winter. Most of them do despite the policy. Today my partner is patting their pockets trying to find the keys that might be lost. No, here they are -- in the pocket all the time.

I look around for monitor. Not there. Where's the monitor, I shout.

Left in the house.

Where's my house bag?

Left in the rain.

Finally we get enroute lights and sirens and nothing I am doing for the woman is helping. She keeps saying help me -- I give her a breathing treatment, but that is about it. Her Sats are only about 80. Heart rate is 140. She is diaphoretic. She is breathing about 40 times a minute. Help me, she says again, give me something. I am tempted to say, I don't have anything I can give you until you stop breathing (or get worse), then I can tube you. I suppose I could try to nasally tube her, but I don't think she'll sit still for it.

She has crappy veins. I miss my first IV attempt. Then as I am getting it on the 2nd try, I see we are getting close enough to the hospital to patch in. They will need some notice, because I want them right there when I come in because I think she will need to be intubated. I have a partner start the patch, but the radio operator gives him a hard time because the driver didn't put us enroute. I am trying to draw bloods and talk to the hospital at the same time. For some reason I say "respiratory sarcadosis" instead of "pulmonary fibrosis."

When we pull the patient out of the ambulance, the blood pressure cuff catches on the wheel. I lean to pick it up, but my partner keeps pulling, and the patient's daughter has to grab the end of the stretcher before it careens around and spills her mother. I throw the blood pressure cuff into the back of the ambulance like I am throwing a brick at a window.

We get in the hospital, no one is looking at us. They are all on the phone or doing paperwork or talking to each other. The woman is still sucking. Finally (maybe only thirty second later, but frustration level is so high is seems long) they notice us and tell us the room.

We go in there, and I unhook the woman from my monitor and unhook the straps, and then we have to slide her over, but niether of my partners (due to strength issues) are able to effectively help, and I have to reach across and lift her by myself.

The staff comes in, helps change her and my partner switches the 02 to their plug as I give my report. The nurses are very nice, say they know the patient, but have never seen her this bad before.

A doctor comes in goes right to the patient, starts asking her questions. Then he looks at the nonrebreather, which doesn't look too inflated. What 02 level is she on? he asks. He then reaches over and cranks it up. The 02 whooshes out. I mean he has it on max -- way above 15. The woman's SAT is now 97, even though she is still struggling to breathe. "There you go," he says, "A little oxygen does it every time," he says, then walks out. Whether he says it or I merely imagine it, I think he says, "There was your problem."

I know this guy so I approach him later. "What was with the oxygen comment?" I ask.

"I've got to much on my mind right now," he says, dismissing me, "Must have just been my magic touch."

Normally things don't bother me, but I'm bothered now. I feel somehow belittled. And I'm frustrated about everything to do with the call, the clumsiness, the lack of help, my inability to help the patient, the doctor's cavalierness -- something I have not really seen in him before -- and most of all the awfull feeling of our response not being professional.

A nurse tells me later, my partner may not have turned the O2 up enough when she switched the connections in the hospital. I'm wondering why my SATs were so much lower than what they are getting. Could the difference between 15 liters and 25 liters make the difference? Or maybe my oximeter was giving me me too low readings?

I go back and look at the patient. She is satting at 97, but still huffing away, holding the mask tight to her face. Her respiratory rate is in the thirties, her heart rate is 138. I ask her if she is feeling better. She just stares at me, as if to say, "Do I look like I'm comfortable sucking on this oxygen mask?"

I don't want to sound like I am blaming my crew. They are nice people, and I am not without error or failing myself. This is a hard job to be infalliable in. And why should I assume my crew should know what they are doing when one is new and the other works infrequently. My crew is my responsibility. Instead of trying to teach them on the way back, I just ride silently. I need to teach them better, but feel without patience today.

Imagine if this was a worse call, if the patient had arrested. There are so many ways a call can go wrong, particuarly when you do not have an experienced crew who you work with on a regular basis. Most days I manage to handle it, not today.

"Your honor, their oxygen tank was empty."

Who do I sign the deed over to? Take my house, take my money, take my car, take my childhood baseball cards and my record collection.

I didn't mean to stuck in the mud, honest.

***

I guess lawyers are just starting to turn toward paramedics and ambulance companies. I have, at times, thought about going to law school. To go on in medicine I would have to take many years of prerequisites. Law school, its just three years of class, four if I go at night. As a paramedic lawyer I would be a hot commodity. But what would that entail, using my knowledge to show how some other medic screwed up. I could do that, but I could also illegally dump toxic waste for a couple hundred dollars a barrell.

Maybe I could represent paramedics and ambulance companies, using my knowledge to show shit does happen, and people do the best they can with what they have.

On the other hand, the EMS system could be a lot better than it is. Maybe people have a right to sue. I mean, who do you want coming to your house?

I guess there are always two sides. What you should expect and what the world delievers, and lawyers are there to argue each way.

I'm Doing?

One of the good things about keeping a journal is it enables you to remember what you have done. I try to write each entry within hours of ending my shift, but sometimes (like now) I write it the next morning, even though it will be back dated to post as yesterday.

I worked for many years and did not write anything down. Ask me what I did in that time and it will be hard for me to fill a page. Here it is the next day and I am having a hard time remembering what I did yesterday. I know I did at least four calls. Come back to me, memory.

There was a seventeen year old girl with asthma who said she had had an asthma attack at work, but she was breathing fine with clear lungs when we got there.

There was a man who'd had a brief period of dysphagia for the second time in two days. We took him in and the hospital was very overcrowded and we had to wait in triage for over forty minutes. To the hospital's credit, shortly after we arrived, they asked for the patient's condition. I said, "Resolved TIA." So we waited while more serious patients were processed. Then when we got in the back we had to find a bed. We found one in the hallway that looked like a patient had just gotten out of it -- maybe discharged or maybe just gone to the rest room. My partner quickly stripped it, then went to get sheets while I stood by the stretcher with the patient. A moment later a nurse and another EMT came around the corner, spotted the stretcher, and tried to make a getaway with it. "Hey, it's already claimed," I said. They looked frustrated and moved off down the crowded hallway looking for another one.

We did an respiratory infection -- a young man with a fever, coughing up brown phlegm.

And then my favorite -- the chest pain at the Alzheimer's place. I usually say, "Where's your pain?" They answer, "What pain?" "You had chest pain?" "I did?" This time I asked, "How are you going?" She answered, "I'm doing?"

At least we had signs we could go on. The lady had an afib in the 100-140 range with no history of it. Our protocol says we can't give cardizem (which slows the rate) unless the rate is 150. I interpret that as an afib that might range from 130-170. The best I could capture on a strip was 129. Her vitals were okay. Her pressure was 140/90. The only symptom was she wasn't her normal lively self. She denied any pain or problem. I gave her supportive care. The hospital gave her cardizem.

One of Us

Another beautiful day. Didn't do anything until late in the afternoon.

Call was at a group home for a patient who fell and had hip pain. I wasn't impressed with the pain, but the patient had osteoporisis, and it was a group home so the patient pretty much had to go get checked out.

All group home patients have a big binder that holds all their medical records. The aides, who accompany the patient, always want to take the binder with them in their car when they follow. I always ask to keep the binder with the patient. En route I read it, and use the information to fill out my trip card, meds, allergies, history, insurance numbers. They let me take it this time without much of a fight. I copy down the insurance numbers. She is on state Title 19 and Medicare.

The woman is in her 50s. She seems very childlike, but fully alert and oriented. She has no physical disabilities. She talks a mile a minute, often laughing and cracking jokes. I ask to take her blood pressure. "Oh, no you don't, call the police," she says. "Help, robber, robber." Then she laughs. "I suppose you want my pulse too, Go on, its yours, I'm helpless. You've got me strapped down, just give it back when your done." And she laughs again.

