Tell-Tale Sign

You know they're in trouble when they try to pull the mask off their face and say they can't breathe, they say they are suffocating.

CHF. Congestive Heart Failure.

There are lots of tell-tale signs -- rales, crackling in the lungs, JVD, pedal edema, hypertension, rapid pulse, diaphoresis, inability to lay down, but the clincher is tearing the nonrebreather off.

The next thing you know the foam is coming up.

You better hope the nitro and Lasix work,

Because you're going to be grabbing your scope.

The lady this morning -- I loaded her and flew, did everything on the way. We weren't far out, she got the Lasix as we were just down the street from the hospital. In the ER they gave her another 60, started a nitro drip and got out the intubation tray. They were just about to lay her down when the drugs finally kicked in.

I saw her later and she was doing much better -- exhausted but with just a cannula in her nose.

***

Also did a dizzy weak lady.

Nine Calls

Nine calls in tweleve hours today.

***

Called to a MD's office for a patient with altered LOC and a blood sugar of 18. The doctor was very cool and helpful. He admitted it was interesting for him. While he had many diabetic patients, he rarely got to actually see one in insulin shock, and then see how quickly they come around with D50. I asked the patient if she wanted us to take her to the hospital. Do I have too, I'm at my doctor's office, she said. Dooh! The doctor got her a cookie and called a relative to come pick her up.

***

We did an assault where a woman got in an altercation with her boyfriend, and he ended up getting peppersprayed and she got some in her eyes -- the kids were okay, but they were upset they were going to get taken away from their mother. The mother was upset DCF was going to find out that she had put the kids in a dangerous situation (again).

***

We were sent on a priority one for severe pain to a nursing home. They got all bent out of shape that we parked in fron and not around back where the ambulance entrance was, so we had to drive around to the back. It was pouring rain and there was no awning there. The patient had fallen at six in the morning, and it was now four in the afternoon. They had done an x-ray that showed in the nurse's words, a fractured left lateral femoral condoyle." So we go to the hospital -- not one we routinely transport too. When we arrived, the harried triage nurse was being very sarcastic to a patient who was using her telephone. "You need to get off the phone, get off right now. Off, off off. I need to use the phone. You're supposed to be dizzy, you need to lay back down." She looked at me and asked what we had.

I try to keep my answer short and sweet to start because it seems she just wants to know the down and dirty while she digs among a stack of papers for a triage report form. "A fractured leg," I say.

"And how do we know that?" She says it in such away like I can't say she has a fractured leg because I am just an ambulance person.

"An x-ray."

"How do you have an x-ray?"

"They took one already, read it, and determined she had a fracture."

"And what time did this all happen?"

"This morning. She was being walked to the bathroom and she tripped and fell."

"And it's four o'clock now." I am not certain whether her sarcasm is directed at me, at the patient of life in general, but the sarcasm is so thick, I can't resist.

"Is there something unusual here?"

"Well, yeah. She fell this morning. Let's say she fell at 11:59. Its now four o'clock."

"And that's unusual?"

"Yes. Why didn't she come when she fell?"

"She's from a nursing home."

"So?"

I am tempted to say, "Is this your first day as a triage nurse?"

Normally, the fall occurs several days before and they don't get an xray for a day or two and don't get it read for another day, and don't transport till the day after that when the patient's leg is massively swollen and bruised, and the patient is crying in pain.

"And where is the fracture?" she asks.

"Left lateral femoral condoyle."

She looks at me blankly.

I point to the spot just above her knee. "Right there," I say.

***

We do a presumption. Old woman last seen last night, riggored with livitity lying on the Persian rug. Probably got up from the couch, but never made it to her medic alarm.

***

A syncopal episode at a bar where a bunch of young people were drinking and eating. The woman vomited up her dinner. She talked all the way to the hospital, suggesting possible reasons why she might be sick. Worked out too much, was in a car accident last week, taking a new supplement, had a glass of champange, suffers from anxiety, starting her period, her cousin has low blood sugar, she passed out once five years ago and they couldn't figure out why, she is allergic to nuts she thinks maybe there were nuts in the food, on and on and on.

***

Did a diaylsis transfer and took another patient back to her nursing home after she was brought in for seizures.

***

A fall where a woman slipped off a chair, then wacked her head on the table when she tried to get up.

***

A woman with lung cancer and a recently discovered brain tumor suddenly develops difficulty speaking and right sided weakness. We took her in on a priority. When we got the the hospital, she started having focal seizures.

No Bumps

Picked up a handicapped patient who rolled out of his wheelchair leaving work and bumped his elbow. We were there with about four people from the agency that takes care of disabled patients. They were all talking on cell phones coordinating his trip to the hospital. Who was going to ride in with him. Who would relieve them. Who would hold the blue book with all his info. We took him in no lights no siren. All I did was take his vitals and write the paperwork.

Went to a house where the C0 detector went off. The lady said she had a headache, but the fire department found no C0 readings on their monitor. She said the headache was probably due to something else. Maybe her kids, they had been driving her nuts. She laughed and thanked us for our quick response.

Did a guy with severe back pain. We found him laying over a chair. You couldn't touch him without him screaming. 20 on a 1-10 scale, he said. He got 10 of morphine. He closed his eyes on the way in and felt no bumps.

Sun Spots/ The Pinch

There is a sun spot storm or some other kind of atmospheric flareup going on today because the radios are terrible. Can't hear anything but a lot of garble.

We've done two transfers to start the day. I put the stretcher back in the ambulance while my partner finishes the paperwork inside the nursing home. I notice we are missing our portable 02. I ask my partner if we left it in the nursing home or back at the diaylsis center.

The diaylsis center, he says. He knows right where he set it down.

We clear and tell dispatch we have to go back to diaylsis and get our 02. We hear some static from another car, who I think says they have our 02. Instead of arranging a hookup, dispatch sends us to a motor vehicle. I'm not too comfortable going on a call without portable 02, but it is a nonpriority motor vehicle, so I figure okay, we won't need it on this one. We'll get it later.

By the time we get to the accident on the other side of town traveling with regular traffic, we get canceled. We ask again about the 02, but are sent on a priority one for the unknown. I say we don't have portable 02, the dispatcher says they are holding priority ones. I ask if a supervisor can bring us some 02.

Again, the radios are full of static so I am hoping they are just not getting what I am saying, instead of hearing it and ignoring it. We ask if Fire is going to be at the call, figuring we can use theirs. No, it is a private emergency. I am very uncomfortable about having no 02 going into an unknown. As we put ourselves out on the scene, the dispatcher asks us to let her know if we need a paramedic.

Several years ago they moved our local dispatch to a statewide location. As a result, we don't know the dispatchers well and they don't know us. I have been a paramedic in the city for ten years. The dispatcher ought to know me by my voice. I'm guessing she is new and there is an error on the daily roster sheet that lists our car as BLS. I tell her we are medic truck and she seems pleased that she won't have to send us any help. She has forgotten about our 02, but fortunately a fly car medic that had overheard our distress calls for 02 is pulling up and leaves us a tank, which we use as our patient is diaphoretic with an altered mental status.

We aren't at the hospital fifteen minutes when we get paged for a priority one call. The problem is we still have a patient on our stretcher. Another crew coming in with a patient tells us they are calling for us. What are we going to do?
We get our patient on the bed, but then get a page cancelling us from the call. I am still writing my run form when we get a page for the next call -- another emergency.

We get out to the ambulance and tell them we are clear, and the new dispatcher asks what time we are getting off. I say not until a time four hours away. Okay, he says. I ask about the call we have been given. He sounds puzzled, but then looks at the board and says, yes, there is a call for us. A seizure. He apparently has just come on duty.

We sign on with the city, and they acknowledge us, and since there is no request for an ETA, we assume it is probably no big deal. The fire department is there, and the fireman left with the truck, tells us they are walking the patient down.

