Que Sera Sera

So-so busy day. Two ALS calls, a chest pain and a seizure. Also did a maternity, an MVA and a couple transfers.

We took a dialysis patient back to his nursing home. I was surprised when my partner told me the guy was only 55. He seemed much older. He'd had a stroke and couldn't communicate. His body was all contracted and he seemed in pain, whenever we moved him like he may have had bed sores. I don't know whether he was with it in his mind, but just couldn't communicate, or whether his mind was also flawed. I was just thinking, man, I hope I don't end up like that.

Who knows what lies ahead for each of us. A week or so ago a guy who rode with me several times as a medic student and also briefly as a EMT, went down to Florida to see a girl. Hadn't been there long enough to get a sun tan when they went out on a watercraft. Reports were they were in a no wake zone watching dolphins or manatees when they got creamed by a catamaran. Didn't even see it coming. Dead. Twenty-three years old. The girl, also dead, was 19.

I think about myself these days. Here I am working everyday so I can own my house, and put enough money in my 401K so I won't eat catfood when I'm old. I didn't use any vacation time last year. At least I work out so my stroke risk is low. I hope so anyway.

Anyway, I was walking out of the nursing home, making certain like I always do to say hello to all the old people sitting lost there in there wheelchairs. They always look suprised when you say hello. It seems to startle there, jarrs them out of their funk and they brighten up for a moment and give you a smile and say their best hello back. I'm saying my hellos, but I'm thinking stroked out in middle age or wacked by a catamaran in your youth. What kind of choice is that? How about dying in your gentle sleep on a stately ranch, surrounded by gennerations of your progeny?

My mother had multiple sclerosis. She got it when she was thirty. She used to beat me in tennis, then she stopped playing. I guess I was ten then. She had trouble walking, had to balance against the furniture. A lady down the street broke her pelvis skining and was back on the slopes the next winter. I didn't understand why my mother could't get back on the tennis court. The disease stayed mainly in her legs for the next twenty years. She'd have attacks, then remissions. She was always going for new experimental treatments, none of which panned out. She used a cane, a walker, sometimes a wheelchair.

Then the disease got into her brain. It was so slow, we didn't see it coming, didn't even recognize it for a long time when it was there. She was a bright woman, but she seemed to loose her sharpness. She'd say the same things over and over. Just enough to frustrate you because you were too busy to pay attention to her decline. "I just told you that," I'd snap when she'd ask me about my day after just having asked me about shortyly before.

And she was all the time using the same stupid phrase. She'd say, "Well, que sera, sera." What will be, will be.

She'd say that constantly, sometimes two, three, times in five minutes. It drove me nuts.

She used to sit on the couch and read. She was a voracious reader. Then we discovered she hadn't just been reading the same book for three weeks, she was on the same page. She'd sit there reading for hours, never turning the page. Shows how well we were paying attention.

Anyway, long story short, her decline was quick. She couldn't be left alone. My father would tell her not to move while he ran out to the store, she'd get up and fall. I was away living in a distant state so I didn't have to deal with it. She ended up in a nursing home. My father visited her everyday. It was a good home -- one of the best -- and they took good care of her. When I visited, I wasn't certain sometimes if she knew who I was. She got a UTI, one of many, and she passed away. She was a DNR by then. That was fourteen years ago.

So today as I'm walking out of the nursing home, saying my hellos, and thinking about the nasty ends many of us have coming at us, I go by the community room where a guy in a Hawaiian shirt, accompanied by another guy in a Hawaiian shirt on piano, is singing "Que Sera Sera," to a packed room. I go past the room, then the song sinks in and thinking of my mother, I stop and go back and stand in the doorway, and watch. I am hoping for some revelation, some sweeping emotion or meaning. I look about the room. Some people are smiling and nodding along to the song, some are asleep, some are drooling, some don't even seem to know they are there. The guy singing seems like a nice man, and he is working the room hard, focusing in on the few alert ones. He's touching hands and making eye contact where he can.

"Que sera, sera, Whatever will be, will be," he sings, as he smiles endearingly at an old woman, who blushes like it is Elvis Presley serenading her.

But there is no meaning for me, no deep message, no answers to my questions. It's just a bunch of old people in wheelchairs -- all with their own stories, their own heartaches, and their own joys, their own harsh and varying declines.

I don't know if there is ever meaning just handed to you when you want it.

I leave the singing behind and continue on out of the home, and out to the ambulance, get behind the wheel, and head out for the next call.

Holiday

Holidays are usually very slow early, then pick up late as people start drinking and old folks, on leave from the nursing home, stroke out at the picnic.

Today we were hopping early. Nothing interesting -- a smelly obese guy with gout, a lady with flank pain, an assault, a knee pain, a back pain, and a couple diaylsis calls. The last three hours we did nothing. Beautiful day, drove to the park, backed in to a parking space near the woods, opened the back doors, and lay on the stretcher, feeling the cool breeze. Somebody was playing Al Green on their car stereo nearby.

It was so slow they were asking for volunteers to go home. At double time and half, stretched out, breathing the fresh May air, listening to the Reverand Green. No Way.

Got to speak a little Spanish today, and after a slow start, I was talking like a native. The lady was telling me all about how "mi familia no me ayudan. Nadie!"

In the mood, went to El Mercado for lunch and had chivo with arroz, goat with rice, with plantains on the side.

Came home and mowed the lawn before the sun set. Had a shake for dinner and am going to bed.

Back for 12 more tomorrow.

A Lot of Hours

12 hours in the city. Five calls. Dsypnea at a nursing home -- had to suction a trach -- a seizure, an MVA, a chest pain, and a false medical alarm. It seemed like a long day. I'm going to bed early tonight. I'll be working a lot of hours this week and this coming month. Fortunately tomorrow is holiday pay, double time and a half for 12 hours. Whoo-hoo!

I confess I felt a little depressed today at work. I think it is because I am still beat down and tired and maybe fighting a bug. It just makes you feel weak, and you wonder if you have the strength to keep doing this for another ten, fifteen years.

Maybe I'm working too much. I'm on pace to make $100,000 this year. I don't think I will. I'll hit $80,000. Its a lot of hours and it has its price. No way will I be able to work this many hours in ten years. No way.

Today I was thinking if I want a different life I will have to make my move soon.

But I don't know what else to do.

Run Forms? Run Forms?

Busy day, five calls all in a row, three transports and two refusals. My ambulance is down for service so I'm working in another one. The medic who works in that one reguarly has the cabinets locked with pull ties so he doesn't have to check the shelves unless they're broken. I check my gear -- everything looks in order.

We always keep a couple refusals in the house bag so if the call turns out to be a refusal we don't have to go traiping back out to the ambulance to get the run box.

The call is for a woman who has fallen and hurt her hip. She is in her nineties and has no family members. She describes her pain as terrible and winces when I palpate her hips. I give morphine before we move her, and she is now, as she says, quite calm.

We get her out to the ambulance no problem, then I can't find the run box. No where to be found at all. I open up the house bag to get one of the backups we keep in there. Used them both up on the refusals. I break open a tab on the cabinet where extra paperwork is usually kept. There is no paperwork there. Not a run form on the ambulance.