I am interested in her, 1) because she is so funny and peculiar and 2) because she has a famous last name. From talking to her further I learn that she does indeed come from the famous family whose name she bears.

While she talks to my partner about all the places she's lived (not Long Island, New York City, Miami, Paris but Mansfield Training Center, and later about eight different group homes), I peruse through her book.

"They thought I didn't know anything, but I could spell, read, write, do arthimatic, geography, history, penmanship. I showed them. They tried to keep me in a straightjacket. Ha ha. Ha. I told them in court what they did us. No more. They stopped that lickeyed split."

The Mansfield Training Center was a wharehouse for people with disabilities who had no one to care for them. After allegations and investigation of abuse, the state's institutions were closed down and patients disbursed to group homes. This was over twenty years ago.

"See this. You know what this is." She points to her throat. "That's a tracheotomy. I had one. I was little. I had pnemonia. I almost died."

I read her chart. It say she was a perfectly normal schoolgirl. Then she got a fever and lapsed into a coma. Her mental development was halted. Her intelligence tests place her between a seven and thirteen year old. She is described as being very pleasent, conversational, enjoys reading, going to the movies and chatting with friends. I read that she is subject to occasional moodiness, usually predicted by the job departure of a aide. She is basically just a young girl in a the body of a fifty-plus year old woman.

I ask some questions, curious. "When did you get sick?"

"When I was little."

"When you were ten?"

"Yes, that's right. I was in school, then I got sick."

"When did you go back to school?"

"I haven't gone back yet. No more reading, writing, artithmatic lessons for me."

I ask her if she sees her family.

"Sometimes they visit."

"When was the last time?"

She shruggs.

"Did you like it at the Training Center?"

"No, but I had friends there. One day someone dropped off a girl in a bucket. Nothing but a bucket. She was a Mongoliod. They didn't want her. That's not right. We're all as god made us, big little rich, poor, fat skinny, pretty, homely, smart, dumb, strong , weak. He loves us all -- that's his plan. People should be the same way. She was just a mongoloid. Didn't hurt anybody, and she was nice, and funny, too. That times we had." She laughs. "I could tell you stories, the trouble we got in. Then one day, somone adopted her. I prayed for her every night that she'd find a happy family. It happened for her. Not for me, but for her it came true. She was my good friend. I miss her. She was nice."

She looks at my partner and touching her sweater says, "White, white, you'll get married tonight."

"Oh, I've already been married," my partner says. "Many years ago."

"You like boys?" she asks.

"I love my husband."

"Let me tell you a secret. Bend over." My partner bends over and she holds her hand up and she whispers in my partner's ear, then blushes and breaks out laughing.

My partner laughs too.

"Can't live with them. Can't live without them," the girl says.

***

There was a patient at one of the local nursing homes I occassionaly was called to help. He was related to a famous American. He shot himself accidently while hunting as a young boy, over fifty years before. Spent his life in institutions. He was just a TBI patient, but could carry on a good conversation.

***

John F. Kennedy had a disabled sister, Rosemary, who spent her life in an institution.

***

I am continually amazed at the number of people I see in this job, who take care of sick family members, family members with cancer, or with physical or mental disabilities, who take care of them in their own homes, with their family always around. I worry that if I were in that situation, I would be the type that might just leave home one night for a drink at the local bar, and then just never come back. It must be exhausting for them. What a tough blow life has dealt them. What a change from everything they had known before. I once said to a person, how much I admired them for the way they -- and their whole family -- took care of their severely disabled daughter. They had to turn her and feed her, and clean her. And she couldn't even speak. She could smile, and had eyes that followed them, and could communicate with grunts. But that was it.

"How could we not?" the mother said. "How could we not? She is one of us. "

Spring Evening

Busy day. Doing 12 hours in the city during the day not much time for a break. They paged us with a call at 8:32. The shift starts at 8:30. We hadn't even got the ambulance keys. Eight calls.

A basic unit was sent to a fall. They called for a medic. I arrived to find an elderly black woman seizing on the bedroom floor, eyes deviated to the left, left side seizing. I gave her two of Ativan and it stopped the seizure. I had my intubation kit out, ready to tube her, but she was breathing okay, satting in the high 90's. I just put a nasal trumpet in. They got her right up to CAT Scan.

Did a lot ot transfers. Everybody was doing them, even the precepting car.

We were called for an abdominal pain. 18 year old intercity girl. Skin hot, upper right quandrant very tender to touch. Heart rate 120. She'd had an abortion two weeks before. No bleeding. Turns out she had a bad infection. Very elevated white blood cell count.

Went to an elderly retirement apartment complex for a man who'd falled backwards in his chair, and hit his head on the ground. He had a small lac. Nothing suturable. He'd been sitting out under the trees with a group of his neighbors. It was a beautiful day yesterday. The woman next to him was asking how to get the blood out of his hair. "Just some soap and water," I said. "Treat him to a sponge bath tonight. He'll like that."

"A sponge bath? We're not together."

"He'll like that," another neighbor said.

"Yeah, Bessie. I always thought you two should hook up. Nice couple you'd make."

"Huh?" the guy with the cut head said. He was a little deaf.

"Bessie gonna give you a sponge bath."

"A what?"

Everyone was laughing.

I was thinking if I'm lucky, when I'm eighty or ninety as this man was, I will consider myself fortunate to be able to sit out under the trees and have neighbors like these, to have a cookout, listen to a ballgame on the radio, to feel the Spring blossoming all around me.

My Bad

Another 12 hours. Beautiful day. We were busy in the morning, then had about six hours without a call. I was able to stop at my house and put in a tape to catch American Idol, although my girl Nadia got voted off last week. My bad for not voting. Bought two boxes of Odwallah bars at the health food store. I like to keep a few of those in my bag, so I don't end up getting suckered into Burger King. Did a fall at a health club. I let my BLS partner tech it. I didn't think the guy was in much pain. He said his shoulder hurt. I couldn't find any deformity, but waiting with him in triage, his pain level seemed a little higher, and the way he was holding the arm, I though maybe he had a little hairline fracture or dislocation. I should have teched it and given him some morphine. I try to be very aggressive with pain relief, but I think I fell short today.

Did a lift assist, getting a three hundred fifty pound guy off the bathroom floor. I used the old, put them on a board, strap them on, then lift them to their feet, making certain to bend my knees, and use my legs as I lift up.

Last call was a lady with a fever, who was confused. She was an insulin diabetic. I went to take her blood sugar, but no glucometer in my bag. I had it there yesterday. Shame on me for not checking this morning, but we locked our car up last night and no one else took it out. Someone must have raided it. Fortunately she had her own so I checked it and it was 100., a normal reading. On the way to the hospital I gave her some fluid and she perked up. I think she had an infection.

Back for 12 more tomorrow.

A Job

12 hours, ten calls. Lots of transfers. Felt a lot like a job today.

***

One interesting situation. We get called for chest pain. 15 year old, says he has a heart murmur, felt chest pain after smoking marijuana. Says he's fine now. I tell him we can't let him go. We have to call his mother. He doesn't have a phone, so I march him over to a pay phone, drop a quarter in the slot, he calls his mom. I talk to her, she says she'll be right down. Then the kid grabs his chest and says he doesn't feel well. I get him in the back of the ambulance, check him out. Pressure's good. Put him on the monitor. Normal sinus. Heart murmurs are really not a big deal. The kid says he feels better. I'm not to concerned about him.

While I'm checking him out, this bearded homeless guy sticks in the back door and says his buddy isn't doing too good, can I check him out. I've got a patient, I say. He's really not doing to well, he says. I nodd to my partner to check him out and call another ambulance if he has too.