I see a mother carrying a child of about four and for a moment I panic. The child appears limp, and I recall a call I did several years ago, where I saw another mother carrying a child, also limp, as she walked with firefighters out of a house and toward our ambulance, and I ran to the child and tore her from her mother's arms, and started CPR and rescue breathing because I knew the child wasn't breathing, and she was in fact, in arrest. I don't quite get that feeling today, but I hurry my step, and when I touch the child she opens her eyes and starts to cry. The firefighter says she had a seizure, full tonic clonic, but that she cries, then goes completely unresponsive. I take the child from the mother and when I lay her down on the stretcher she is out cold. The hand drop smacks her in the face. I open her eyelids. Her eyes are still, seeing nothing. She's breathing though and has a good pulse. The mother is not the mother but a babysitting aunt, and she is very upset. This has never happened to the girl before that she knows of. The girl feels hot. It has to have been a febrile seizure. The fire guys look concerned. I'm concerned, but then I remember an old trick. I take a little bit of skin around the belly, and pinch it lightly, then turn it quickly as I pinch hard.

Wallah! The child opens its eyes and begins crying. It's eyes focus on me in terror.

I feel much better now.

This is a move I learned years ago from an ER physician at the Children's Hopsital. I had come screaming in lights and sirens with an unresponsive kid. The triage nurse was also freaking out when she saw the kid, then the doctor came over and did the pinch. The baby started crying and the doctor smiled and went back to his other patients. Later every time the doctor walked by the room, the kid started screaming again.

Countless times since I have arrived on the scene of unresponsive small children to find every cop car in town there and everyone frantic. I do the pinch, the baby opens its eyes and cries, everything is okay.

Bottom line, the kid has a febrile seizure, which tires the kid out so it just drops off to deep sleep. The pinch brings her back around.

***

Seven calls, two cancelled, the above calls and a pancretitis.

Picnic

Didn't work today. I swapped my regular shift for Tuesday because the Tuesday medic needed the day off. I was going to pick up a city shift, but today they had a reunion picnic for everyone who went on the Dominican trip. It was a beautiful day. We sat out by the pool. They had chicken and pork, and rice and beans. I stopped at Las Americas and bought friend green plantains, cassava, alcuppuria, and sweet plantains stuffed with meat. I also brought twelve Presidentes, of which I had three.

It was great to see everyone and talk about another trip.

Still when you work as much as I do, even a day off can give you withdrawl. If I hadn't had the beers I probably would have called in and asked to work a shift.

World Champion or Flamming Idiot?

Called for a possible stroke. Find a middle aged woman lethargic, skin very warm, blood sugar reads HI, which means over 600. Delayed capillary refill. Pressure 76/40. Heart rate on the monitor - 120. Respiratory rate in the low 30's. Can't get a SAT. History of IDDM and a kidney transplant, with subsequent infection problems.

I put her on a non-rebreather and tell the family I will be doing an IV in the ambulance and giving her some fluid. "You won't get an IV," the daughter says. "She has no veins."

I like a challenge. Patients or their family members often say they have no veins, then when you get one, they are very impressed, but when you miss after they have told you they have no veins, well, you're an idiot. I've been the stud and I've been the idiot.

When I check her out in the ambulance as we head lights and sirens to the hospital, I spot a tiny blue vein on her bicept. Can't feel or see anything else. It is a vein that will only take our tiniest catheter -- a 24, and I manage to pop one in and get a good flash. I hook up a bag of Saline, and by the time we are at the hospital I have run in 250 ccs. Not as much fluid as she needs, but better than nothing, and she has access for the IV insulin she needs.

I have patched ahead, and we are quickly hustled to a critical care room, where we are greeted by doctors and staff. Someone says they need to try to get another IV.

"Let a paramedic do it," a flight medic says. "Get me a 18 or a 16."

I am standing there watching as I write my report. This I have to see to believe. Either this guy is the world champion IV master or he is not just an idiot, but a flamming idiot.

He puts a tourniquet around the woman's forearm, and then getting the 16 needle from a nurse, pats the woman's wrist, then plunges the huge needle in. He digs around. Nothing.

"I'm going to put a central line in," the doctor says.

The medic takes the needle out, then to my surprise plunges it back in -- the same needle. He roots around some more.

"I'm concerned she's really not reacting to your poking," the doctor says.

The medic pulls the needle out, and announces, "She's completely shut down."

I guess he was the latter of the two.

On her healthiest day, you couldn't put a 16 into her wrist.

The woman goes up to the ICU in DKA, diabetic ketoacidosis.

***

Called to a Doctor's office for anaphalactic reaction. Find a woman with a swollen face, an itchy rash and difficulty swallowing. They have given her bendryl and a steroid called kenolog. She had IV dye three days ago, but can't think of anything else that might be affecting her. The rash started two nights ago and got suddenly worse this morning. The nurse says the woman had stridor when she came in and a face more swollen than it is now. When she gets anxious and says she feels her throat tightening and can't swallow, I give her .3mg epi SQ.

She says she feels a little better. Her vitals are all good and she is moving air.

Strange case. I can't believe the IV dye from three days ago is causing the reaction.

***

Do a seizure -- a guy I have taken care of before. He has had epilepsy since he was a baby and has 10-14 seizures a month. They have given up trying to regulate his meds. He normally doesn't go to the hospital after a seizure, but today he hit his head and has a lac that needs some stitches.

He tells me he thinks the epilepsy came from a doctor's error when he was in the womb. They thought his mother had had a miscarriage so when they went to vaccum her out, they bonked him in the head. At least he didn't get sucked out. A bad news/good news story.

Direct Admit/I Did?

Doctor's offices. There are many of them in the town where I work. The normal way I handle them is go in, get the report -- either from the doctor himself or the nurse if the doctor chooses to delegate the task to a nurse. Put the patient on the stretcher (put them on 02 and/or the monitor if they are in distress), take them down to the ambulance, put them in the back, then do what I need to do. I try to avoid working a patient in a doctor's office. I like to be on my own turf.

Lately I have had a couple calls that pose a small dilemna. I get called to a doctor's office for patients who the doctor decides he wants directly admitted to his service in the hospital. Now technically when 911 is activated, you are supposed to transport to the ED, not to a floor. But if you refuse to transport them, it just causes a rash of complications. Mainly you have to sit and wait for a commercial ambulance to come, and they will only do direct admits if the transports are approved by the patient's insurance company, which takes more time. What I have done on some occasions, is just transport the patient to the ED, and when I get to the ED, tell them the patient may be a direct admit to whatever floor. They call the floor, confirm it is a direct admit, then I bring the patient up. To the floor via the ED. Works for me and works for my paperwork.

The dilemna is when you have a cardiac patient, having a cardiac problem, and you go from a cardiologist's office to a cardiology floor. This is what I had today. Patient not feeling well with a pulse of 32, slow afib, dizzy when standing, pressure 88/40, good cap refill, hands and face warm.

What did I do? Put him on 02 in the office, then in the ambulance, put in a line, gave him a little fluid, and did a 12 lead. He probably could have used some atropine. If he was going to the ER from home I would have given it to him, but I felt that I would be going around the cardiologist's back giving it to him on a trip that in reality is a transfer from the doctor to himself.

I feel like I used common sense -- and the floor nurse appreciated the line, but I am a little uneasy on these types of calls. I don't ever want to give a drug because I can, but on the other hand -- here was this guy from all I could see in the notes didn't even get his BP taken, and who could have used some 02. The doctor didn't give me orders for oxygen and I gave that. He probably has no idea that we even carry drugs. I don't know. I get the patient there okay. If he had any change in his condition, I would have done what was neccessary.

***

Only other call today was for an abd pain at the Alzhiemer's Home. The patient had no idea why we were there. "You had abdominal pain earlier?" I asked. "I did?" she replied.

This happens all the time at this one nursing home.

Her vitals were all fine. "What have I done to deserve this treatment?" she protested as we put her on the stretcher. "Unhand me. Unhand me right now!"

A Break

Did two calls -- a nursing home patient with pnemonia and a patient from home who was dehydrated. Five hours into a twelve hour shift my partner wasn't feeling well so she went home. They had no one to work with me so I sat around for three hours finishing the poker book I have been reading. They told me I could go home if I wanted, so I said okay. I did a power workout at the gym this morning, which left me worn out, and I have to be up to work tomorrow at 6 A.M.

So I'm home early, eating leftovers, watching the Red Sox game and playing some on-line poker -- all very relaxing.

"I Can't Find My Son!"