I look at my partner. There is no family going with us, no one following. The patient is resting quite comfortably, eyes closed, feeling no pain. What do say, you swing by the bay on the way out of here. It's not but a couple minutes out of the way. No one else is back at the bay. The place is empty. My partner knows where the run forms are. There's a big box under the desk in the office.

When we arrive at the hospital, my paperwork is done. No one the wiser.

***

Get sent for a difficulty breathing. Find a huge barbecue going on, about eighty people, all ages. The complaintaint is an elderly woman feeling dixxy and a little nauseous. She is alert, skin warm and dry, and not complaining or pain. With about ten people gathering all around us, and others milling past and a giant screen TV blaring The Matrix, I decide to just get her on a stretcher and do everything in the ambulance.

She pukes up three emeisis basins worth of food on the ride in. I want to give her some phernergan, but when I ask her about allergies, she goes into the long winded answer in a deep southern accent all I catch is the words, "my daddy, sweet potato pie, get me some ribs, the strong stuff." In the meantime the woman in the front, her daughter is yelling at my partner because he said he wouldn't give her a ride back to the party. She turns and yells at me, "How are we getting back to the party? I ain't had my ribs yet."

I just shake my head, and grab another emesis basin as the patient is puking again.

At the hospital we find the run box we left earlier in the day.

Number Three

I found out today that one our frequent fliers is moving to a nursing home in another town. Whoo-hoo!

I would estimate we have transported him over three hundred times in the last five years. Always for constipation or a clogged urinary catheter. He has visitng nurse who comes, but he can never wait for her. His house is a pig sty.

Many times I see him lying on a stretcher in the hallway at the hospital, waiting for a commercial ambulance to come take him home.

He was always miserable.

I feel bad for anyone who has to live like that, but when you see so many people who are stoic, you do lose a little compasion for the chronic complainers.

He was probably our third most famous frequent flyer.

Number one was a younger person with sickle cell, who called in the middle of the night all the time. Sickle cell is horrible disease, and I have given people in sickle cell crisis megadoses of morphine, but I never gave this guy morphine one. He just didn't appear to be in any type of pain. And it seemed he always called after a night out partying. He'd come home, then call for his ride to the farthest hospital. There were always three cars in his driveway. He's dead now.

Number two was a diabetic, who dropped her sugar two three sometimes four times in a week. She had a baby and a young child of maybe five, then six, then seven, then eight, who always called the ambulance. Her problem was she didn't like to eat. We rarely took her to the hospital. We'd give her D50, she'd come around, then refuse to go to the hospital. I wasn't hungry she'd say. Her son would fix her a peanut butter sandwich and we'd sit there and watch her eat it. She moved out of town. We heard a report of another responder going to her apartment in the other town an finding her unresponsive with a low sugar. Then she moved back to town, then moved away again. No sightings for over a year now.

This guy was number three.

***

Two calls today. Both cold and flus from elderly communities. Both went to the farthest possible hospitals.

Paramedic Aptitude Exam

So you want to be a Paramedic?

Question Number 1.

Your elderly patient, who was vomiting last night, has fallen out of bed onto the carpet and is too weak to get up. The patient has been on the gound for over an hour and was unable to hold off amazingly large loose bowell movements that are now all over the patient's front side, some dried, some not. By the time you arrive, the patient has been face down in the mess and rolling on it for over an hour. The patient denies any pain, is alert and has stable vitals. Their bathrobe is also smeared in the stuff. After clearing cspine, and doing your full assesment, what do you do?

A. Put lots of chucks and blankets on the stretcher to protect it from the body fluids and to wrap the patient up in it so you don't have to smell it all the way to the hospital.

B. Try not to puke while you wipe the feces off, going through several wet towels, a box of Kleenex, more towels, a sheet, then finally get the patient up, take off the robe and teeshirt, help the patient into the shower, and bathe and soap them, getting all the crap off, so they are clean and sweet smelling, and then set them down on clean sheets, and bundle them up so they are warm, then later take your work shirt off and wrap it in a plastic bag and tie it tight, then go rewash your hands and face multiple times, and suck down some powerful Halls coughdrops to try to drive the smell from your nose.


***

Ended up with five calls, four ALS. Nothing exciting. A pneumonia, a couple syncopes, question of a hip fracture, CO poisioning.

A Troubling Feeling

I arrived at work last night at ten for a 16 hour shift only to find another medic there. Before I left on my trip we had talked about him doing the overnight portion of the shift for me because I don't like doing the overnights, but I hadn't thought we had firmed it up. I was happy to let him do it, and since I was already out there, I decided to stay and sleep. I got a good night's sleep, but so did he. When the alarm went off at six so I could punch in, the overnight crew was sound asleep. Zero calls in eight hours. Five minutes later, they toned us out.

I did three calls, two at nursing homes. Two chest pains, both with good cardiac stories and a CHF/pnemonia.

How did it feel to be back?

I have to say, and I am a little worried about it, the number one feeling I had today was not refreshment, ready to tackle the job with new vigor, but boredoom. This despite three good ALS calls.

Was I bored because I was tired or because because my world seemed small and predictable again? The same bumpy ambulance, the same nursing homes, the same partners, the same vista, the same treatment plans, the same hospitals, the same faces.

I don't want to be bored in my job or in my life.

Better

Feeling much better today. My fever has broken, the GI problem is under control. The pain in my calf gone. I am ready to go back to work. I'm on the schedule starting tomorrow night.

Fever

Oh, I am beat down today. My whole body hurts. I have a chest cold, a fever, some GI problems, my feet itch, my shoulders are sunburned from the two hours at the pool, and I have a pain in my right calf. I have typhus, diptheria, malaria, a PE, rare fungal infections and parasites, not to mention skin poisioning.

I am too tired to mow the lawn. I sleep through the day.

My body needs rest.

Back

The flight home is smooth, and soon we are on a bus back from JFK. I arrive to a quiet house and a stack of newspapers. The lawn is overgrown. I feel oddly out of place. I unpack, tidy up the house. I download my pictures into the computer and watch them all.

I think of Jesus and how last night, after being garralous all week, despite his regal attire, he was oddly quiet. This morning I gave him my new Littman stethescope. I told him that I wore his watch on my wrist so that when I felt my patient's pulses, I would always think of him, and now when he listened to people's hearts when he helped out in the hospital, he could think of me. We embraced fiercely.

I play no music, just sit in the quiet house.

There are clouds in the night sky, ocassionaly breaking to show the heavens.

Santo Domingo

We take the long bus ride down from the mountains to Santo Domingo.



At a rest stop I eat chivo -- goat -- along with rice and beans and fried plantains with Jesus. We arrive at our hotel in the city at one, and we all head down to the pool, where we enjoy the sun and play nerf football in the water.



I think if I had a choice between a week at an all-inclusive resort versus this experience with just our two hours of pool time, I would take this without question. In the past I was always the type to never leave a resort, content to lay in the sun with a drink in my hand. I can't imagine any better way to see a country than to do what we have done on this mission.