A minute later, my partner comes back and says, maybe I should check him out, he really doesn't look very good. Call another ambulance, I say. I've got this kid on the monitor. He calls another ambulance, but they are five minutes away. He comes back and says, this guy looks like he's about to go out, I really need to check him out. He's cold and diaphoretic.

Now, basically once I have established care with one patient at an ALS(heart monitor in this case) level, I can't abandon him. My partner is not rookie, so if he says, this guy is bad, I'm concerned. I picture the guy going into arrest while I babysit the kid waiting for his mother.

I make my decision. I disconnect the monitor, tell my partner to sit with the kid, then take my bag and go to the other patient who is sitting inside a conviience store. He is in his thirties. he is dripping water and is very cold to the touch. Fortunately, I can now hear sirens approaching. I take his pulse and pressure. Not as bad as I expected, 98/60, heart rate in the 80's. I put him on the monitor. Normal sinus, no ectopy or ST changes -- at least in the inferior leads. I try to call to my partner to bring some oxygen for the man, but he can't hear me. The guy denies any pain, but says he feels lousy.

The other medic arrives, and I give a brief report. I take my monitor off and go back to my patient, only to find the back of the ambulance empty. I ask my partner where he went and says, his mom came and snatched him. He at least got her signature on the back of a form.

Turns out that the other crew couldn't convince the other guy to go either and they ended up with a refusal AMA.

The call just illustrates some dilemnas, you can get yourself in: What if the kid suddenly coded while I was checking out the other guy, who might be coding at the same time? What if my partner hadn't gotten the refusal and the kid coded on the way to the doctor's, which is where his mother said she was hgoing to take him? What if I stayed with the kid and the guy coded and then his buddies dragged me out of the ambulance to help him?

All you can do is try to use your best judgement at the time. Sometimes I think your best judgement might cross the line of what you are supposed to do. I judged the kid to be okay, and guessed the guy needed urgent help, and had assistance on the way.

24 Hours

I've worked my sixteen and am doing eight more because they had no relief for me. That's okay. I can use the money.

Six calls so far today. A pedi seizure, a woman with hip pain for a week, a woman who became depressed while visiting her mother at the nursing home, a nursing home patient who fell and needed a stitch for the lac on his nose, a man who needed help getting up off the toilet, and a dead body -- a woman who died alone at home.

I'm hoping to get to bed soon, and am wishing for a quiet overnight.

I'd like to go to the gym tomorrow and also work some in the yard.

***

2:00 A.M. I don't even hear them call for us. Fortunately my partner does. We're sent down to the jail to check out one of the guests. I sleep walk in, check him out. While my partner takes his vitals, I ask him what's wrong.

"I got hit on the head."

"Yes, and..."

"Huh?"

"You got hit and the head, and..."

He looks like he doesn't understand.

"You were hit on the head, and then what happened next," I say.

"Nothing. I just got hit on the head."

"Nothing more happened?"

"He just hit me on the head one time."

"Did you get knocked down? Did you pass out? Did you see stars? Did you get dizzy? Did you develop a severe headache. What happened after you were hit on the head?"

"Nothing."

I ask him his name. Ask him he knows where he is. Ask him the date. He answers everything appropriately. I take out a refusal form. "Sign here."

I'm back in bed by 2:40.

***

4:00 A.M. I hear the tone this time. They send us for an unconcious man. It is an address I have already been to. Not the jail, but for the man who needed help getting up off the toilet. I'm thinking, damn, I was going to write about him. I was going to write about how I see this all the time, a person living at home, who just reaches the point where they are too weak to live in their house. They can no longer transfer themselves from their wheelchair to their bed, or standup from the toilet with their walker in front of them. And for a few days we get called over and over to give them a lift assist until they either go to a nursing home or get some better help in, or get a hospital bed from which they now spend their day. I was going to write about him speculating when we would be called back. I had even said to his wife. If he can't get up now by himself, he's not going to be able to do it later.

Then I remember the call is for uncouncious, not lift assist. I am thinking maybe I should have really pressed him on going, maybe something else major is going on.

We find him on his bed -- his skin is pale and yellow, almost opaque. His eyes are glassy, open, not blinking. He looks dead, except there is some movement when I touch him, and he says a few words slowly. I have to keep nudging him to see that he is still alive.

I ask the wife about his medical history. She says he has a heart history. I ask for the list of medications. His pressure is a little low. 100/60. His heart rate is in the 60's. I do a twelve lead -- he's in a bifasicular block -- Right Bundle Branch with a left posterior hemiblock. Given how he looks I am sort of suprised his vitals aren't worse. He is Satting at 93. He is acting almost like he is drugged. His grips are equal but very weak, he can't even hold his arms up. His abdomen is distended. His capillary refill is a little delayed.

I ask again about medical history. The wife repeats he has a bad heart with many blockages. She is very distraught. I ask my partner to see that she finds all the meds and writes them down.

A police officer and I carry him down on the stairchair, which is hard because he is a big man and dead weight, plus the stair chair is an old old model, and one of the pins comes loose, so I am holding tight and pressing at the same time to keep it together. I keep looking at the poatient to make certain he is still alive. I have had many patients code on me while I was carrying them in a stair chair. He is still there.

Finally in the ambulance, I get a line, then get out the glucometer. My partner checks the sugar for me.

"83," she said, then adds "Last result."

I'm not so sleepy that I don't remember 83 was the number of the last patient I checked a sugar on -- the pedi seizure I had the prior morning.

"Give me that," I say. I put a new strip in the machine, then apply a drop of blood to it. She must have hit the botton on the machine, thinking the button was what turned it on. Instead, you just put in a strip, then the machine reads, "apply blood now."

The result comes up -- 27.

"You have the list of medicine?" I ask. She is driving now. She reaches into her pocket, unwrinkles the paper and holds it out for me. I run through the list. There's glyburide -- he's a diabetic. "You can shut off the sirens," I say.

I give him an amp of D50, and he comes around to the point he says he feels better, his grips are strong, and he even knows where he is. He says this has never happened to him before. He only had a small lunch -- no dinner.

I think there is something else going on with him -- nothing that will kill him tonight, but some disease process or something working on him. I'm glad he's going in to the hospital. I recheck his sugar -- 200. By the time we are at the hospital, we are actually having a decent conversation.

I wonder if I knew he was diabetic when I was there earlier, if I would have checked his sugar, and what would it have been? It seemed just like a simple lift assist, with a mandated persuade him to go to the hospital. I don't think it would have been too low -- he was fully alert then, just feeling weak. I'll be curious to see if we go to his house again, or if his name shows up in the obits sometime in the near future. When I reviewed his medical history after he came around, I found he had been on diaylsis in the past. Not a well man.

***

We stop at Dunkin Doughnuts on the way back. My partner gets a doughnut and a coffee. The day before someone left a dozen doughnuts for us, and I ate one -- one with pink frosting and sprinkles on it. I ate it in four parts over a course of two hours. Doughnuts are one thing I don't eat. About ten- fifteen years ago when I had a coat and tie job, I ate two doughnuts every morning and I must have weighed 240. I stopped cold turkey. Now I'm 215. Lean and Mean. I really wanted a doughnut.

As I write this I am eating All-Bran. I went home and went to bed for about three hours, sleeping with a blanket draped over the curtains to better darken the room, and with a black sock strapped to my eyes under some swim goggles. In a few hours I will go to the gymn. I need to stay strong, need to be able to lift myself off the toilet when I am old, need to hold diabetes and other diseases at bay.