Ahead we see two state police cars and two private vehicles pulled over on the left side of the highway. Another car has gone off the road and into the trees on the median. We can only see the rear bumper sticking out from the green vegatation and branches. The people near the car suddenly look frantic. A large man is holding his arms out bellowing to the heavens. The others scatter and start searching the bushes. We are out and advancing toward the car.

"He's missing his boy," one of the private citizens there says. "He had his boy with him and he can't find him."

People are fanning out looking in the bushes. I watch the man at the center of the scene -- the father -- the driver. He is fat, sloppily dressed. He is sweating profusely. It's hot out, but not that hot. I ask him if he is okay. He says he's fine. "My son! My son!" he shouts. "I can't find my son."

I feel his pulse. He is banging away at 140-150. I ask him about the accident. He says a car cut him off and he had to swerve to avoid it. I look at the car. The windows are all closed. There is little damage. He is lucky the branches and bushes slowed the car. There is no invasion. No deformity to the steering column, No starrring of the windshield. In the backseat there is an empty child seat.

"No, no, wait a minute," the man now announces to the state trooper who is talking urgently into his radio. "He's not in the car. He's at home. I forgot. I got confused."

The trooper looks relieved, then angry. The word is quickly passed to the searchers.

What follows is the man being questioned, a phone call made to confirm the boy is safe at home, the man being spread against the car and patted down. He denies any drug use. Well, at least not for a couple months. Well not today anyway. The needle marks and bruise under his wrist are old, he says. A couple days. What about the needle in the car? He was going to buy drugs, but then he changed his mind. His story keeps changing. They get word he's also driving on a suspended license.

His eyes shift from one trooper to the next to us.

His pupils are pinpoint. Sweat is pouring off of him.

"You need to go to the hospital," I say.

I'm fine, he says. I was just confused.

"No, the officer says. "You need to go to the hospital."

"Listen to what the officer is saying," I say. "Make the smart choice and go to the hospital with us. You don't want the alternative right now."

He quickly says, okay.

We c-spine him and take him in. His heart rate is in the 130's. His pressure 180/110. I put in a lock and draw bloods.

When we are leaving the hospital, the state trooper is walking in.

***

Did a stabbing to the arm, a weakness in a diaylsis patient, and a man who had a tool box fall on his hand and gouge a small chunk out.

***

I told my partner about the call I had the other day with the guy who coded. He says there is a new drug out called "Black." It has heroin, cocaine and PCP all mixed together. The guy, just out of prison, probably wanted to party, and his body wasn't used to the stuff. I talked with the ER doctor about it and he told me he got a chance to talk to some of the guy's friends afterwards and they said he did a ton of drugs.

The Plan/Nothing

Lady falls coming down the front steps, carrying her baby. She twists suddenly as she falls so she will land on her back, and protect the baby. She does, but she hears a snap in her ankle and is in severe pain -- lying there on the front lawn.

I don't need an X-Ray to see it is broken. 10 out of 10 on the pain scale. No allergies. Medication time. She weighs 200 pounds. I give her 5 of Morphine. It takes the pain down to a 7, but she is considerably calmer. My routine has always been to give 5, wait a few minutes, then move the patient, and then give them more if they need it in the ambulance. Today I decide to give her another 3 before we move her. I can do that now under the new weight-based protocols. I give it to her. We wait. She has been having a conversation with the neighbors. All of sudden she says something about not buying ice cream sandwiches, when she starts laughing. The laugh does not end. It goes on and on. She is laughing so hard I am worried she is going to pee herself.

"Looks like the Morphine is working," her neighbor says.

In the ambulance, I give her the last milligram allowable under standing orders. She is still cracking herself up. She isn't thinking about the pain. And that was the plan.

***

An hour to go before crew change and we hear a basic unit call for a medic for the diabetic. The dispatcher tries to rouse the precepting crew, but they are in the hospital. They call us.

When we arrive, the fire department says the BLS crew is bringing the guy down on a stair chair. The fire fighter says the man doesn't have a diabetic problem, but is on meth. I get my first glimpse of the patient as the crew say he is on methadone, not meth-ampedamine. They also say he is a diabetic who did heroin today. His pupils are constricted. His brow is warm and dry, but his hands are cool. He answers me, but I can't understand what he is saying. He has some white foam on his lips.

I get him in the back of the ambulance. I can't get a BP, but then use the monitor's BP and it says 109/54 and he is chugging along in a sinus tack at 120. I'm not certain if I trust the BP, but with a sinus tack, it seems reasonable that he has a BP.

I have my partner start toward the hospital on a non-priority. We are not that far from the hospital -- maybe four or five minutes out -- and I figure it will give me time to check his sugar and give him D50 or narcan or both if needed, along with some fluid. I prick his finger, and he starts waving his finger, and I have to tell him to hold still so I can touch the glucometer to the blood on his finger to check the sugar.

It is 224. No problem there.

I look for an IV, but he has no veins. I jab him in the AC, and fish around, and get nothing, then look up at because I am concerned he is not really reacting to my fishing around with the needle. I look at the monitor and am confused that his rate is down to 60. His respiratory rate is down to about 6. I draw up some narcan, and hit him with it, but he does not react.

I tell the rider I have with me to drop him down and start bagging him. I tell my partner to step it up to a one and call the hospital to patch for me. His heart rate is dropping. I quick get out my intubation kit, and tell the rider to switch places with me.

By the time I have my blade out he is down to 20. The man has buck teeth, but some cric pressure from the rider, puts the chords into view and I sink the tube. I am expecting his rate to pick up by now, and it does briefly. We're pulling into the hospital now. "Start CPR," I say. He has no pulses.

I push some epi and atropine down the tube, and that picks the rate up back into the 60's, but still no pulses.

In the ER, they try get a central line and try everything. Epi, Atropine, Bicarb, Calcium, Narcan, D50.

Nothing.

Dead.

***

Did five calls. Besides the above two, did a seizure, a diaylsis transfer, and a COPDer.

Out of Here

Get woken from a sound sleep for insulin shock at a nursing home. The patient just got out of the hospital following a stay for increasing edema throughout her body and increasing dementia. They have already given her 2 milligrams of glucagon with no effect. She is cold and clammy with junky lungs and drool in her mouth. Her blood sugar is laess than 20. On the paperwork they give me she has a list of 15 diagnoses. She is also a full code -- take all heroic measures.

I get an IV in her arm and give her 25 grams of D50. She wakes up and starts thrashing. The IV line comes loose and blood flows out until I can refasten it. I end up giving her almost another amp.

She is alert for her now which is a state of complete dementia, where she makes a fist and tries to punch me and talks like a two year old. When I am not looking she grabs my skin hard and pinches me. I yell at her to cut it out. We're in the ambulance now headed to the hospital. Her lungs still sound junky and she is wheezing, but her saturation is okay and she doesn't appear in too much distress. I try to put the oxygen that she has torn off, back on her, but she tears it off again.

This is probably about the fourth time I have transported her. I remember the snarled lip, the clenched fist held out ready to punch like an archer with bow drawn.

She trys to get loose from the straps.

"Where are you going to go?" I say. "Where are you trying to get too?"

Anywhere -- out of here.

Calls

Two decent calls to start the day:

Call number 1: End Stage Renal Dialysis Patient with decreasing LOC over two weeks, now barely consious with no plapable pulse and irregular respirations. Family has signed DNR papers, but MD hasn't signed them yet. I can't feel a pulse or head a BP either. The monitor gets BP's between 119/70 and 74/40 so who is to say. The monitor shows a bifascicular block at a rate of 108. No IV access. Respirations between 6 and 14, irregular with periods of apnea.

I keep him on a non-rebreather, check his sugar -- its 220, and take him to the hospital. I don't stick him because I can see or feel nothing. I don't try to tube him because even though his doctor hasn't signed his DNR, for all intents and purposes those are his family's wishes, and at the hospital they can call the family and the doctor. If he stops breathing. I'll bag him. I like to be aggresive with the airway, but I also believe in letting people go gently when it is there time( and their family agrees), not showing a steel blade in their throat and pricking them just to make a vain attempt them.

At the hospital, they call IV down, but they have no luck. The doctor is putting in a central line as I am leaving. The patient's still on a non-rebreather. They have a call in to the patient's doctor.