At the pool I talk with the trip's medical director and he admits he did not the difference between and EMT and a paramedic before the trip started. He seems happy with my work and asks me if I am interested in a trip they have planned for next year with a smaller group, a first time mission into Boliva. I tell him I am very much interested.

I will be sharing a room with Alexander and Jesus. I make a note to myself to ask my friend Annie for extra ear plugs she said she has. Jesus dons a red suit and wears a mini sword, giant dagger on his belt. He says it is dress befitting a "rey," a king, which he claims he is, a king of Barahona, the Dominican town where he is from.

We go shopping for two hours. I buy a Presidente tee-shirt, a set of dominoes, rum for my father, some jewelry for friends, and some CDs -- bachattas and merengues from a street vendor.

At night we eat at a restaurant where I order a Dominican platter of shrimp, meat and eggs in rice and beans, accompanied by several more Presidentes.



I go in the casino where I find myself in a game of no-limit Texas hold'em with a table of crazy dominicans. Texas Holdem is a game that requires patience. While I fold continuously, the Dominicans play nearly every hand. When one wins, he gets up and does a merengue dance while the live band blares the music closeby. "Ladron! ladron!" one accuses the other when he catches a long shot card to win a pot. "Te Quiero, Maria, Te Queiro," another tells the dealer when she deals him a winning card. A waiter brings out a plate of meat and onions and fries for all the players. I am continually amazed by the wildness of the play. When one raises another, the other calls with a poor hand. It is as if to fold to a raise is a sign of lack of manhood. At one in the morning I finally get my hand, and win a big pot, walking away a $1200 peso winner for the night. (About $50 US). The next morning I give the money to Jesus to use in his work for God.

When I go back to the room after cashing out of the poker game, I can hear Jesus snoring from down the hall. Alexander has both pillows pressed against his ears. "I can't take it anymore," he says.

Jesus is sleeping on the floor due to his bad back. We debate rolling him out onto the porch, but he is a former Olympic death match fighter, and his ceremonial sword is by his side.

"I'm not moving him," I say.

***

I would like to thank my long time friend Annie, and long-time, but not much anymore occasional partner on the volunteer ambulance, and now an awesome ER nurse, who told me about the trip and helped me hook up with the group going. You're the best! Come back and ride the ambulance some day.

Ballad

Our last day of surgery. On the ride in to the hospital, I stare out the window taking in the view. I will never have a commute like this again.



The operations today are largely minor as we will be leaving tomorrow. It is a day for taking time to remember the sights and the patients and the people I am working with.



A woman who earlier in the week was here helping a family member, has returned to help volunteer with us. She has a wonderful way with people, and tells me she would like to be a nurse, but cannot afford to go to school. I think if I had the money I would pay for her education. I hope she will met a benefactor or that someone will take her under their wing and guide her along. I give her my blood pressure cuff and trauma shears at the end of the day.

I go out and buy a cold pepsi from the vendor across the street. We talk in Spanish. I talk with some children outside the gate and take their picture and show it to them in the viewer. They laugh.



On one hand I am anxious to go home, to return to my work, to see how my world is changed. On the other I want to savour this world I am in now.

At the end of the day, we hand out bags of presents for the children.



I wish the best for these people, particuarly for the children.



I hope their lives are rich with love and they are always blessed by someone.




***

We return to the bar at night, and I talk for a long time with the bartender, and hear about her life. She would like to one day see America. It is pouring rain outside so we stay longer, any excuse for another Presidente. We learn the bartender's seventeen year old son has a crush on one of the young women in our group, who came to the bar a few nights ago, and he has bought her a teddy bear, and when it stops raining he is going out to find a guitar player and a singer to serenade her. We tell him to wait for us before going. When he returns, the bartender closes up the bar and we all walk back to our camp on the dark road.

The girl is reluctant to come out and meet him. She is in her twenties and he is seventeen, but I convince her it will be safe. He is after all just a boy with a crush, and she can give him a gift that will last his whole life, just by coming out and accepting his gift, and hearing the music he has arranged. We meet halfway down the driveway. I hold a flashlight up high and shine it down on the guitar player's fingers as he plays. The music, a slow bachatta is wonderful. The singer has a rich mournful romantic voice. The music carries out over the countryside.

When it is over he presents her with the bear, they hug briefly, then we all hug around and say our good nights.

The next morning the people who had been sleeping talk of the wonderful music they heard in the night. I tell the girl that years from now she will a hear a ballad on the radio of the love the boy had for her, and of the smile she gave him, and how it helped make him a man.

The Self

On the bus ride to the hospital I talk with one of the doctors who has been on other medical trips to help the poor. I wonder what it would be like to go to some of the places she describes -- villages that have never seen a doctor, people in refugee camps. We talk about how these trips can change you. I feel for me the changes are subtle. It is about shifting the focus away from the self, about opening up to the world and to the patient. I want to be transformed.

I find myself saying to many of the patients when they are discharged, "Que Dios te bendiga." May God bless you. I am not a Christian. I do not believe in God. I believe in helping others, in trying to find in yourself a better, purer person, you best serve others, you best serve the world.



Am I a fraud when I say may god bless you. I don't think so. What I mean is may good things happen to you, you are loved. They smile when I use the words. They seemed touched. And that's probably why I keep saying it. That and it is a simple thing to say. Maybe I am an instrument or maybe I'm just trying to get them feel better and maybe less afraid.



A woman has hypertension. Her pressure is 220/120. She is only 34. The doctors won't operate on her. She could stroke out. She hasn't taken her medicine for two weeks because she doesn't have the money. She needs the operation because she is pain. We tell her another group of doctors will be coming soon, and they will be able to operate on her if she can get her pressure down. But she has no money. The nurses and I join together and slip her some money as she leaves. She cries and hugs us.

***

That night we go back to the bar, the two nurses rom pre-op join us along with others from our group. Jesus plays air guitar on a broom and sings songs of God he has written. It is a fun evening.



In bed I wonder again about the self. Am I trying to good because I want to be seen as someone who does good. If that is true, is that wrong? I want my deeds to be purer. I want to be able to do good, and yet be unseen.

One Day at a Time

The morning begins as all have with the old country song "One Day at a Time" being played over a loudspeaker. We use this as our true wakeup call, ignoring the silly rooster who begins crowing at 2:00 A.M.

One Day at a time, sweet Jesus,
that's all I'm asking of you.
Teach me today, to do all the things
that I have to do.
Yesterdays gone, Sweet Jesus,
and tomorrow may never be mine.
Lord, for my sake,
teach me to take,
One day At A time.

There is no water this morning, just a dribble from the spout. Still I take a shower and am refreshed by it.

Before eating we stand in a circle and sing a song, then someone from the group says a benediction. Our breakfast and dinner is prepared by a woman named Maria. It is simple food, but delicious, often accompanied by fresh fruit -- mango, papaya, pineapple. Every time I am served, I think of something to say o Maria. This morning I tell her, "Anoche cuando dormindo tengo un gran sueno, un sueno de la comida de Maria." Last night when sleeping I have a great dream, a dream of the food of Maria."