Flash

Dispatched for a lady not feeling well. The cops have her on a non-rebreather at 15 lpm. She doesn't want to go to the hospital. Her lungs are decreased with a slight wheeze. She has a low-grade fever. She has been treated for broncitis for the last week. She saw her doctor a week ago. Only history is hypertension.

She keeps getting up. She doesn't trust me to lock the back door. She wants to get her purse herself. There is something in a drawer she needs to get herself. We finally get her on the stair chair and carry her out to the stretcher, and get her in the ambulance. Her Sat is 92%. respiratory rate 24. Pulse - 120. BP 180/100.

The paramedic student/ER nurse puts in an IV, and gives her a breathing treatment through a neb mask while we go on an easy lights and sirens.

The patient starts pulling the mask off her face. Too much air, she says. We put the mask back on her and tell her to settle down.

The 12 lead shows lateral ischemia. We give her some baby ASA as a precaution.

She is getting a little grey. She starts to sweat a little. We switch to a non-rebreather, but still she keeps pulling the mask off her face. We are just blocks from the hospital.

"Let's listen to her lungs again," I say.

Before we can put the stethescope to the back, we can hear the bubbling. Imagine bubbling like popcorn starts to pop. You just hear a few pops, then more, then it is popping all over the place. That's how it is with the bubbles.

"She's flashing," I say.

We're in the driveway now. I draw up some Lasix and while the student injects it in the IV line, I give the woman a nitro spray. Her Sat has plunged to the 70's.

The ER doctor takes one look at her -- she is obtunded, grey, diaphoretic, breathing hard -- and calls for the intubation tray. Five minutes later she is on a vent. The chest x-ray shows fluid everywhere. Congestive Heart Failure. Flash Pulmonary Edema.

I tell the student/nurse. "She's flashes five minutes later, we look like idiots."

She nodds. Lesson: trust what the medics say when they tell you the progression of the event.

Later we talk with the ER doc about treatments and flash edema. "I know you want us to give the treatments, but it always makes them flash," I say. "Or at least half the time."

"Studies show it helps."

"I just know what I see. The question is "is the edema there? and the treatment just let's you hear it, or does the treatment worsen it?"

He is about to answer -- this is question is one of the great questions of paramedicine -- but then he gets a phone call, then another, and we get a call, and we never hook up again to discuss it.

I have been asking this question for years, and every doctor has a different answer.

I find the following article that suggests the breathing treatment increases their tachycardia and worsens the edema. It also says, a medic needs to use their head and discretion on giving a treatment to someone with possible CHF. We both thought the lady had a pnemonia-broncitis. She may have, but she also had some new onset CHF.

Pulmonary Edema

Here's a link I found to an old bulletin board discusssion on the question; some for albuterol, others vehemently against.

http://www.uhmc.sunysb.edu/emed/paramedic/archives/1996/1190.html

Here is another detailed article on CHF from Prehospital Emergency Care, whicih says bronchodilators(albuterol) is okay in CHF when the wheezing is caused by bronchospasm, but it should not delay treatment with other drugs such as nitro and diuretics.

Prehospital Emergency Care: CHF Article_

I have to say, I have wavered back and forth on this issue, mainly pushed for it, by the physicians who say use it to open up the airway, and pushed against by occasional experience. Maybe these people were going to flash anyway, but it seems like I've seen it one too many times where they flash shortly after the treatment.

I guess when I sense they have CHF, I may consider withholding the treatment. In this lady, the CHF blindsided us.

***

Busy day. Good for the student. We do an SVT at an insurance company that breaks a minute before we arrive. Fortunately the company nurse captured it on a 12-lead. rate of 236. We do an OD and a bleeding diabetic wound.

Something to Care About

I had the day off. The second Tuesday of every month I go to the regional council education and medical advisory meetings. I sleep till I get up, drink a diet coke and read the news on the internet, go to the gym, shower, change, then go to Quiznos and get a mesquite chicken sub, which I eat at the meeting -- everyone eats their lunch at the meeting.

I am the paramedic representative on committees made up largely of clinical coordinators and physicians. I generally hate meetings, but we get work done. I am involved in many projects, most particuarly rewriting the old protocols and coming up with new ones. I feel like the committee members listen to me and the work we do makes a difference.

In May, we will change the standing order dose for morpine from 5mg to .1mg/kg, which means a 220 pound man with a broken femur can get 10 mg before we have to call medical control rather than just 5mg. We're introducing the bougie as an aid to intubation and CPAP for pulmonary edema for services who chose to use it, permitting medics to give narcan intranasally, lowering the minimium BP to give NTG from 120 to 100, permiting reglan or phenergan to be given on standard orders for nausea/vomiting, and starting a data collection project on intubations.

A few years ago, we couldn't even give morphine without calling to talk to a doctor. We're able to cease resucitations in the field if the person, who must meet certain criteria, hasn't responded to ACLS interventions and we have a spinal immobilization algorithm that enables us to decide which patient should be c-spined instead of having to c-spine everyone.

I'm most proud of the work I have done to make giving pain medicince easier. A number of years ago I helped change the state law that had required on-line medical control to give controlled substances. I did the background research that was presented to the legislature and I testified before them.

When I go to a scene where a man has fallen and his bone is sticking through his leg, I can grab a quick BP and then if he isn't allergic, get some morphine on board right away, and not have to go back down to the ambulance, get on the radio, and call the hospital and wait for a doctor to come to the phone. I can help his pain right there.

I love clinical medicine and hate missing a day of work, but sometimes you can help your patients more by going to meeting.

Maybe when I'm too old or injuried to work the streets I'll have a job where I can help people, where I can champion a worthy cause, something I care about.

***

I'm off the next two days -- going to Fenway Park. Go Sawx!

The Healer

We're dispatched to a nursing home for the woman who won't open her eyes.

We find her laying on the floor next to the bed of another patient. She is a woman in her early fifties. She does not look ill. She just looks like a person laying on the floor with her eyes closed.

I pick up her hand and move it over her head and then release it about ten inches above her face. She moves the hand slowly back to her side.

We pick her up and put her on the stretcher.

The nurse hands me the paperwork. I see the woman has a psychiatric history.

The woman doesn't open her eyes or say anything until we get out in the ambulance, then once the doors are closed, she raises her head and looks around.

"Hello," I say.

"Hello."

"So what's up?"

"Nothing."

"What happened? Why were you laying on the floor not responding? And what were you doing in a another patient's room?"

"I was trying to heal him, but I guess it just took too much out of me."

"You were trying to heal him?"

"Yeah, I'm new at it, and I guess I just can't control my energy very well."

"You're new at it?"

"Yeah, I just started. I've been working on it for a couple days. Since I got here. They want me working on my self-esteem. I thought being a healer would help with it. Its hard work. Tiring."

"Evidently."

***

Did a chest pain in an Alzheimer's patient who forget that she had chest pain, and a refusal from a woman with a temporary migrane.

I'm Walking

I had the day off today so this morning I went to a Jamaican church in the north end of the city. I arrived late and was escorted by chance to the front row just as the lead vocalist and gospel choir started singing "Highway to Heaven," which was great because I knew the song, so right away instead of feeling awkward I was clapping my hands and rocking along with the congregation.

(Lead solo) My way gets brighter; (Choir) Walk on!
My load gets lighter. (Choir) Walk on!
(Choir) ‘Walking up the King’s highway.
(Lead solo) Christ walks beside me; (Choir) Walk on!
His love to guide me. (Choir) Walk on!
(Choir) Walking up the King’s highway.

(Choir) It’s a highway, it’s a highway,
It’s a highway up to heaven.
None can walk up there
But the pure in heart.
It’s a highway, it’s a highway,
It’s a highway up to heaven.