***

Call Number 2. Lady recently discharged from nursing home following bout of pneumonia.She lives in a elderly housing complex and the woman there with her I think is a nurse, but she may just be an housing director, who thinks she is a nurse. I don't know. She takes a BP and pulse and calls us because her BP is 80 and her pulse is 80 also, when it normally is 60 she says. The woman appears in no distress, although she says she feels weak. I listen to her lungs -- nice and clear.

Every one has their own routine for doing calls. When I first started I always took a blood pressure and pulse and counted respirations at the patient side. Now I tend to do it in the ambulance unless something in particular merits it. The nurse/Housing director has just told me her vital signs, the woman is in no distress, her skin is warm. I have the woman help me get her into a johnny top, then I take her out to the ambulance.

As we start toward the hospital, I have the EMT riding in the back with me take a blood pressure and do a SAT, while I put in an IV. The pressure is 110/60. The SAT - 97%. I put her on the monitor and whalla -- she is cranking along in a rapid afib at 160. There is no notation in the paperwork of afib. She is on metoporol. She has HTN. No mention of afib. Not on any blood thinners. I ask her if she has ever been told she has afib. She looks very puzzled by the word. I give her some Cardizem and the rate slows right down to the 60-80 range. I hang a drip. She says she feels better. We continue on to the hospital. All stays well.

***

Rest of the day -- a medical alarm false alarm no one home, an asthma and an abd pain. They had no one to work the overnight so I am staying until six in the morning. I hope its quiet

7.5 milligrams/Yucca Root

We get sent for a lady who dislocated her hip. The regional Dispatch EMD tells us to go BLS cold. I rarely ask them questions back, but this time I ask, "Is the person in any pain?" They say the caller is not with the patient. BLS cold.

That just doesn't seem right. Dislocated hips are almost always painful.

We're coming back from another call when this one comes in. It takes us nine minutes to get there going without lights or siren.

The lady is in tears when we arrive. She is 10 out of 10 on the pain scale.

I give her 5 mg of morphine sitting in the car, let it set in a bit, then move her to the stretcher. She is still feeling the pain. In the ambulance, I ask her her weight. 169, she says. I calculate that out so at .1mg/kg I can give her up to 7.5 on standing order rounded off. I give her the additional 2.5. I am excited because this is the first time I have been able to give the higher dose on standing orders since the new protocol when into effect on June 1.

She says she is down to a 7 on the pain scale, but she seems pretty calm now, no longer clenching her teeth. I have found many people say they still have pain after morphine, but often I don't believe it is as severe as they say, beacuse they look pretty darn peaceful compared to how I find them initially. And they talk slowly and have a glazed look in their eyes.

I tell the woman I have given her all I am allowed to give without consulting the doctor. Would she like me to call the doctor to get her some more pain relief. "Wait till the hospital," she whispers.

She even sleeps some on the way to the hospital. It is rush hour and with all the construction downtown and that fact tht we are going to the southern most hospital, it takes awhile to get there. Total transport time is 35 minutes. I gave her the last 2.5 of morphine en route at 4:15. We don't get her to the hospital until 4:47, and then, thanks to a long line at triage, not into the room until almost 5:10.

They want us to put her on an xray frame, but we can't find one. Often if I can't find one, I will move the patient anyway and they can transfer them later when they find one. We normally can't wait. But this woman is starting to feel her pain again, and it will be too hard to move her to the bed, then after lift her up and slid a frame under her. I go back and look again, searching all the supply closets. I find the nurse and ask what he wants me to do. We have to have a frame, he says. No one can find one. They finally send a tech off to a distant section of the ER to find one. In the meantime, the woman is crying again, and moaning, please, please help me. And I am feeling like a bad guy for not taking her pain away.

The thing of it is, I got the regional protocol changed so patient's could get weight appropriate relief faster without having to call medical control, but if the protocol hadn't been changed, after 5 mg, I would have called for an additional 5, and she would have gotten 10 instead of the 7.5. I should have called for more. Then I could proably given her 12.5 and she'd be feeling no pain then. Why was I even asking her if she wanted more. I should have just taken the pain away. Called and gotten the dose needed. Here it is now almost an hour since I gave her the medicine and it is wearing off.

I tell the nurse about her pain coming back, and he goes off, then comes back with a syringe, and shoots her up with more medicine. We finally, get a frame and move her, but she still looks uncomfortable. I'm hoping the fresh medicine will kick in soon.

Bottom line. Just yesterday, I was swearing I would be the man, take their pain away, sell them on the curing powers of my wares. And again, I let them down.

Tomorrow, tomorrow will be different.

***

Did a lift assist, a canceled call, and a lady with a skin tear that basically took half the skin off her forearm, exposing fat and muscle. Nasty looking.

***

I was in a bit of a foul mood today. When I get tired, I am easily agitated. I don't know if it is not getting enough sleep or not eating enough. At the lift assist I was abrupt with the woman who just wanted her husband lifted from one wheelchir to another because the first wheel chair had a problem with the wheel. He's heavy, she said. Don't drop him, you'll need the hoyer. You can't do it, by yourself.

"Yes, I can," I said, then snapped at my partner for fumbling with the man's legs when I lifted the man up from under the shoulders. We moved him fine. My partner was sweet with the lady and man. I just went outside to the ambulance and got the glucometer and checked my sugar, I have never had a problem with sugar, but was looking for an answer as to why I had a headache and was crabby.

98.

Nothing wrong with that.

I will tell you those little finger prickers hurt. I would rather have an IV then one of those little bee stings in my finger tip.

I ordered a pepperoni pizza, hoping the fat and carbs would help my brain. The pizza didn't help much. I took a little nap this afternoon, then for dinner ordered take-out from the Hospital's EMS room phone to the Comerio, where I got stewed codfish, root vegetables(Yucca, boiled bananna and plaintain) and tostones. Didn't get to eat them until just now, and didn't start feeling better until I ate the Yucca root.

Yucca Root

Yucca serves as a blood purifier. (Maybe I should try to get Yucca extract added to the EMS formulary.) I feel a little better, but think sleep will probably be what I really need.

The Man - Check it out!

Three calls today. A man who dropped a steel beam on his foot and smashed it. A minor MVA with neck pain, and a school child who had an hour long episode of lethargy, not unlike a postictal state, except there was no witnessed seizure. We gave the first guy morphine, we boarded the second, and just provided supportive care to the boy, who returned to alertness with us.

Our White Cloud nurse rode with us today so I was glad to see she got three calls.

***

The steel beam guy was sitting on the cement floor when we entered the warehouse and he looked to be trying to hold back tears. I took his boot off and looked at his foot, and, at first, it didn't look too bad to me, then he said, "My toe don't go that way." His big toe was a little bit askew and when I took off the other boot and compared, it was obvious. One big toe was pointing at twelve o clock, the other at almost three. It also looked flatter by about a third. It hurt when I touched it.

We got him in the back, and I asked him how bad his pain was and if he had any allergies. I like to be aggressive with pain control. He said he was okay. I offered the morphine again, and he said, "What's it going to do? Put me out?"

"It's just going to take the edge off," I said.

"I don't want any needles," he said. "I'll be all right."

So I let my partner tech the call. My partner later told me as soon as I stepped out of the back, the man said, "This pain is baad!"

Fortunately, on our way to the hospital we passed the ambulance quarters where I saw the White Cloud, our nothing ever happens when she works paramedic student. I waved to her to hop on, which she did. I started back toward the hospital and not a minute later I saw a car barrelling up behind me, trying to pass, then driving along side me like we were neck and neck at Daytona. I glanced angrily at the driver and saw in the passenger seat my 8:00 partner. So I pulled over -- there were no other cars on the street, and I had her get behind the wheel, while I went in back, and the tech in back got in her car and was driven back to the base so he could go to his other job.

So now in the back with the medic student, I had an opportunity to press the guy again on his pain, and the both of us were able to get him to agree to get a little relief, so we gave him 3 of morphine. I was planning to give him more, but he felt a little flushing with it, and so refused anymore. By the time we got to the hospital, the pain was getting even worse.

It turns out he broke his foot.

The point of writing all this is so many patients try to be stoic at first. And while I am much more aggressive with pain management than I used to be, I need to be more so. There is no need for people to suffer trying to be macho.