The day is very busy. Everyone seems to be melding as a team. I love the two women I work with in pre-op -- they are good hearted. I am again doing double duty between pre-op and post op. There are more ceasarians. I try to take time to talk with the patients, try to make them feel comfotable, get them to laugh and smile.



My Spanish is getting much better.

***

At night I go with Jesus and the other Dominicans to play pool in the town. With Spanish music blaring, and a light rain, I am a lone Yankee in a pool hall of Dominicans, many wearing shirts of USA athletic teams or names of cities. I feel grateful for being able to travel the world and see what I have seen.

A Place

There are many more patients awaiting us this morning than yesterday. I am assigned to help translate in pre-op. Patients are identified with surgical needs in the clinic, told to come back the next day after having not eaten or had anything to drink. Their names are called, and they are brought to pre-op, where we have them change into a hospital gown, they weighed, vitaled, reinterviewed, then given an IV.
Then they wait until surgery is ready for them. The nurse anestheists come down and reinterview them and have them open their mouths so they can guage how easy or difficult the intubation will be, then they are lead down to surgery.

I get my first chance to do an IV when one of the nurses misses, and I tell her I'll scope out the other arm for her. I point out a vein, and she looks at it, then tells me to do it if I think I can get it. I put the IV in, then ask her, if she has a preference on how it is taped down. They later have me do an IV on a child and on a darked skinned Haitian.

I admit to having some trouble with not being in charge. As a paramedic you are trained to take charge. Here I have to tiptoe around. I irk one of the anesthiests when moving a patient. I am used to moving a patient with just two people. They use six here. For a large woman, I suggest letting me grab her from the top, but he is at the head, and I learn the rule is the anesthist in the hospital is like the paramedic in the field -- they control the airway, even when the patient is alert. I make certain to stay at the feet end.

Coming down I had wondered if I would get the chance to intubate, but I see that I will not. With two anesthists in each room, they have that covered, and my job is outside the OR. When a cesearian comes in, Annie, the nurse running post-op, who is also a close friend of mine and who has worked with me for years on the ambulance, where she is a volunteer EMT-I, tells me to replace her in post-op. Her job will be to catch the baby and rescusitate it. She tells me later when they asked her to do the job, she told me I had probably had the most experience with rescusitaions and delieveries. They responded that they needed a nurse.

The good thing about it that when things get busy, if you can get the job done, then the job is yours. In post op, I take the report from the doctor and the anesthetist, then monitor the patient, vitaling every fifteen minutes for the first hour, then every half hour after that.



If they have pain, I can give them Morphine, phenergan for the nausea.



When they are stable, they are transported down the hall to a large room with many beds where their families can take care of them until they are ready to be discharged. I give many discharge instructions, handing them percocets and ibuprophren.

My friend tells me there is some grumbling from nurses about a non-nurse giving medicine, until she explains to them that it is something that I do all the time on standing orders.

The pace is hectic. I am constantly being called on to treat someone's pain, take a report on a new patient, answer a family members questions, translate for a doctor, move a heavy patient, do an IV on another child. The rooms are hot and humid. I am sticky with sweat. I make a point to drink as much water from the color as I can to stay hydrated. There are several ceasarians done, one child needs bagging and I am so busy I can only glimpse as my friend helps with the child's breathing, bagging, and then hitting her cupped hand against the infant's back.



We are the last to leave. The babies are all fine, the patients transfered down to the family room, where their family members wil look out for them, bringing clean sheets from home for the old mattreses, brushing their foreheads with moist towels, feeding them home-cooked food. I say good night to them all, and we walk back to the bus, and I feel that today I found my place. I won't get into the OR again, and I won't be there for the delieveries, but I have a job that is important, and I believe I have proved myself.

***

After dinner I go for a walk off the complex with Santiago, one of the Dominicans, Nancy, an OR tech who speaks fluent Spanish, who speaks fluent Spanish, and Alexander, a thoughtful college student, who is also serving as one of the translators. We stop at a roadside bar, which is really no more than an open shack and drink beer by candlelight as we talk in Spanish to the bartender, a beautiful woman, and her children who stand behind the bar with her. I can say it is the best beer I have ever had -- I get a cold liter bottle of Presidente and we click our bottles and I know already that these people will always be my friends for what we are sharing tonight and this week.



We were told that we were coming to a poor country to help people who have nothing, but what I am starting to believe is that while these people may not have financial wealth, they are richer than many of us for their family bonds, for the love they show each other, and for the joy they take in each day, in breathing the clear mountain air. They have laughter and smiles for each other. You cannot call them poor. In the United States, people work too hard to have more than their neighbors, to consume. We spend too little time with our families. Who is poor and who is rich?

First Full Day

In the morning the patients are ready for us. They are lined up outside the hospital doors. A resident asks me to scrub in on the first operation -- a gall bladder removal. I "retract" which means I hold these long metal scoops in the body to pull the muscle facia out of the way to enable the surgeons to better see what they are doing. At one point I have my hand inside the body. The surgery lasts a couple hours. My arms and back feel the tension from holding the retractors. It is hard work. I'm sure if I was a pro at this I would know how to hold in a way that would cause less muscle strain, now I rely on brute strength. While I am holding retraction, the surgeon on the other table asks me to translate what his patient is saying as they induce him to sleep. He says, he's feeling sleepy, I say.

After the operation, I help clean up, emptying the bloody suction canisters, then find myself repeatedly being called on to translate. I can handle most translations easily, the type where I repeat a medical person's commands to a patient or conduct a simple interview, but when they answer rapidly with a prolonged answer, I am sometimes lost. A couple times I have to go find one of the Dominicans to assist.

During lunch, some children have found their way to the back window by the supply room where we have a cooler of water, bannanas, and peanut butter and ham and cheese sandwiches. They call in to us, to get us to talk to them or give them food. We have been warned not to talk to them here or give them anything because if we give it to one, there will soon be a swarm, demanding the same. It is hard not to talk to them. One of the translators, a high school girl, gives them some of her sandwich and talks to them, they immediately start making kissing sounds and telling her they love her.



Later in the afternoon I help the two nurses in pre-op put together IV sets, attaching stopcocks and extensions to the drip sets. They ask me if I know how to do it, I nod, and mention I do it as a paramedic.

That night I wander about the camp siting with various groups. The doctors seem the most laid back. This is a vacation for them. They can practice for the pure joy of practicing. There is no paperwork, no lawyers, no regulations, just pure taking care of people. I listen to them tell stories about the hassles of the American medical system, their fights with insurance companies to get paid, and the rising cost of malpractice. Two of the OBY/GYNs have quit delievering babies due to the exhorbitant premiums.

The nurse anesthetists sit together going over their game plan for the next day and talking shop. They seem the most intense of the group. They have the most to prove, plus in many ways the most responsibility. In many ways they are as misunderstood as paramedics. They are not just nurses who intubate. They do spinal taps, push medicines, and constantly monitor the patient.

The nurses and OR techs seem fairly happy go lucky. Their conversation is more about their families than work.