(Lead) I’m walking. (Choir) ‘Walking up the King’s highway.
(Lead) I’m talking. (Choir) ‘Walking up the King’s highway.
(Lead) I’m singing. (Choir) ‘Walking up the King’s highway.
(Lead) I’m shouting. (Choir) ‘Walking up the King’s highway.

(Choir) I am walking up the King’s highway.

I'm not really very religious and I haven't been to a church for years. When I do go I sometimes finding myself wanting to be suddenly overtaken. I want my eyes to tear up and a wave of tingling to come over me, I want my burdens lifted, but I never quite get the feeling. People come forward and get on their knees and profess their love for Jesus. I just stand back and watch.

It was a nice service. (I sometimes had trouble understanding the minister Jamaican accent.) At one point they had all the children come up and they asked them questions like "What does Easter mean?" The first kid said, "The Easter Bunny comes." The minister laughed. Wrong answer. Some precocious kid, said, "It's when Jesus died and was resurrected from the grave." That's right!

A baby was baptised. Later the minister asked people who were feeling desolate to come forward and give their lives to Jesus. Probably about thirty people come forward and knelt before the alter.

While I mainly work in the suburb north of the city, I still do a lot of calls in the city's north end, and am very fond of the community. When I first started in the city -- I was always posted north. I have no doubt been in the houses of some members of the congregation, and cared for them and or their family members.

I thought of all the children standing up at the front of the church listening to the woman tell them that all we want is peace, no ill feelings to anyone, just to live our lives with love. I wonder if I will ever take care of any those kids in years to come. Will Jesus protect them? Or will I have to wash their blood from my ambulance? I wish them only love and health.

I think it is good for a paramedic to know his community. I used to think it was better to not know anyone because then you didn't become emotionally attached, but I think there is too much emotional detachment in the world. It is better to care.

Jesus didn't show himself to me, but as I was leaving, several old women in Sunday hats shook my hand and thanked me for visiting.

It’s a highway, it’s a highway,
Walking up the King’s highway.

Random Musings on a Saturday

Beautiful day. Have only done 1 call so far, taking a woman with cancer into the hospital. A week ago she could go up and down stairs, today she couldn't get out of bed.

I just went out and vaccummed out my car using the power vac. It was so warm out, I took off my workshirt and just had a black tee-shirt on. On the radio this morning they said back in 1996, it snowed 24 inches on this date. I feel pretty sure that we are done with the snow for the winter. Thankfully. I love Spring.

Coming back from the hospital, we stopped at Seashore Seafood in the city and I had a Jamaician breakfast of ackee and codfish, boiled green bannana, yam and dumpling. Good. If I get a chance I may get some jerk chicken for lunch later. Maybe even get a Ting -- grapefruit soda.

I have heard rumours that one of medics of ten years has been fired for running a red light. He didn't get in an accident, he just ran a red light. The company has a zero tolerance policy, although I have heard some say the operative line is "may" terminate, rather than "will" terminate. I'm all for the safety measures the company has instituted -- ranging from mandatory seat belt usage to installing black boxes to montitor and rate our driving(the ambulance makes noices, beeping and shrieking if we hit certain speeds, too great G-forces on turns, too sudden stops or don't use a spotter to backup). People definately drive better than they did, particuarly the new younger EMT hotshots and I do feel much safer, but there is something harsh and unsettling about terminating a long-time employee, who from all I have seen, has done his job well and faithfully. I await hard news on this rather than rumor. There has to be more to the story.

My knees have been bothering me a little the last two days. I don't know if it is the heavy squats I have been doing in the gymn or all the hours I've spend scrunched in the cramped front seat of the ambulance of late. I'm going to back off the squats and try to stretch more in between rides. I have to stay fit.

Baseball season has started. The Red Sox are 2-2, tied with the Yankees after dropping the first two games to them. I'm going up next week to Fenway. I'm looking forward to seeing the game and drinking beers with my best friend. Going to Fenway is a tradition for us, and we usually take in 3-4 games a year.

I used to play in a competive softball league every year -- the highlight of my week was game day, but have turned down an invitation to play this year. I can't afford to get hurt. Plus there are other things to do on my day off. My last at-bat I hit a game-winning triple over the head of the right-fielder, who I saw out of the corner of my eye creeping in too shallow. I turned my shoulders and blasted it the opposite way. Oh, did it feel good to get a hold of that pitch. And I ran with no intention of stopping till I got to third. Made it standing, just beating the throw. A good memory to quit on.

I've been reading a blog by another medic, and find it very interesting. He has been a medic even longer than me and seems to be going through an angst (that I occasionally share) between loving being a clinical paramedic and wondering if maybe he should move on to something else. Here's the link to his blog:

http://www.themacmedic.us/

Saturdays are nice at work when they don't have any classes going out here. It's just me and my crew.

I'm listening to some early Bob Marley right now as I write.

"These are the words of my master...
Who so ever diggeth the pit, shall fall in it...

In a little while I will switch to the Red Sox game.

My crew is watching an early Clint Eastwood movie. He just tossed a lit stick of dynamite at a bad guy holding a hostage, who looked like a young Shirley McClain. The bad guy ran, Eastwood shot him, walked slowly over to the woman, looked down at the dynamite, and then stepped on the fuse.

I saw an ad in the paper for the Circus, coming to town in May. I think I'll go. I love the circus. It's been years since I've been there.


***

Picked up later in the day: a seizure, a girl who tripped and fell in a store and bruised her hip, a pnemonia from a nursing home who I gave two neb treatments, and an assault.

O2 at 3 lpm via Mask

We walk in the door and find the nursing home patient trying to pull the mask off his face. He is on oxygen at only 4 lpm(liters per minute) , which is more than the amount -- 3 lpm -- written on the W10 the nurse has handed me.

Oxygen by mask at 4 lpm is like putting a plastic bag over someone's head. You need at least 10 lpm to keep the patient from suffocating on his rebreathed carbon dioxide. 3 liters is obviously even worse.

I think about reaming out the nurse, but she seems flustered and there are many aides around her and patients. I hold my tongue because once you start...

This is not the first time I have seen this. This has been going on ever since I started in EMS back in 1989. Even before then as my EMT instructor warned me I would encounter this. I see it all the time.

The patient is, what else? lethargic, suffering from advanced cancer. His breathing is better once I take the mask off his face.

As we head out the front door, I am just about out when I hear someone say, "Where's his oxygen?"

I stop cold in my tracks. "Pardon me?"

"Where's his oxygen mask? He needs it, he keeps pulling it off."

That's when I lay into her. I use the plastic bag line.

"Don't blame me, I'm just an aide. I'm going to call the nurse and tell her you said that."

"Good, about time someone told her."

And she picks up the phone and starts dialing.

With a cannula the man's SAT is up to 95%.

I show the W10 to a nurse at the hospital. "It makes me embarrassed to be a nurse," she says. "They went through the same training I did, and they flush it down the toilet. But the sad thing is it's probably a doctor's order."

"For 3 liters by mask."

"They're not required to get continuing ed."

I glance at the doctor's name. I recognize it. I went to his office once for asthma and found a patient on a mask at 1 liter. Oh vey.

***

I imagine myself on Capitol Hill testifying before the legislature. "We need this bill to outlaw once and forever the practice of giving people oxygen by mask at less than ten liters of oxygen. Please join me today in ending this terrible suffocating abuse of our senior citizens, who deserve so much more for making this country great."

Ovation. American Flags.

***

Did a dsypnea, a woman feeling woozy after three days ago having an incident than left her with difficulty in using her fine motor skills of the fingers of her right hand, and a diabetic. The diabetic came in as a stroke, and the patient was gurgling and flaying about. His skin was very hot -- he had pnemonia. Blood glucose less than 20. I gave him two amps of D50. I wanted him to go because he'd never had a similar episode and was not an insulin dependent diabetic -- he took numerous diabetic pills, but he stubbornly refuused. Talked to his MD, who said it was okay he stayed home, provided his friend monitored him closely.