When he said to my partner that his toe really hurt when I got out of the back, my partner said to him. "Dude, you just told him, it didn't hurt!"

He could tell my partner about the pain, but not me because I was the authority figure -- the Man.

But the Man needs to do his job and sell drugs to his patients that they need.

"Hey Check it! Check it! I got Blue Star, man, Blue Star. Ths stuff is premo, premo, man. Code Three rating, man. I got the best, right here, man, right here! Check it! Check it out!"

Federal Leadership of Emergency Medical Services

There is some brewing activity in Washington to finally give EMS the federal attention it deserves. It has largely been overshadowed by Police and Fire. What follows is an intereseting article on the issue and a link to a new federal report.

***

Tension Between Emergency Medical Crews and Firefighters Stays on Simmer
By Eileen Sullivan, CQ Staff

From pay disparities to what they see as a lack of respect for their mission, emergency medical services providers say they have felt slighted by firefighters for years. In normal times, public service rivalries like these would be the stuff of firehouse sessions and city council meetings. But now, a prominent think tank’s recommendation that emergency medical services (EMS) providers get more money and clout has turned up the heat. It began in May, when George Washington University’s Homeland Security Policy Institute recommended moving EMS into the Department of Homeland Security (DHS) from the Transportation Department’s National Highway Traffic Safety Administration (NHTSA). The idea would be to create a separate program, similar to the U.S. Fire Administration, which was moved into DHS along with the Federal Emergency Management Agency (FEMA) when the department was formed in 2003. Friction from the recommendation garnered the attention of the House Homeland Security Committee, which may hold a hearing on the issue. One hurdle the committee will have to clear is the sticky question of exactly what an EMS provider is. Some say it is a state-certified, medical responder who arrives at the scene of an emergency and treats patients. Others say it is anyone with state certification to handle an emergency, including workers with private ambulance and organ transport services.

A History of Friction

EMS came on the scene as an organization in the 1970s, making it the youngest of the three first responder groups, which includes police and fire, by hundreds of years. As fire departments began to respond to fewer fires and more medical emergencies, it made sense to combine EMS with fire, experts say, although not all communities chose to do so. Currently, 44 percent of EMS providers are located in fire departments. The rest are private, hospital-based or housed in a separate government agency. There is not one correct way to organize EMS, and this has led to some of the tension between EMS and fire, said Jeff Dyar, the EMS chairman at the U.S. Fire Administration’s National Fire Academy in Emmitsburg, Md., from 1992 to 2003. “There’s always been turf battles about who should house that function, how it should be dealt with,” Dyar said in a telephone interview. “Fire thinks they do it [EMS] best. Private [EMS providers] think they do it best. Hospitals think they do it best. That all leads up to competition on the street.” Philosophical differences about whether EMS is part of a fire department’s mission also causes tension, Dyar said. “[Some departments] tend to say fire departments just fight fires,” he said. Larger, more established departments in cities such as New York tend to have this view, he said. However, some departments, like Phoenix’s, have embraced the EMS mission, realizing it is most of what they do. “With fire protection efforts, improved fire codes, fewer people smoking, the number of fire suppression runs has dropped dramatically in the past 20 years,” said Dan Rosenbaum, editor of fireEMS, a New Jersey-based magazine. About 80 percent of the calls fire departments respond to are medical emergencies, Rosenbaum said. “When fire departments began taking over EMS departments . . . you had a significant culture clash,” he said. “You had the guys who walked into the burning buildings and the guys who didn’t. Now, more fire departments are cross-training firefighters and EMS providers,” said Jeff Zack, spokesman for the International Association of Fire Fighters, a union. “It’s the future of the entire emergency response system,” he said. “The most efficient way to provide EMS services is through the fire service.” It is important to realize that EMS is still comparatively new on the first responder scene, Rosenbaum said. “Some of what we’re seeing now is growing pains, which doesn’t make them less painful,” he said.

More Clout

The EMS office in the Department of Transportation is staffed with eight full-time employees, according to NHTSA. In the fiscal 2006 budget, EMS is lumped in with $74 million in highway safety programs. The George Washington University study recommended that EMS be moved to DHS to bring it into the homeland security community. “Catastrophic events such as terrorist attacks will demand significant resources and specialized capabilities from first responders,” according to the GWU report. “However, even in a post-9/11 environment, a fundamental component of the first responder community, Emergency Medical Services (EMS) is a missing piece of the preparedness puzzle. Today, EMS needs a seat at the table as first responder policy, funding and operations are debated at the federal level. NHTSA would not comment on the GWU proposal. Proponents of the move argue that the EMS community is too fragmented and does not receive the attention or funding it deserves. “We are the left-alone public safety entity that’s not getting any attention, and we’re doing the bulk of the work in the United States,” said Donald Walsh, assistant deputy commissioner for EMS in the Chicago Fire Department. “DOT has been working their hardest with the resources they have,” he said. But put EMS under homeland security with the rest of the public safety community.” Consolidating federal EMS functions may be in order, said a Homeland Security Committee staff member, who asked to remain anonymous. “Everyone recognizes EMS is not getting the amount of attention they deserve,” he said, but the GWU proposal to create a separate office within DHS might not be the solution. “You don’t want to pit first responder groups against each other.” Some say it’s a little late for that.

Rescue Me

The complaints of EMS providers in Washington mirror those of providers in other communities. Two D.C. EMS officials, both of whom spoke on condition of anonymity, say they do not get the respect they deserve from the fire department, in which they are based. There is a feeling that you don’t belong, that you’re tolerated, one said. Firefighters, the officials said, seem to think their jobs are more important than EMS. The difference in pay contributes to this perception, they said. An EMS lieutenant in the District gets paid between $43,690 and $57,005 annually, whereas a fire lieutenant is paid between $61,920 and $93,534, according to statistics from the EMS Officers Association. Where firefighters make more money, it’s because they work hard and negotiate good contracts, said Zack, of the International Association of Fire Fighters.

One of the Washington EMS officials said, however, “Our hazards are as great as police and fire. What’s simple to me is hooking up a hose to a truck and spraying it on a building.” His colleague added, “Give us our fair share, that’s all.”

***

Click here to download a copy of federal Report.

Back to the Future: An Agenda for Federal Leadership of Emergency Medical Services

***

I have some run-ins over the years with fire departments, but in most cases, it was either a run-in with a badly designed system or with a particular individual, as opposed to a problem with a group of people. Years ago when I worked as a volunteer, the fire department was feuding with the ambulance, more of a clash between the two people heading each organization -- long-time small town foes than anything. The problem was the fire chief used his authority as head of the overall scene to control what the ambulance did, when he would have been better to just let EMS do what EMS does. I remember several times being denied access to patients in cars that in other towns, the fire department would routinely let us get right in the car and with the patient. Not here-- the scene wasn't safe for us, they said. Yeah, right. Fortunately, now I only rarely function anywhere where the fire department gives me any kind of problem. In the city, they are very helpful. The only problem I have with them is they often get dispatched before us, get better dispatch information and get all the credit in the paper when their role is really often just one of assisting us. Rarely do we venture into a town where the fire department has paramedics who are in charge. There we must allow the fireman to enter our ambulance and call the shots even if we are there first and have everything under control. Fortunately, I know many of the fire medics there, and have never had a problem. Other people have, but I guess that comes with the territory.

I have nothing against fire. I wish that there were departments in this state where instead of crosstraining people as firefighters and medics, they had a role for just medics. I personnaly think that paramedicine is complex enough that it demands a person's total attention. People who serve as medics should be first and foremost medics. They should be medical specialists. That's just my opinion.

Day Off

Spent the day cleaning the house, doing laundry. I went to the gymn. Ran a few errands. Studied some Spanish. Got the mail. More bills -- car taxes, monthly gymn fee, phone bill. Took a short nap. Played some online poker. Watched the Red Sox sweep the Reds. Aim to get to bed soon. Hoping the Pirates hold off the Yankees. Two outs in the 9th. Damn. They tied it. Extra innings. I'm going to bed.

Are you Feeling Me?