Many of the doctors have brought college age children, some destined for medical school. They serve as translators and general helpers, as well as scrubbing in on many of the surgeries. They dissapear on long walks.

The Dominicans sit together and play dominoes or talk quietly.

It is nice to have quiet evenings like this. No TV. No hectic bustle.

I sleep well this night.

Shangri-La

After a three hour bus trip up into the mountains that included a land slide that temporaily blocked the road and a near stampede as a herd of cattle met us head on on the road, we arrive at the camp high in the mountains. The camp, despite its primitive living conditions(at least for us) -- two story cement bunkhouses under corrogated roofs with what will turn out to be only occasional electricity, cold showers and sometimes no running water at all, is Shangri-La. The bunkhouses and open air dinning hall under a slanted roof are surrounded by lush green tropical trees, many fruitbearing. The view is spectacular -- green mountains, sometimes shrouded in clouds. We are, in fact, above the clouds.



We take a fifteen minute ride into the town where we enter the hospital for the first time. The initial view is impressive. It looks like a 1950's era building -- one floor, but when we walk in, it is as if it is the hospital of a town that has fled an alien onslaught with just enough time to strip the hospital of most of its equipment.



The place is deserted. The rooms we will use are dark and spare. I am of initial use, standing on a step ladder to change the light bulbs in the cieling.



Paramedic to the rescue!

We set up two operating rooms, a preop, post op room, a post post op room where the families can take care of the patients when they are stable enough to leave post-op, a supply room, and an equipment sterilization room. The anesthetists seem initially puzzled by the ancient machines they will have to use to gas and ventilate the patients. The patient rooms have old stained mattresses, no pillows and no sheets. The only room with is AC is the operating room. The patient rooms appear to have little to no ventilation at all.

Nevertheless by the end of the day the place actually looks like it may work. We'll start seeing patients tomorrow.

Jesus asks me if I want to play pool in the town with him and some of the other Dominicans. I am excited to go, but then the power grid goes out, and so we stay at the camp and play dominoes instead.

I go to bed early. Jesus snores like a snorting bull. The cement room vibrates. He sleeps so soundly despite nearly everyone talking about how unbelivable his snoring is, he does not awaken. One doctor asks if anyone has a hammer.

I sleep poorly, anxious about the next day. The assignment nurse has told me I will be in the OR. While that prospect is interesting, I mention I do speak some Spanish and can do IVs as well, whatever is needed. She says well maybe I can help the nurses out in pre-op translating if I'm not needed in the OR.

"Salta! Salta!"

Packing for a place you have never been is difficult, particuarly when it is an impoverished area. I like to travel light, but I don't want to be without something I need, but won't be able to buy because the nearest Wall Mart is not even in the same country.

I have heard that people just leave their suitcases and many of their clothes behind because the people are so poor so I pack more than I need. Still it is nagging me that I am missing something important.

I wear just a polo shirt and jeans down to the hospital to meet the bus. Everyone else wears jackets and sweatshirts. By the time they gather us for a group photo I am shaking so much, if the photographer doesn't have a fast shutter speed, I am afraid I will appear as a blur in the photo.

The hospital CEO and some other suits are there, which I gather is a first for these trips. They are proud of their employees and have donated many supplies for the opcoming surgeries.

The bus ride to JFK is fine. While everyone is eating at the food court, someone asked me if I have packed toilet paper. Toilet paper? I excuse myself and go to the men's room where for the next fifteen minutes as I unroll and then reroll.

The flight is without event. the ticket agent noting my height was able to reseat us to an area with leg room. My traveling friend is a vegetarian. I get a double order of chicken.

At the Santo Domingo airport, they wave us quickly through customs. Helps to be with a missionary group. I'm thinking about Arlo Guthrie coming into Los Angeleez.

We spot a Dominican in an MMI shirt who nodds vigourously at us. He quickly grabs our bags, throws them on a cart and takes off like a bat out of hell, or maybe like a, in espanol, un ladron. We chase after him.

He's legit. When we catch him, we find him throwing our bags into the back of a truck and he gestures for us to get on the old old yellow school bus next to the truck.

We head for a place called "The Chicken Hilton." It is a waystation campground for various groups. We are sharing it tonight with a teenage church group of Dominicans from an area an hour away.

We will be sleeping in mosquito net shrouded bunks in small concrete rooms. For dinner on open picnic tables, they serve us arroz con pollo, chicken with rice. We get water from a cooler. The local tap water is contaminated.

I sit down with two of the Dominican volunteers and make immediate friends. Jesus is a bullchested thirty-five year old. He is eager to help me with my Spanish. When he shows me his watch is always an hour early because "no queiro estar tarde." He does not want to be late. I mention I like that, he takes it off his wrist and gives it to me. I a have forgotten to take a watch. Still I say no a couple times -- I hardly know Jesus, but finally I take it when he says, "You can remember me by it." His wrist is much thicker than mine, and the watch hangs loosely from my write. I thank him profusely.

After dinner, he introduces me to the pastor of the youth church, and I meet many of the young people. While it pours rain, under the corrugated roof of their open "church," they sing a Dominican version christian gospel rock accompanied by electric guitar that is unbelievably good. I am mesmorized by one young girl as she sings "Salta! Salta!" which means "Jump! Jump!" and they all jump as they sing and shout out praise.



Later I lay in the dark under the mosquito netting. I wonder what the trip will bring, wonder about my role. There are nine doctors, four nurse anesthetists(who will be operating without an anesthesiologist), eight nurses and several OR techs, in addition to some general helpers/interpreters. I sense most of them don't know what a paramedic does. I just want to be useful, but I also know like most I have an ego, and I believe this is a trip where ego will need to be pitched.

Off

I'm off on my trip in about twenty minutes. So no more posts until May 21.

I am ready for a life-altering experience, but will settle for a good time and helping some people.

Freshly Made

There was an article in the paper this morning about the trip.

Medical Team Headed for Surgery Blitz in the Carribean

Medical Team Headed For Surgery Blitz In Caribbean
May 12, 2005
By GARRET CONDON, Courant Staff Writer Things routinely get busy for Dr. Ibrahim Daoud at St. Francis Hospital and Medical Center. But the general surgeon's workload will really go up beginning this weekend.

Daoud is leading a team of 33 doctors, nurses, technicians and interpreters in a one-week blitz of surgery on as many as 150 patients in San Jose de Las Matas, a remote community of 45,000 in the Dominican Republic. The team leaves St. Francis on Friday.

"I usually do about 20 operations a week," said Daoud, who will be making his fifth annual trip to the Dominican Republic. "We're going to be doing - as a team - about 20 a day."

The procedures range from gallbladder surgery to hysterectomies. Each of the participants carries two pieces of luggage, one with clothes and personal necessities, the other stuffed with medical supplies such as gloves and sutures, donated by St. Francis and various drug companies. Daoud's patients have donated $2,150 in cash.

Daoud's team, which is drawn mainly from the ranks of St. Francis employees, is sponsored by Medical Ministry International, a Texas-based evangelical Christian organization that deploys volunteer teams to needy locales throughout the developing world. Although the first priority is healing bodies, some MMI volunteers also tend to willing souls by praying and reading passages from the Bible. Neither prayer nor conversion is a condition for medical care, which is given freely to the poor, said Russell Browder, communications director for MMI.