Let's Analyze This

A couple days I ago I discussed the problem with complaining about the job – and how I didn’t want to turn this blog into one long whine session about nursing homes, dispatchers, and only extremely occasionally triage nurses – that troika of fienddom.* I want to be able to write about the paramedic’s axis of evil* in a way that is not petty whining, so I will try to write this in a way that tries to examine the system rather than the individual because it is always the system that puts the individual in place to be the system's face.

Here’s the scenario:

The nursing home has a patient who for the last five days been more lethargic than usual. Her labs taken two days ago show her white blood cells, nuetrofills, BUN and Creatine are elevated. The nursing home nurse is aware of her nursing home’s policy that requires nurses to call 911 for all nonscheduled visits to the hospital, i.e. –the emergency department where the doctor wants the patient evaluated. She dials 911 and tells the police dispatcher she has a non-emergency routine transport to the ER.

He tells her to call the commercial ambulance service. She does.

Eleven minutes later the commercial ambulance service calls the police dispatcher and says they have received a priority one call from the nursing home that they are compelled to transfer to the town’s 911 provider because it is a priority emergency. The priority is for the lethargic patient.

We are then sent lights and sirens along with a police car for the lethargic patient.

We go charging into the nursing home and they want to know who we are there for. Do we have a patient name? No, we’re sent for the emergency. You have a lethargic patient? We don’t have any emergencies here, they say.

Eventually we find the patient. A lady who is not lethargic and in no pain or distress. She just feels tired. We take her to the hospital.

Down at the hospital we see her Doctor – Doctor Miles. He has so many nursing home patients, they are have earned (from some) the collective and unfortunate name “Miles’ Reptiles.” No Joke.

Now how does this happen that a nursing home calls a 911 emergency line for a non-emergency, says it’s not an emergency, the police department tells them to call a commercial service (that is being offered a money making transport -- the reason they are in business), and then somehow the commercial service kicks the nonemergency call back to the town transforming it to an emergency in the process and then the town police dispatcher tells the town ambulance to go lights and sirens to the same nursing home call they have already directly been told is not an emergency?

Let’s analyze this:

#1. Why can’t the doctor see the nonemergency patient in the nursing home?

He’s too busy. Let the ambulances bring his patients to him. Fair enough, I guess. To his credit I have seen him at nursing homes before. Still, sometimes I wonder.

#2 Why does the nursing home call 911 for nonemergency calls?

Complicated answer. An attorney general ruling several years ago ruled that emergency calls needed to go to the town’s 911 service and not a commercial service, then some bureaucrat lawyer went on to define what an emergency call was and it included just about anything causing distress or pain that was unscheduled.

What followed was chaos with volunteer services being besieged with nursing home transfers that had previously gone to commercials. The town where I work saw its volume increase by 25% in one year.

While the town service was doing the transfer, someone in the town would get in a bad car wreck and the closest ambulance had to come all the way out from the city to get there, while everyone cried “Where is the ambulance?”

The state finally reacted by writing a letter to the nursing homes telling them they could use their discretion in defining whether a call was an emergency or a medical transport, calling 911 for the emergency and the commercial for the transport. So just because a patient was in pain from a five day old fall didn’t mean they had to call 911.

Somehow this nursing home never got the updated memo. Or if they did, their lawyer told them to be safe call 911 for everyone.

#3 How does a commercial ambulance turn a non-emergency into an emergency?

When calls come in to their dispatch center, they are EMDed (Emergency Medical Dispatched) meaning the caller is asked a number of questions based on an algorithm, the answers determine how the ambulance is dispatched. EMD's backers claim the EMD system is medically sound. It seems to not allow the call taker much leeway, probably for legal reasons. We are often sent lights and sirens based simply on a patient's history or based on a caller's choice of words, when a more in depth interviw would reveal severe bleeding is no more than a small cut on a finger, that the cardiac patient's fall was a trip not a dizzy spell, that the lethargy is minor and has been going on for five days.

Is the blame on the algorithm the call takers use? Did the word “lethargic”automatically trigger the priority one response? Or did the individual call-taker just have no sense and completely disregard the nurse's statement that it was not an emergency? '

I have no problem going lights and sirens only to find out there is no emergency when I get there, but when you can easily determine that there is no life and death emergency over the phone, don't send an ambulance and police cars or fire engines lights and sirens. We always say it -- "Someday someone is going to get killed." Imagine if the ambulance going emergency to the above described non-emergency crashed, causing a real emergency. You are talking serious liability.

I ask these questions everyday because the same scenarios seem to occur everyday. They happen to me. They happen to everyone working the streets.

I am not complaining about doing the call or the workload. I am on both sides of this because I work for the commercial early in the week and the town 911 service later in the week. So I either do or don’t do the call depending where I am. I just want the system to get it right.

***

The second call is for a violent psych. Here’s how it goes down:

Another nursing home in town calls the commercial ambulance for the psych. The commercial passes the call to the town as a violent psych. The town sends us lights and sirens along with a pistol-packing Kevlar-vested handcuffs on the belt police officer for muscle.

We find a blind sixty-year-old woman sleeping in a chair. We wake her up and have to help her to the stretcher because she walks so poorly on her own.

The nurse says the patient threatened to scratch the nurse, thus earning the “violent” label from the call-taker. (“Violent” of course signals the need for police presence. Remember Scene Safety comes first.)

The patient says she has no desire to hurt anyone one.

We take her to the hospital. I will note I have transported her on other occasions for the same offense. (I am worried this may be three strikes and she’s out for her. Instead of residing at the convalescent home, she may end up shackled to the wall at the Institute for the Criminally Insane up on the mountain.

People following well-intentioned policies cause strange things to happen.

***

We also did a seizure. It wasn't me seizing, though I felt I was about to convulse several times.


* The trioka of fienddom and the paramedic's axis of evil --nursing homes, dispatchers, and sometimes triage nurses -- these flashing danger zones are where the medic has his main interaction and possibility for unpleasant skirmishing. I mention triage nurses mainly jokingly as I have great respect for 99% of them.

ACLS

Had ACLS today. Advanced Cardiac Life Support. You have to recert every two years. When I first started ACLS was this two day extremely intense class where you were ridgedly tested. Now its a one day recert, and more of a collaborative learning experience. It was taught by our chief paramedic who does a good job of going over the material and reemphasing the key points we need to know as well as going over any new material.

The new ACLS Guidelines will be coming out in November.

http://www.americanheart.org/presenter.jhtml?identifier=3022512


The evidence evaluation worksheets are very interesting to read and suggest some of the possible upcoming changes.

http://www.americanheart.org/presenter.jhtml?identifier=3026177

***

I also talked to our payroll person today. I used zero vacation last year so its is being cashed back to me. For the next eight weeks, they will add 20 hours of pay to my checks. Can't say that I can't use it.

15 Times, The Gift, No One Home

15 Times

Woman with asthma at the doctor's office down the street from the hospital. Has gotten two Xopenex treatments with minor relief and a shot of Xolair. She was tight.

I know what Xopenex is -- the single albuterol isomer (Levalbuterol, it supposedly works better than plain albuterol, but is more expensive. I have noticed a lot of primary care docs are using it in treatments for their patients, while a few ER doctors have still not heard of it)-- I went to a CME on it, but I had never heard of Xolair. I asked the nurse what Xolair's mechanism was. She said it for asthma. Yeah, I said, but how does it work? It makes them better, she said. She didn't know.