We're sent for a difficulty breathing. As we arrive, we see a police car blocking the street and two fire engines. A fireman tells us there is a downed power wire and we should swing around the block to approach the address from the other side. Because of a dead end street our trip around the block is more like a trip around four blocks, and we have to go around a cemetary. As we race past, we see a man on a bicycle, laying on the ground, who looks like he is trying to get up, but can't, and another man seems to be trying to flag us down. Since we are already en route on a priority to a difficult breathing we are committed to that call and cannot stop. I call it in on the radio instead.

The difficulty breathing turns out to be nothing. It takes us several minutes along with the fire department to find the caller, and we finally discover it is a woman on home 02, who has had to switch to her portable because of the power failure, and she is worried her 02 will run out. She has over 500 lpms in her E size tank, which she is only running at 1.5 liters. I estimate she has an hour and a half left. While we are explaining that we do not refill oxygen for people, and are helping her get the number for her oxygen company, the radio dispatches a car for a shooting nearbye. I'm am wondering if the guy we saw on the downed bike was shot. As we hear sirens all through the neighborhood, we finally get the woman's daughter to agree to take her mother to the hospital or call us back if the oxygen company does not come or the power does not come back on before the tank runs completely out.

On the radio, they have not found the shooting victim, and they ask us about the guy on the bike. We say we'll go around the corner and see if he is still there. We find the police out with a man in the general vicinity. We spot the bike laying against a fence. The man is not shot, but he has a huge hematoma on the side of his face, and he is talking jibberish. He has alcohol on his breath. As near as we can figure out, he got jumped by two men. The jibberish seems to be a combination of alcohol and Southern dialect that reminds me of the guy named Leroy Wells who tried out this year for American Idol.

Leroy Wells Audition

He was from Lousiana and was completely incomprehensible, except when he said, "Can you Dig it?" This guy talks on and on, and then says, "Are you feeling me?"

The cops are cracking up. I think the guy is just drunk, but he has a huge hematoma and I can't rule out that his brains haven't been scrambled because when I ask him simple questions like his social security number, I get a long stuttering bebop type answer that ends with him saying, "Are you feeling me, dawg?"

We finally convince him to go to the hospital. He is concerned about his bike, which has a smashed front wheel. We resolve the issue by hiding it in the bushes on the other side of the cemetary fence, and promising to write its location down so he can retrieve it the next day.

"They jumped me dawg," he says, "But I fought back. I made them feel me," he says.

"Well, maybe we'll find them at the hospital," I say.

And then he starts to laugh, and goes on to another long uncomprehensible riff.

"I feel you," I say.

"That's right, tell me now," he says offering me a soul shake, and then he goes back to his own language, but at least he is smiling, his semitoothless smile. "Maybe they can check my teef," he says.

We take him to the hospital.

***

Did two transfers, an OD, and a non person home medical alarm.

I went to this great vegetarian Rastafarian restaurant, and got dinner -- rice and peas, stew peas, potatoes, and two kinds of funky vegetarian entrees. All very good. And healthy. The Spanish food, which I also like tends to be mainly fried or fatty.

I'm off tomorrow.

Have to get back to the gymn.

I'm Glad I Wasn't There

Medics like to be on great calls. For all the I want a quiet day talk, when all is said and done, medics want to be challenged, they want to be able to point to the big call and how they handled it. They may not want it every day -- in fact I am sure they don't, but they need a few jewels under their belt to define themselves.

And then there are those calls you hear about that all you can think is I'm glad I wasn't there. Here's one of them:

(Now I wasn't there and have only heard preliminary reports about it, but I was almost there. I just missed it. And because I don't have a first person account, I'm only going to lay out the situation. And in doing that I might not even have the facts right, but that's not what matters. What matters is a situation I would want no part of.)

Young person has their jaw wired shut post surgery I'm assuming on a broken jaw. Something goes wrong. Their airway swells. They vomit. Who knows?

The medic shows up. Young person in cardiac arrest. Jaw wired shut. Neck swollen to the point there are no recognizable landmarks. You have no time to think about what you might do. You are just dropped in it, and I am imagining a horrific scene complete with crying panicing family, desperate first responders, etc.

Boy am I glad I wasn't there.

***

Here's two more calls that I later heard about that I was glad I wasn't there for.

1) An undercover police office codes, just drops dead of a heart attack. A non-emt is driving an ambulance with an out of service sign on it. He is pulled over at virtual gunpoint and ordered to aid the officer. The best he can do amid all the shouting of ever multiplying police officers is call for help. I would not want to have been the arriving medic who finds the officer in arrest with puke streaming from his mouth, with the enraged masses of officers swearing at him, demanding he get moving to the hospital, and still not even knowing if it is a non-traumatic or traumatic arrest.

2) Man smashed in the face with a baseball bat breaking every bone in his face and throat. You arrive to find him unconscious moaning and drowning in blood.

I have no real problem with difficult calls(baby codes, traumatic arrests, etc. calls that require me to use my usual skills. I feel bad for the people, but I can do them because that is my job. In reflecting on this today, the two calls I most fear are calls that require you to do a surgical trach where the anatomy is screwed up, and calls involving crazed shouting police officers when their fellow officer is truly injured.

I have never done a surgical airway. I have done many calls with crazed police officers. For all their training when an officer is injured, their fellow officers routinely endanger them with their hysterical shouting. I was on a call where police officers dragged a officer with a neck fracture, 50 yards down the streets and threw him on my stretcher.

Both calls require maintaining extreme cool. When given a choice between the two, I will take the crazed officers over the surgical airway calls, particuarly over a surgical airway on a kid. I'll take that anytime.

***

Worked eight hours tonight. Hot and sticky again. Did a couple transfers out of the box. Then did two disturbed mother calls. One was for an assault on a child, which may in fact have only been an overworked mother spanking a child who wandered out of their apartment in a bad neighborhood, and was seen by a friend of her estranged husband, who called police, knowing it would bring in DCF. There wasn't a mark on the kid, who lived in a clean apartment in a bad housing complex, but it triggered an investigation.

The other call was for a nineteen year old girl with side pain, and her four hundred pound drunken mother was flipping out that her baby was sick. She tried to fight her way into the back of the ambulance. I did all I could to assure her her daughter was fine. At the hospital, they put her in the waiting room. The hospital was as packed as I have seen it lately. I assured the mother her daughter would be seen quicker this way, but she was barely containing herself. She's going to explode at some point in the six, seven, eight hour wait her daughter is facing.

Stew Chicken Sauce

Worked ten hours. I was training a new employee today, so we had him drive, except on priorities, while my partner and I switched turns riding in the back. It was great AC on stretched out on the stretcher.

We did five calls -- nothing too exciting: a lethargy disabled person, a vomiting nursing home patient, a psych, a seventeen year old with a pain in her side, and a baby cut by glass.

Highlight of the day was an awesome jerk chicken over rice and beans with stew chicken sauce, accompanied by a Ting grapefruit soda.

Hot and muggy today.

New Experience

On June 1 the new protocols went into effect. I took great joy in removing the big vials of solumedrol from the med kits. They took up so much room and we never used them. I haven't had a chance to apply any of the new protocols yet. I anticipate using the new morphine dosing regime, phenergan on standing order for vomiting, and the lower minimm BP to give nitro for chest pain and pulmonary edema if its not contraindicated by the patient's presentation.

Here's a link to our protocols.

North Central Paramedic Protocols June 2005

***

First call of the day was sort of a new experience. Called for an unresponsive at a nursing home. Arrived to find patient awake and stabilized. The nurse told me they found him unresponsive in the bathroom, having just had a large bowell movement. She was on the phone to the doctor, trying to get him to cancel the order to transport. I checked the man out. The vagal story was good. The doctor told the nurse to alter the man's atenolol, and agreed the transport could be avoided. I told them to call us again if needed, and we left with a refusal. I appreciated them using some sense.

***

Did a diabetic refusal. Blood sugar of 30. Got an amp and a half, then his family brought him lunch.

***

It was sort of a slow day. Only did two more calls, an abd pain and a guy who thought he had a chicken bone caught in his throat. The last call came in at 9. Every Saturday night I get a call bewteen nine and 10. And he wanted to go to the farthest hospital. Even though he lived just a block from the closer hospital, he said a family memmber had died there and it gave him bad memories. How do you agrue with that. I only got off fifteen minutes late.