The medical team will stay in a rustic dormitory during the trip - except on the last night, when it will stay in a hotel in Santo Domingo, the nation's capital. Daoud said he has a waiting list of clinicians and technicians eager to go .


***

Started the day out with a code. Asystole. ALS resucitation for 20 minutes. Intubation. IV. 3 epis. 2 atropines. Still asystole. Called the time.

***

Our state medical advisory committee is working on a state presumption/cessation of resuscitation policy that will require us to call medical control prior to termination. While I support statewide protocols, I am working (unsuccessfuly so far) in opposition to requiring doctor permission fto terminate asystole codes that have gottten their 20 minutes. These patients are dead and are not coming back. If you were guaranteed that the doctor would go along with termination that would be one thing, but when the odds are high that the doctor answering the phone is a moonlighter or someone unfamilar with prehospital protocols, you will inevitably have many of them telling us to continue working the code and bring it on in.

Here's an interesting discussion on the general issue.

Adios, Rampart

***

Did a patient with chronic constipation, got called for a pulled chord at an elderly housing complex, (where the chord switches have a habit of falling down on their own -- and has always we were cancelled before arrival) and a stroke at a nursing home.

***

Had lunch at a Chinesse Buffett. Got there at 11:00 which is the best time of day -- all the food comes out freshly made.

***

Did a diabetic refusal -- a regular. Guy was vising someone's house and dropped his sugar down to 30. I thought I recognized him. It took me three shots to get the IV. I never had a problem with him before.

I think it happened because I semi-trashed another medic this afternoon. I saw a first responder who was on scene at a call I did not go to -- but I heard about both the call and the patient outcome later. I was curious whether it was a hospital screwup, a prehospital screwup, a dual screwup or no screwup at all.

So I asked the guy who was there what the deal with the call was and he told me what he saw.

I asked who the medic was and he told me, and that made some sense to me because the medic was not someone I considered a strong medic and then I told the guy who was there that.

As soon as I said it, I knew I would pay. Throughout my career, I have found that whenever I say anything bad about someone else in EMS, I end up doing something that makes me look bad.

So I go to this call, and with the same first responder I had semi-trashed the other medic too, I blow two not that difficult IVs before finally getting one in. All the time I am thinking, he is sitting there shaking his head at how can I miss these IVs.

A good rule is never to judge anyone unless you were there. There must be a passage in the Bible that would be appropriate. Maybe I will ask some of the more religious mission-goers that. I am always open to self-improvement.

***

Sorry to be so vague in describing the above. As much as I want to record just what it is like to be a medic, there are many areas and things I just can't get into for judgement, fairplay, and liable reasons.

***

One of the newer EMTs just came in for the evening shift. He is a good kid and he often brings pizza, so I just had a slice of pepperoni.

The night crew has been playing lots of good natured practical jokes on him. One night they showed him how the body bag works, rolled him up in it, then, as they had arranged, the horn goes off, and they are dispatched to a train wreck, and unable to disentangle him quickly, they leave for the big bad one.

Another night, after he has fallen alseep in a chair, they pull open the shades, open the windows, pull up two ambulances with their lights off, then all at once, hit all the lights and sirens on, while shining the higbeam spotlights in the kid's eyes. He woke up like Daffy Duck. Who? What? When? Where? Why?

Last week I guess they had him in the back, and pretended to stall on the railroad tracks with the train coming.

There's probably something in the Bible about that too.

But the kid seems very happy to be here. It's a beautiful evening.

I'm happy too. It's crew change. I won't be working again until May 24. I'm off on a grand adventure, and hopefully will have much to report on when I get back.

Preparations

Continued preparations for the trip. Bought some scrubs, got a haircut, mowed my lawn, started packing. I work twelve hours tomorrow, then leave Friday morning. We fly into Santo Domingo, then will bused an hour away to place called the Chicken Hilton, where we will sleep uner mosquito netting, then the next morning take the four hour bus trip into the mountains. Our destination -- San Jose de Las Matas.

San Jose de Las Matas - photos

History of San Jose de Las Matas

Mi Campina

The Establishment/My EMT Assistant

Had my monthly regional council meetings today. We passed out the final version of the new protocols. Then I discussed a memo I wrote outlining the revision process for the next go around, along with ideas about how we could implement some changes quicker. One of the points in the memo was about how to increase provider input.

When I first joined the committee, I found myself saying, no one in the field knows what we do. Just because we do something or pass a policy, doesn't mean everyone knows. My job was to represent the field and see that paramedic voices were heard. A couple weeks ago I was in the EMS room at one of the hospitals talking with the EMS coordinator, when a paramedic began complaining to him that the protocol process was held to close to the vest and the provider input needed to be solicited, the committee needed to listen to people in the street.

I got a little agitated about it. I have always gone out of my way to gather input and do my best to represent the field, but here I was now several years later, the unknown subject of my old complaint. Just because I knew what was going on, didn't mean all the medics in the street knew what was going on. In a way, I have become the establishment. So, anyway, I will make a big effort to increase outreach for the next go around.

We also talked about combining our protocols, BLS, Intermediate and Medic into one book, which, although it will be a lot of work, makes sense.

***

Continued to make preparations for my trip. There will be 29 of us going. 5 surgeons, 2 residents, 3 nurse anesthatists, 8 nurses, 3 surgical/OR techs, 3, general helpers, 3 translators, 1 paramedic (Me) and 1 EMT.

What I will do, I don't know yet. I'm happy to do anything. Give me a mop and I will sweep the floor. Or give me a mop and I will give it to my EMT assistant and tell him to sweep the floor. (Just kidding).

The organization is called
Medical Ministries International.

They do similar trips all over the world. While it is a Christian organization, I was not required to show them my church attendence record when applying. Under describe your faith, I just wrote, "I like to help people." I have always wanted to do something like this, and am thrilled to have the opportunity.

Incense and Blessings

I went to New York City to visit friends who lived in a section of Manhattan that is heavily populated with Dominicans. I got a chance to talk to some Dominicans, and when I went into a bookstore looking for books on the history of the Dominican, I got in a conversation about my trip with the Dominican owner and he would only take $20 for the $24 worth of books I bought and he threw in some incense for free as a gift to me, along with his blessings.

On the train I read a great book called Why the Cocks Fight: Domincans, Haitians and the Fight for Hispanola.

Talking with the Dominican superintendent of my friend's apartment, he echoed what I read in the book that for most of their history the poor in both countries have been disenfranchised and victimized by corrupt governments, and now multinational corporations. The Haitians are treated even worse than Dominicans. It will be interesting to get there and see what it is really like.

I've also been listening to some Dominican music including Juan Luis Guerra: Bachata Rose.

On Saturday I bought two suitcases, one of which will be filled with medical supplies. I leave on Friday. I'll write more about the trip tomorrow.

For What We Might Do

A medic I know likes to say we don't get paid for what we do every day, we get paid for what we might have to do.