Imagine my impression if she rattled out the following:

http://www.rxlist.com/cgi/generic3/xolair_cp.htm

Here's some info on Xopenex:

http://www.rxlist.com/cgi/generic2/leval_ids.htm

We got the woman out to the ambulance, and she volunteered that she had been tubed 15 times. We were two blocks from the hospital. She was starting to wheeze worse. I told my partner to drive and call the hospital. I banged in a line, and started a combivent. As soon as we pulled her out of the back, the wheezing amplified yet again. Wheeling her down the hall caused everyone to take notice. By the time we got her into the room, people were running over. The doctor asked if she'd gotten epi or solumedrol. "She came from across the street," I said. "She's getting worse with each breath." I wasn't disputing that she could have used both drugs, but a) she just started plummeting as we hit the hospital and 2) you have to call for orders for both interventions, and if I had called, I'd still be in the ambulance. As it was, I was in the hospital 10 minutes after we arrived outside the medical building where the patient was seeing her doctor.

He gave her both meds and some ativan and then shortly declared she was doing better. She wasn't. I was standing right there shaking my head. She'd getting worse, I said to the RT. They tried heliox and she was sucking the nonbrebreather bag empty with each breath. She got tubed for the 16th time.

While we're at it, here's a good article on asthma:

http://www.emedicine.com/med/topic177.htm

***

The Gift

A forty-five year old man lays slumped against the storefront of the Erotic Palace. He is out cold, drooling. He clearly has done some drinking from the smell of his breath. Doesn't respond to sternal rub. We take his jacket off so we can get access to his arms. No track marks. He is clutching a small box in one hand. We get him up on the stretcher and then into the back of the ambulance, and get him stripped down on the top. His pupils look pinpoint, but he doesn't respond to narcan, which I give him in two doses, .8mg, then 1.2mg IV. His blood sugar is 244. He is tachycardic at 120. His blood pressure is fine. His respirations are snoring so I put in a nasal trumpet that slides in easily and helps with his breathing. In his wallet there is a non- driver's ID card, and a mental health clinic appointment notice.

I'm trying to piece it all together. I glance at the box, which sits by my clipboard now. There is a gift bow around it. I open the box.

In the ER, I give my report, running down what I have done. The doctor and nurses ask many questions.

"The answer," I say, "is in the box." I open the box and show it around.

A small diamond ring.

"He has a broken heart."

***

No One Home

A seventeen year old mother called 911, saying her one year old had fallen and was bleeding. When we got there no one would answer when we buzzed the apartment from outside the security door. We had a callback put in, but they just got the answering machine.

We got in the apartment building, went up and knocked on the door. "EMS!" my partner said.

The door opened after a second and third knock. She said she didn't hear the buzzer, the phone or the first two knocks.

The child was fine, a small cut, maybe a stitch needed. Nothing suspicious, according the cops who had come up with us. Just an honest accident.

On the way to the hospital, the mother told my partner she called 911, then called her mother, and once her mother calmed down enough to see the child wasn't hurt, she warned her not to answer the door. The police would come she said, and think you hurt your child, then DCF would come and take your child away.

***

Also did a chest pain, a TIA and a seizure.

Dilbert Land

We're called for dsypnea at an insurance company. A security guard leads us up to the third floor on a frieght elevator. The elevator opens horizontally like a giant steel mouth, and we step out, go through some double doors and then through a maze of cubicles. I have been here before. As often as we have picked up drunks on city street corners, done wrecks on the interstate, pnemonias in nursing homes and broken limbs on athletic fields, we do anxieties in Dilbert Land -- vast floors of nothing but cubicles. The calls come in as dsypneas, CVAs, unconciouses, diabetics, chest pains. We treat them, work them up, but in the end, they are almost always about stress and anxiety.

This time it's a woman in her late thirties, under stress, lots of problems, at work and financial. Tomorrow it will someone else melting down. There's worse jobs than being in EMS.

***

Did a basketball injury, a severe vertigo, a dehydration, a teenage psych, a neck pain from a rear end MVA and a probable pnemonia.

***

At the end of the day I talked to one our medics, who I precepted, who is now a new firefighter. He said he thought the fire department was still planning to try to take over EMS in the city, upgrading from first responders to being medics, and maybe even taking over transport. I can't see the city coming up with the money to swing it, but who knows. The day may be coming. Maybe two years out. More likely five. By ten, maybe its done. You can't count on life staying the same.

It will be a hard day for me if they ever shut us out of being medics in this city. We've put a lot of ourselves into these streets. The city is a part of us.

The Man

I recieved a form letter this week from the company president asking if I, as a paramedic and company employee, was interested in buying a share of the company. Paramedics can invest from $2,500 to $5,000. The letter was more an inquiry of interest than a firm offer.

I don't know whether it is a good investment or not. But I like the idea of employee ownership. That's why I bought a hundred shares of our company's previous owner when the shares were selling at .73 cents a share. Today that stock is worthless, but what the hay. I'm a believer.

Instead of working for the Man, I can be the Man. Or so I can tell myself.

"Where Are You Going?"

What a difference a good night's rest makes. Woke up feeling full of vim, vigor and vitality.

***

Went to a nursing home for a diabetic. We're chugging down the hall, my partner and I pushing a stretcher loaded with medic gear and a police office following right behind. A nurse standing by a pill cart asks us, "Where are you going?"

"Someone called 911 for a diabetic."

"Right there," she says pointing to the room.

"Well, okay," I say, "By the bed or by the window?" You always have to ask that. (I was sent to a room once where one person was in CHF, the other was recently deceased and the body just hadn't been moved. You can see the confusion possible.)

"By the window," she says.

I glance in the room. I would have guessed the patient was the one in the wheelchair by the door, who leans to the left drooling. The woman in the bed by the window, appears awake and not in visible distress. I recognize her as a patient I have treated before.

"And what's the story?"

"She's a diabetic. We found her unresponsive this morning with a blood sugar of Low. We gave her some oral glucose, then a shot of glucagon IM. Her sugar now is 40 and she won't eat."

"Did she eat this morning?"

"I don't know."

"Can we find out?"

"No, no one here knows. We had shift change. I just came in."

"Okay," I say. "Do you want me to just get an IV and give her some sugar and get her back to normal or do you want me to take her to the hospital?"

"The doctor wants her to go to the hospital."

"But if I get her back is he still going to want her to go to the hospital if the only thing you want is to restore her to her baseline." I point to the paperwork she has just handed me, which lists "Restore to baseline" as the reason for transport to the hospital.

I am trying to be helpful, as I often come to this same nursing home, get a line in a hypoglycemic patient, give them the D50, then have them consult with the doctor or I speak with the doctor and the person stays as there is no longer reason to transport unless there are other circumstances.

Another nurse who has come down takes the paperwork from me, crosses out "return to baseline" and writes "treat for hypoglycemia."

"Unless there is something else you want looked at, they are just going to turn around and send her right back."

"The doctor wants her at the hospital."

Fine. The patient is alert enough to follow me with her eyes, squeeze my hands on command and tell me her name. I notice all this red sugary drool on the pillow by her mouth where they tried to squirt sugar into her mouth. Not a smart move.

Her sugar is 55. I get a line and give her some dextrose IV. The first thing she says is "Can I get something to eat?'

"Did you eat this morning?"

"No," she says.

"Why not?"

She shruggs. "I was sleeping."

At the hospital, her family complains that she doesn't eat enough at the nursing home, they take her food whether she is done or not. The family says this is her fourth hypoglycemic episode in a month -- all because of not getting enough food to eat. I'm thinking now maybe it is a good thing I brought her in, maybe they will call social services or maybe try to find her a bed at another home that cares enough to see she eats.