He's Back

I come in to check my gear, but think to myself, no, the night preceptee probably did it after I mentioned the problems I had yesterday.

Go on the first call for an overdose -- female took 20 benadryl trying to off herself, then called the police to tell them about her plan. She is a little sluggish -- heart rate is 130. I go to put her on the monitor. There are plenty of electrodes, but the monitor starts beeping at me. Battery 1 and 2 are down to one power bar (out of 4). I pick up the spare battery on the bench. 1 power bar. I get enough juice to get a strip, then I turn it off. Belushi is back. At the hospital I find a commercial rig who will swap me a fresh battery.

When will I learn?

Later in the day, I do a diabetic refusal. After an amp and a half of D50, the man does not want to go to the hospital. I reach in the blue bag for a refusal. None. My partner has to take the elevator downstairs and out to the ambulance to get a refusal form.

Returning to the base, I do a thorough and complete inventory of all my gear.

***

Took in an 11 day old baby who choked on his milk, but was fine. 1st time mom. Off to the hospital we went.

When we walk out to the rig after leaving our paperwork, I hear on the PD channel, an officer say, "Tell him to bring in the defib."

We make ourselves available, and we are sent to a local pharmacy for a woman down. We are told the commercial ambulance is on the way. I figure we can just back them up if they get there first. Instead we beat them.

It's a code. Lady is asystole and she has puked all over the carpet. When I go to tube, her mouth is full of watery puke, but I can make out the chords and I slip the tube in with a crick pressure assist from a friend of mine who has arrived with the commercial basic unit. Some epi IV and we have an accelerated idioventricular that holds all the way to the hospital, but we never get pulses back.

***

The other call of the day is a nursing home lady with a distended abdomen. I took her in a few weeks ago for pneumonia. We get to the hospital, and it turns out a family member of hers is in the room across the hall, and soon there is a gaggle of folks crossing the hall to see granny.

A day of viewing life: a woman who doesn't want to live, a child not two weeks old getting milk from his mom, a eighty year old woman who dies alone in a public place, and another eighty year old woman who has a family reuinion at a hospital. A full day.

John Belushi

Came to work tired because I had worked till midnight the night before, then had to get up at five. The night medic has a preceptee so I figured the ambulance would have been well-checked out, so I just dropped my bag in the front seat, and went right to back to the bedroom and crashed.

Hit the pillow at six-zero-five. The tones go off at six-fifteen. We're sent for a person feeling weak, whose doctor wants him transported to the hospital. No lights or sirens. Cold response.

The guy is lying on the bed. His wife says he has been having diarrhea and is weak, not his usual self. The first responder tells me he can answer questions when he sees I am directing my questions all to the wife. I then ask the patient how he feels, if he is in any pain. He looks me right in the eye and says, no.

On the way to the hospital, I do my routine ALS, )2 IV monitor. I draw labs, and then check his blood sugar. There are only two chemstrips in the glucometer -- and none on the shelf(I'm still in the other ambulance -- the one with the tie-locked cabinents), and I am a little pissed -- pissed at the preceptee for not checking his gear and pissed at myself for assuming he would. I weigh not doing the blood sugar to conserve the strips in case I really need them if I get a call before I can get back to resupply, but then decide I should, just because I should, and the patient is a non-insulin diabetic so they will ask me what his sugar is so I need to know. I put a drop on the strip, wait ten seconds.

27.

I am glad I checked, happy that checking sugar is a part of my routine, but feel like a knucklehead that I did not even think of hypoglycemia, low blood sugar, as part of my differential diagnosis. I find I get lulled into a here's another old sick person, put them on the stretcher, do routine ALS, take them to the hospital. In the clinical impression box, I just want to write "old."

I give him some D50 and he perks up some. At the hospital, his wife says he's definately improved.

Speaking of D50, here's an interesting article that suggests D10 might be better for patient's than D50.

Why Not Use 10% Dextrose Instead of 50% Dextrose in Hypoglycemia?

***

My next call is for a syncope. I'm not working with usual Thursday crew today, so when I go to put the electrodes on the patient, I open the back of the monitor, and there is only one package of electrodes left. Fortunately, I'm in the back of the ambulance, and I have plenty on the shelf, so I do the twelve lead, do my routine ALS, take the patient to the hospital. I think it is just a vaso-vagal episode.

I do not have an afternoon crew so the commercial ambulance sends us a rig with an EMT as per the town contrcat and I ride on the commercial ambulance, who gets to bill for the calls. First call is for a dsypnea at a nursing home. COPDer, who has a fever and is coughing up green phlegm. In the ambulance, I go to put the patient on the monitor, open up the back of the monitor. No electrodes. My last crew didn't replace them. Again in the classic words of John Belushi in Animal House, "You fucked up, you trusted me." I reach for the shelf where the spare elecrodes are always kept in the commercial ambulance, except there are none. I go through all the cabinets. No electrodes. John Belushi is sitting there in the captain's chair, laughing at me. But I have him fooled. In my briefcase, I carry lots of spare things for emergencies -- spare sissors, a spare stethescope, an attachment to bag a treatment into a patient, spare field guide, eye glass repair kit, nailcutters, tylenol, cough drops, plastic spoon and fork, and spare electrodes. You never know when you might get caught short. I reach through the doghouse window, tell the EMT driving to not mind me, as I dig through the bag and whallaa! come up with my electrodes. I put them on the patient. The machine doesn't read. I reposition the electodes. Nothing. I turn the monitor off, turn it back on. I get something, but it is like all 60 cycle interference. Completely unreadable. The electrodes are after all about five or six years old -- they are a little dried out. I feel stupid. Fortunately, the lady doesn't appear to be having an MI. I'm pretty confident she just has pneumonia. Her pulse is strong and regular. I weigh slapping the defib pads on -- there's one way to get a strip, but at $80 a pop, I think I'll just go in without the monitor on, and just notate too much interferenece to get a good reading. I could write equipment failure as an excuse, but it is really paramedic failure. At the hospital, I grab some extra electrodes and put them in the monitor.

There are two types of medics when it comes to stocking an ambulance -- those who overstock and those who don't. Those who don't get pissed off if you have more than the legal minimims on the shelves. Me, I like to have plenty of stuff. I ALS a lot of calls and I am very busy so I'd rather throw some extra electrodes in in the morning, then have to resupply after each call. I like to be prepared so I have a saftey net when the unexpected happens. I need to remember to put more electrodes -- fresh ones this time -- in my briefcase. I should probably put an extra run form or two in there also. You never know when someone will leave your run box on scene or you will leave it at the hospital.

When you work overtime, you get your routines and you like to keep them regular. I work with so many different people, it is hard to do unless you set yourself up after every call. It is hardest in the suburban town. I like to leave the BP cuff on the bench. Some partners always put it on the shelf. I like to leave the portable 02 on. I like to leave the trash can against the bench seat where I can put the IV trash rather than trashing the bench seat, then having to pick it all up and walk across the ambulance to the trash can. I like to leave my tourniquet on top of my little IV supply kit. People put the trash can against the far wall, and take the tourniquets and tie them to the overhead rail -- not over my head, but way out of reach so I have to stand up and reach over for them. And I like to always have a johnny on the stretcher. I like to always have a johnny to put on the patient so I can access them more closely, and it makes it easier for the nurses at the hospital so they don't have to undress the patients. Some of my partners never remember to get me a johnny. Sometimes other crews toss the johnnies because they are not on their checklists. I think I'm the only medic I know who uses johnnies.

These aren't complaints so much as little small details of my day. It really isn't too much to ask of myself to after every call, set the ambulance up just how I like it, so I will be ready, so I won't be caught without some needed equipment. I always check my car out throroughly when I am in the city, but I have been lazy in the suburbs lately, and if I don't crack the whip on my own back, I am going to pay on some call. I've got to keep Belushi out of my rig.

***

Four calls total for the day. Diabetic, syncope, pneumonia, and weakness.

Neck

A hot day and evening in the city. We got sent for an assault only to find no patient. We hung out for awhile while the cops searched the area. They said they'd gotten a phone call that five guys were chasing after another kid. When the cops finally cleared us, one cop said, heat like this, I'm sure we'll be seeing each other later.