This is the second day in a row, I haven't done squat. I had a lady with a nose bleed this morning and an MVA refusal this afternoon. Other than that, I've just been sitting around.

That's probably what the two EMTs in Long Island were doing the other day when they got a call for a chest pain.

Two EMTs Killed in Crash



***

Services Held for Two EMTs
(Aquebogue, Long Island-WABC, May 7, 2005) — Services were held today for two EMTs killed in a horrific ambulance accident on Long Island.

They were rushing a patient to a hospital when the ambulance crashed into a tree in Aquebogue on Tuesday.

A funeral service was held today at St. John's church in Riverhead for 23-year-old Heidi Behr.

She leaves behind a 13-month-old son who suffers from cerebral palsy and epilepsy.

And a memorial service was held in Setauket for 30-year-old William Stone. He was engaged to be married.

Stethoscopes

My new stethoscope came in the mail yesterday. It is a Littmann Cardiology III. Navy Blue 27" Paid $116 for it, plus $9.95 postage.

I bought it because as I have related, I have found myself checking the decreased box under lung sounds on an increasing number of patients lately. I have been putting ear wax remover in my ears the past several nights, and in the shower, squirting warm water in my ears with a syringe. I hope the new scope does the trick.

My first stethoscope was a Sprague that I paid probably $12 for in my first EMT class in 1989. I can remember how excited I was to get it. I also bought a BP cuff and practiced on everyone I knew. Having my own stethescope meant I was really a medical person now. I was on my way to being a healer. I could place it against someone's chest and hear them breathe, hear their heart beat.

But even then, I had trouble with lung sounds. Some are obvious, others you really have to listen to. I bought a tape called lung sounds. You played the tape and pressed your stethoscope against the stereo's speakers and tried to learn what the sounds were. It was hard.

I soon decided I needed a better stethoscope if I was going to be able to do a professional job. My old teacher had said there were two kinds of scopes -- short ones and long ones. The short one was better because it kept you closer to the patient. So I bought that one -- a short Littmann Cardiology II. I was working as an EMT now and it didn't take me long to realize why most of the people I worked with opted for the longer scope. There were some patients you didn't really want to be that close too. Call me uncaring, but a fundamental tenet of EMS is scene safety, and when it comes to gnarly patients, the prudent, the safest bet is to have the longer scope. (Unless you wants bugs falling on you.)

That stethoscope lasted me a number of years, then one day it was gone. I don't remember if I left it somewhere or if it was stolen. I just couldn't find it anywhere. Not in my car, not in my home, not in any of the ambulances, not at the base. Vanished.

I bought another Littmann -- this one the long one. That scope lasted me until about three years ago, when it was stolen. I remembered putting it on the dash at the hospital and when I came out of the hospital, it was gone. A clear cut case of theft.

For the last three years I have been using (off and on) a stethoscope I won in a contest. I don't even know what kind it is -- it is better than the cheap $5 stethescopes the ambulance service provides, but no where near a Littmman. I just didn't feel like laying out another $125 plus. Many times I will misplace the scope and then use the ambulance scopes. I can hear a blood pressure okay. I can verify lung sounds after an intubation. I just can't hear lung sounds to well.

Hopefully, with the ear wax removal treatments and the new Littmann, it will be a new day. If not, I may have to visit an ear doctor.

***

Here's where I bought my scope:

Stethoscopes

Here's a web site on the history of the stethoscope:

History

Here's a web site for lung sounds

Lung Sounds


***

I think wheezing, crackles, and his cousin rhonci are afraid of my new Littmann, as eight and a half hours have gone by without a call. In the meantime, I sit hear sufing the net. Just got this EMS joke from a friend:

Due to a power outage, only one paramedic responded to the call.

The house was very, very dark, so the paramedic asked Kathleen, a 3-year old girl, to hold a flashlight high over her mommy so he could see while he helped deliver the baby. Very diligently Kathleen did as she was asked.

Her mother Heidi pushed and pushed, and after a little while Connor was born. The paramedic lifted him by his little feet and spanked him on his bottom. Connor began to cry. The paramedic then thanked Kathleen for her help and asked the wide-eyed 3-year-old what she thought about what she had just witnessed.

Kathleen quickly responded, "He shouldn't have crawled in there in the first place. Smack his ass again."

***

Somewhere someone must have some fine crackles starting to percolate.

***

Not a call. Littmann undefeated in debut.

Dead Dog

Three calls today. An old lady with a headache, an industrial worker with a gashed chin and a chest pain. While we were taking care of the old lady there was a bad MVA in town where the driver's dog was killed when the driver hit a tree. He was alive, but not in the best of shape. Good thing for seat belts.

***

I got an interesting email today about a new study that shows morphine may cause more harm than good in chest pain patients.


Morphine for chest pain worsens death risk-study

The study can be accessed through the link below:

American Heart Journal article pdf


One of the most interesting aspects of being in EMS now almost seventeen years is how medicine continues to change. As a kid, I used to laugh at the story of how George Washington died because they bled him to death, thinking they were letting the evil humours out, and how they used to put leeches on people. But every year it turns out that things we think are good, may not be -- they are in fact the equivilent of putting leeches on someone or bleeding them to death.

EMS, like much of modern medicince is trying to become more evidence based, and do things not because we think they might work, but because studies prove they work.

One area that has come under attack has been what is called RSI, for rapid sequence intubation, where a patient who needs an airway, is paralyized and sedated. Studies are showing it is causing more harm than good, and many programs are abandoning it. RSI is something the services I work for don't do, and while many medics have advocated for it, I don't see it happening here anytime soon. While securing an airway in a patient who needs one is the gold standard, sometimes the attempt to secure the airway can cause more damage than good. Prolonged hypoxia, misplaced tubes. I've heard horror stories of people breathing perfectly well, getting RSI, the crew not getting the tube, and the patient dying. That's doing harm. It only takes a few cases of harm to outweigh a saved life or two.

I was at my monthly medical advisory meeting and one service demonstrated a new intraosseous device they were considering using, which is like a power drill, it drills the IO right into the bone. See this link:

http://www.vidacare.com/

I went home and on an EMS discussion group I belong to, there was heated debate among doctors about the benefits of IOs at all, particuarly in trauma, where even IV fluids have been questioned. I've only done a few IOs in ten years -- all in kids in cardiac arrest. Some went in easy, one got bent and stuck in the bone. I've heard that services that are adopting the new adult IO devices are finding their medics like to play with the new devices and are "missing" their initial IV attempts to justify using the IO. We all like to play with our toys. I'm glad that some people are paying attention to research.

I will continue to post new research about EMS issues as I encounter it.

Magic Fingers

Met one of my EMS partners at the gym before work and we did upper body training -- chest, back, shoulders, arms. It helps to have a workout partner, though I am finding when I workout with someone else I tend to overdo it a little.

After our first two calls, a lady with pnemonia, then a transfer, we were posted at the west end of town. I went in the back of the ambulance and lay down to stretch out. We were in the old rig they always give me, and it was great with the diessel rocking the ambulance, laying on the bench seat was like being on a vibrating magic fingers mattress without having to put a quarter in the slot. A half hour later, I felt much better.