***

Next call is for a tachycardia at a retirement community. The man is in rapid afib. I give him Cardizem and the rate slows from 160 down to 100. All the way in he complains of back pain. He has chronic back pain and has had it for twenty years. Every other minute he is asking me to help adjust his position on the stretcher. The ambulance ride is rather bumpy -- they still don't make ambulances for comfort.

At the hospital the triage nurse from the other day(hypothermia) is very concerned about the back pain. "Maybe he has a triple A," she says.

"He's had it for 20 years," I say. "Its chronic. Its old pain. The stretcher is uncomfortable. The road was bumpy."

She goes and asks him about ten questions about his back pain.

"The reason for the call was tachycardia," I say again. "The back pain is old. He was in rapid afib. He has no history of afib. I gave him Cardizem. His afib isn't so rapid anymore. He's feeling better, aside from his usual back pain."

When she finally looks at my before and after 12 leads, she says, "That's an awfully wide QRS. It looks like V-tach."

"Its a Left Bundle Branch," I say.

"But its very wide."

"Its a left bundle," I say again.

"Oh, that's right," she says.

***

I have been thinking about this journal and have thought about just writing about the most interesting calls or moments of the day, and not trying to record everything for fear it will get tiresome -- that it will get whinny. But if I were to do that, you would lose the truth and that is that this job is often mind-numbingly frustrating. Whether its nursing homes or triage nurses or stupid 911 calls -- it seems you are every day shaking your head, saying "Can you believe?"

Crew change everyday almost inevitably includes a "You wouldn't believe how stupid" story about something.

(I read a book a few years back called "Talking Trauma" written by a folklorist, who analyzes paramedic's stories. I am going to have to look at the book when I get home tonight and read what he has to say about storytelling and comment on it here.)

Now having said that, I will freely admit that there have been times when I have been the stupid one -- whether it has been calling for a paramedic when the patient didn't need one back when I was an EMT -- missing an easy diagnosis or doing something else dumb -- I do not exempt myself. We all have our stupid moments. I do try to get less stupid as I grow older.

I'm sure triage nurses have lots of stories about dumb EMTs and even nursing home nurses may have similar stories (I doubt it).

I just wish that there was more common sense in the world.

***

Couple hours later after I wrote the above, I am thinking about deleting it or else commenting on it more fully. I constantly rewrite my entries and I have deleted as much whining as I can. Because on one hand, the stupidness is a daily part of the job, on the other, it is not the noble part of the job, it is the small stuff that shouldn't be sweated, and maybe only bears only a minor mention. I should maybe focus on the bigger things, and if I don't have bigger things to write about, then maybe I ought to start looking. That's where I ought to be headed.

***

Ended the day with a CVA -- a seventy year old woman with facial droop and slurred speech since earlier in the day. Old black couple. House full of kids and grandkids. The husband was gruff. When I tried to question him about when the symptoms started, he answered impatiently, "She just ain't right. Take her down to the hospital. I'm coming too."

"I need to know exactly when the symptoms started."

"Well, I noticed about an hour ago, but the kids they say she ain't right this morning. I don't know. I was going to drive her, but she ain't steady."

It was pouring rain out, and he was busy trying to get a coat for her and for himself, and find himself a hat."

"You go to cover up that bald head, granpaw," one of the children said, "The rain going be splashing off you."

Out in the driveway, he tried to step up to get in the back. The step was high and he wasn't that limber at his age.

"You're going to have to ride in the front with me, sir," my partner said. "She'll be in good hands in the back."

We went to the hospital on a priority. I was going to patch in a stroke alert, but in going over the story again with the man, it was pretty apparent that the symptoms had begun at ten that morning, putting her well outside the three hour stroke window.

At the hospital, once they heard the symptoms were almost eleven hours old, they shrugged and put her in a room at the end of the hall. We made the bed up, disconnected her from our machines and slid her over.

"They got you guys doing everything," the man said. "I thank you for helping my wife."

When I asked him for insurance he said he had Blue Cross. I asked if she had Medicare, he said he didn't use it because he was still working.

When I left the room, he was in there alone with her, leaning over the rail, asking her how she was feeling, his hand brushing her hair.

Rapid Afib

Afib after 25mg Cardizem

Man of Steel

I didn't sleep well last night, felt a little nauseous, and puked this morning when I woke up -- only one time. I never puke. It was too late to call in sick, but I thought I could make it through the day if I could get some sleep as soon as I got in.

Walk through the door, the tones are going off.

Four hundred pound guy on the floor needs help getting up.

He was in an awkward position, laying wedged against the bed. My plan was to slid a board under him, slid the board along the floor, then strap him on the board, and then bending my knees, lifting the top of the board until I had him standing with my partner and an officer helping lift/support the man as I raised the head of the board. Leverage.

Trying to get him on the board, he complained I hurt his shoulder, I apologized, then he started giving orders about a better way to lift him up. He wanted to roll over, then have us lift him to his knees, then have him use a chair to lift himself up with out help. I just stood back. Since the patient and I had clashed however briefly I let my partner handle it, but that wasn't working.

They finally agreeded to try it my way. Fortunately another officer came in and he helped me lift the head end up. Worked like I charm, except I was feeling really dizzy from the effort.

Just then the cops got dispatched to another medical on the other side of town. My partner, looking at my sad tired face, knew just want I was thinking. We sat the man down and did a full assessment and did a full and proper handling of the refusal paperwork, rather than just getting a scrawled signature and tearing off to the other call, to which they dispatched a city ambulance.

We went back to the base, and I lay down on the couch and watched TV. I was just whipped. I had aches in my bones and felt nauseous. I didn't sleep, but rested as well as I could.

Along about noon, we got sent back to the same address. The man had fallen again and needed help getting up. I tried to get him to go to the hospital as this fall left a hematoma on his head, but he would have none of it. There was just three of us this time. We lifted him up the same way. I handled the head end by myself and got him up fine, but again standing there holding the board against him till we had him steady against his walked, I felt the dizziness come over me. the man thanked me after I told him to call us at any time. He said I was okay in his book.

Back at the base I called my relief and asked him if he could come in early for me and he said it would take him an hour and a half or so, and I said that was fine. I called the supervisor, told him I was sick -- he started to sound annoyed, but then I told him I had already arranged for relief. That was fine by him.

As soon as I put the phone down, got a call for the unconcious baby. The baby allegedly fell and seized, and was now unconcious. I didn't like that combination. We went lights and sirens along with several cops cars, and when we arrived family members were standing on the lawn crying. That is never a good sign. I went into the house, into a small room crowded with people who were all yelling, and I saw a cop leaning over the baby who was not movingl. "Is he breathing?" I asked.

"Yes," he said, "He's just out cold."

I was hearing explanations of what happened. He fell off the bed. He seized. His lips were blue. His eyes rolled back in his head.

I looked at the cop, then pulled up the baby's shirt slightly, grabbed a little fold of skin and pinched and twisted it hard.

Wallah! Tears. Crying baby. The cop smiled at me. Everything is good.

I still c-spined the baby, put him on oxygen and took him on a priority to the hospital. He alternately cried and slept deeply. I couldn't find any bumps on his head, and when he was sleeping and I tried to pry his eyes open, he fought against opening them. I also found out he just hit his head on the bed post and did not fall. They had placed him on the floor.

Bottom line he was okay.

When we got back, my relief arrived shortly therefter and I went home.

This is the first time I have ever left work early due to not feeling well. I've only called in sick twice. Twice in ten years. Not counting when I had a broken wrist. I worked through a broken finger once when I was first starting. I didn't want to miss work. Man of steel.

Man of steel starting to feel his age. My relief agreed to let me come in three hours late tomorrow so I can get a good night's rest.

Tomorrow's my long day.