Did five calls all told. A migrane, a good motor vehicle, where we were the third car in, and a drunk.

At the motor vehicle, I was sent to the car where the patient was just having neck and back pain after being rear-ended -- the other two patients from the other cars went ALS Lights and Sirens to the trauma room. I had the stretcher and was trying to cross the intersection to get to the car. A cop finally saw me, and held his hand up to stop traffic, then looked at me and waved me through. I just stood there, and he got really impatient. "Come on already," he seemed to be saying. I pointed behind him. While he still had his hand up stopping traffic, because he was looking at me and not at them, they were strill going. He finally saw that and got pissed and started yelling at the cars. We finally were able to cross.

The drunk was a regular. There were two empty vodka pints on the sidewalk next to him, another in his back pocket and a fourth in his vest pocket. He'd gotten out of the hospital detox the night before and still had his hospital band on his wrist. We brought him back.

Why Fight?

We get called for a violent psych at the juvenile school. Wait for PD, our dispatcher tells us.

A violent psych at the juvenile school. The last violent psych I had at a juvenile school was a fifty pound ten-year-old who was standing up on top of the cabinents in the principal's office jumping up and down screaming at the top of his lungs after already having thrown all the books that were on top of the cabinent down on the floor. I reached up, plucked him off the cabinents, tucked him under my arm, laid him on the stretcher and wrapped him in a blanket, then told him to knock it off, which surprisingly he did.

When we arrive, a staff member meets us in the hall and asks us if we are familiar with Andy. I am not. Big kid, thirteen years old, autistic, out of control today. They have six people holding him down, he says.

Six people, I think, right. Talk about overkill.

I enter the room, nod to the cop, who is standing by the door. I look about the room, then look down on the ground, where there are indeed six people holding Andy down. Andy is two hundred fifty pounds minimum, maybe two-seventy. He has the muscled shape of a big bear. There is a grown man on each limb, a large grown man leaning over his torso, and another man holding his head down. He looks up, despite the hold the man has on him, and roars. I swear the room shakes.

"You're just one crew?" the cops asks. "You have restraints?"

***

Now when I first took my EMT class many years ago, I wasn't too keen on the section of the course where we practiced restraining patients. I mean I wasn't certain I wasn't going to vomit at the first sight of any icky gore, and I wasn't certain how good I was going to be at wrestling patients. I was as tall as I am now, but not nearly in the shape I am in now. I was sort of skinny and flabby at the same time.

I was lucky that one of my partners when I first stared working was a black belt karate instructor, but other times I worked with tiny women. In the same way I hoped that I never had to deal with the massive chemical hazmat train wreck mutlicasulaty plane crash call, I hoped I wouln't get called for the big guy who wanted to kick my ass.

I cultivated a calm approach, and learned to rely on my voice and on the trait of patience, which I have in fair abundance, and when faced with being patient or getting pummeled, I am always happy to be patient. But there are always some patients who patience doesn't work on. That's why we have cops, but cops don't like to get worked up any more than paramedics.

In recent years, restraining patients has also gone somewhat out of favor due to some tragedies. A couple years ago, our protocols were rewriten to address issues of restraint. In the case of Andy, in my mind, I flip through the first two pages of the protocol to half way down the third page, under the title "Chemical Restraint."

***

"We're going to sedate him," I say.

2 mg Ativan and 5 mg Haldol IM.

He screams when I stick him in the thigh. He presses against his restrainers, tries to spit, but they quickly put a face shield over him. He calls me nasty names.

Then we sit and wait. He settles down for a moment, but any time anyone moves or tries to talk to him, he starts fighting again. Ten minutes go by. He is still angry and yelling. I excuse myself and go out to the ambulance and call medical control. The doctor approves my request for a second dose. "By all means," he says.

Andy nearly throws everyone off him when I hit him in the other thigh.

I sit down in a chair and wait.

A staffer asks what the plan is now.

"I'm going to sit here until he's asleep," I say.

Five minutes later, he starts to snore.

One by one I have each of the restrainers get up. We nudge Andy, and he opens his eyes, and sleepily gets up and lays down on the stretcher like a little boy who has stayed up past his bedtime.

He sleeps all the way to the ER.

Why fight it?

Here's an excellent web site on restraint asphxia:

http://www.charlydmiller.com/RA/RAlibrary.html



***

Only other call was a transfer.

Tired

Day started off with a maternity call. A 20 year old woman with abdominal pain, six months pregnant. This is the third time in the last two weeks she has called 911. She's being treated for the flu and dehydration. The only difference is this morning she isn't feeling the baby moving around in her. We took her up to L&D and they shooed us out before we could find out if they still had a fetal heartbeat.

The women up at L&D are protective of "their" patients to the point they are rude to us. I brought a near delievery up there once, and after we'd moved the woman over to the bed, they asked us to leave the room so they could change the patient like I hadn't already examed her for crowning. You try to give a report and they ignore you and ask the patient questions instead. Unless I have something essential to say, I try to just give an abbreviated report and then leave as quick as I can.

Usually an L&D call is BLS -- patients are rarely iminent delieveries. I used to wait on the floor as my partner would finish the run form, then one day a nurse asked me what I was doing up there. I'm wearing a uniform that says "paramedic." It ought to be self-explanatory. "I just brought in a patient," I said. She looked at me like I needed to give her a further explanation. I pointed to my partner. "I'm waiting for my partner to finish his run form." When that didn't seem to appease her, I added, "So I can sign it." She grunted and walked away then.

Last week we brought up a woman having contractions two minutes apart and were joined in the elevator by a woman in a wheelchair, being pushed by a nurse. We let her go ahead of us at the registration desk. The woman was panting and grimacing. She delievered before we had even gotten our patient to her room. I had a bad feeling about the patient today. I hope everything is alright with the baby.

We did a dsypnea, CHF/asthma, big obese woman with elephant legs that were even more swollen than normal. She was walking out the door when we got there, all done up in a full-length bathrobe and other clothes. I managed to get the bathrobe off before we sat her down on the stretcher, then she plunked herself down. I couldn't hear any lung sounds again. I tried putting earwax remover in my ears last night (I also ordered a new stethescope), but this lady was so fat, I don't think I could have heard even with it. I didn't even try to get IV access. We were a few blocks from the hospital, and her arms were like elephant skin. I asked her where they usually got IVs in her, and she rolled her eyes and said they didn't. She was speaking in full sentences so we just took her in on 02.

Also did a syncope refusal AMA -- old lady who passed out, but was better when we got there, said she just hadn't eaten. She checked out okay, but still I try to always convince syncopes to go, particuarly with no history of it. But she was adament, and that was that. At least she had her daughter with her to call us back if anything happened.

Last call was a nursing home unresponsive. Fever, pnemonia, UTI, hyperglycemia, MRSA -- usual nursing home unresponsive story. I gave her some fluid.

I was tired all day. Tired at the gym this morning and tired at work, now I'm tired at home.

Listening to Bruce Springsteen's new CD. "Devils & Dust."