Around ten, we got sent for a shooting. Found the kid sitting on a stoop with a bloody towell wrapped around his neck and shoulder. I removed the towell and saw two holes. One in the back of his neck, just to the right of the spine, and the other coming out the front of his neck. He was alert, talking, moving all extremities. I slapped a collar on him, we laid him on a board, and we were off. Total call time scene arrival to trauma room was ten minutes. Scene time was five. The kid was lucky. Through and through, and the bullet missed his spine, missed his major vessels, missed his trachea. Big holes too.

This is the second through and through neck shooting I've done where there was no major damage to the patient. I did another one, where the guy shot himself in the neck. The bullet missed all the big vessells, and missed the bones in the neck. But it completely severed his spinal chord. I had to intubate him, but he lived. I even took care of him again later.

This the third time I've been in the trauma room this week. I do like the traumas. I like the challenge of doing everything as fast as possible and on the fly. All the studies show paramedics make no difference on big traumas, so you have to be in BLS mode. It's all about time. I popped a 14 in just as we hit the hospital. Eveything else done before hand.

I talked to the kid's mother afterward. I told her how lucky he was. "Did you tell him that?" she asked.

I think she was pissed he was hanging with the crowd he was.

***

We did seven calls. Beside the shooting and the no patient assauly, we did two transfers, a guy whose fingers got mashed by a piano, a heroin addict sleeping under a tree, and another refusal for a lady who fell and banged her knee.

I felt bad about the guy with the mashed fingers later. He said his fingers just felt numb. He was in no pain. The fingers were already a little swollen. I didn't palpate them. I let my partner tech the call. No pain, no morphine. But then by the time we got to the hospital, he was starting to feel the pain, but we were already walking down the hall. They put him in the waiting room. I would have liked to have seen the xray. When my partner checked on him later, they said he had gotten angry about not being seen quicker and had left. If I had given him some morphine, he'd have gotten a bed right away, had his hand looked at quicker and not had to endure the onset of pain. I like tecking all the calls because I get to assess the patient longer and can find out more information, some of which as it unfolds changes my impression and sometimes treatment. If I had teched the call, I probably would have gotten the morphine out and ended up giving him some as his pain started to unfold.

***

I continued my Spanish food cravings, getting pork and fried green plantains -- tostones. Very good, except the lady gave me lots of pork skin, which was excellent, but very fatty, and gave me a brief stomach ache like I had a knife in my gut for a little while.

***

They asked me to train a new hire starting next week. He is just an EMT, but I guess they have so many new people coming on, they don't have a slot for him to hook up with a field training officer. Since I am a medic preceptor, they asked me. I had no objection.

Old Partners

Worked 12 hours today (noon to midnight)with one of my old partners, who I don't get to work with much anymore. We had a good laugh right off the back with our first call.

It was a patient being transfered from intensive care to a rehab hospital. She had a trach and was on a vent and required suctioning and cardiac monitoring. When we arrived at the floor to pick her up, her parents were there, and then they left. As always happens, for one reason or another we were delayed leaving the hospital. The paperwork needed to be put in order, the patient needed to finish her tube feeding, the foley emptied, the feeding tube disconnected, etc. We finally get on the road. I hate these transfers. I hate suctioning, and I'm not really wild about intrafacility transfers, particuarly on real sick patients. About halfway there, the woman touches my leg and looks like she wants to say something urgent to me, but I can't for the life of me figure of what she wants to say. They teach you not to rely on your machines, but as long as her pulse was staying where it was --120 -- normal for her of late, and her SAT was staying at 100%, I took some comfort. I never could figure out what she was trying to tell me. I just kept telling her we'll be there soon, and was wishing my partner would just drive a little faster and get us there before anything went wrong and I'd actually have to work besides periodic suctioning.

When we get to the place, her parents are there already, waiting for us. The mother approaches me and says what company do you work for. I give her the initials. She asks again. I tell her the full name, and then she says, "Where you at the Food Sack?"

"What?"

"Where you at the Food Sack?"

"The Food Sack?"

"We saw an ambulance at the Food Sack."

"Oh, no, that wasn't us. We were delayed at the hospital."

I think my complete befuddlement convinces her we didn't abandon her daughter to run in and buy cheetos and scratch-off tickets.

Before we leave, she thanks us.

The Food Sack?

***

Working with my old partner was fun. We rehashed old laughs. When you work with someone long enough their ecentricities really come out. People have said partnerships are often like marriages, and many hit a wall after a year where people have to breakup because they can no longer stand each other. We worked together for a number of years and had our times when we would get tired of each other. Its good every now and then for us to work together though I don't know if I could last full-time again with him.

While in some ways a Type B personality in his friendliness to patients and his, where's the stress we get paid by the hour philosophy, he is a type A driver. He gets very irritated with the traffic. Today at one of the hospitals we saw a nurse who had ridden with us years ago during his orientation. "Hey," he said to my partner. "I saw you on the highway yesterday and you flipped me off."

"I did not. I would never do such a thing. That's vulgar. I wouldn't do that."

"It was you. I came up on you fast, and sort cut you off, and I looked up and you were shaking your fist at me and you flipped me off."

"It wasn't me."

"There's nobody else who looks like you."

"Had to be someone else. I wouldn't do that."

"Dude, it was you. I've know you for years. You flipped me off."

The conversation is good natured. The nurse almost feels it is a badge of honor to be flipped off by my partner. My partner on the other hand is insistent it wasn't him. "I'll swear at someone," he tells me later, "But I never flip them off."

Yes, you do, I say.

No, I don't.

***

He is driving much better than he used to. At work they installed these computers in the cars that beep if you go too fast or stop too quickly, and every month we get a grade based on the number of violations, including backing up without a spotter (there is a spotter switch that your spotter has to hit when you backup) per mile. My partner is always in the top tier. His competitiveness has harnessed his speed and sudden braking, but not curbed his anger at other drivers.

At one point during the day, he buys a lunch of chicken fricasese from an Italian Mom and Pop restaurant, and as soon as he comes out we get sent on a transfer. I offer to drive while he eats, which he accepts. I get behind the wheel, and immediately backup. "Hey, you're on my fob," he says. I've just cost him a point. Sorry, I say. Ahead the light turns yellow. I start to brake, but there is no way I can stop in time without setting the brake alarm off and also sending the buttery fricasse all over my partner's shirt, so I cruise through the yellow. "I just saved you a point and your shirt," I say. Please fob in, he says. I reach down and touch my fob -- my identifier -- to the command button so all future violations on this trip will be on me.

I am also a top ranked driver. Last year one month I won the free DVD player as the raffle winner from among the top drivers. The only violations I ever get are the backup alarms. Sometimes I just backup without thinking I need to ask my partner to get out and spot me.

***

One of my partner's other eccentricities is he loves to get a McDonald's ice cream. Today, everytime we tried to get one, we'd get a call. He was getting very annoyed. It was cracking me up. What are you laughing at? he said, as he got back in the car, and slammed his shoulder belt on. Nothing, I said. Then I'd pick up the radio and tell the police dispatcher we were enroute.

***

We did six calls. Its hard to even remember what they are. After awhile the job sometimes doesn't even become about the calls. Its about the people you work with, driving the streets, the things you eat, what you talk about.

He and I are both recently divorced, so I listened to tales of his ex-wife and her lawyer. I told him about my trip to the Dominican. We listened to the baseball games, switching back and forth, me listening to the Red Sox, him to the Yankees. Both teams lost.

***

For the record the calls were the vent transfer, a guy detoxing with tachycardia, an old lady not feeling well with an ECG with some ischemia, a fall with hip pain, a diaylsis tranfer and a syncope who was probably dehydrated, but who we couldn't convince to go the hospital.

***

The last three hours we did nothing. I took an hour nap in the back. He got his ice cream cone and bought one for me. We told stories of the old days. He kept the air conditioning on. I rolled the window down. I thought it was nice out. He likes the AC to keep the air cleaner.

At 10:30 the dispatcher told us to go to Area 9. My partner thought he said "bring it in." I tried to tell him the dispatcher said area nine, which is just a post. He called the dispatcher on his cell phone and the dispatcher reiterated Area 9. My partner doesn't hear as well as he used to. Several times he'd say, "Huh?" and I'd have to speak louder. I should talk because I find myself saying "Huh?" alot too.

***

We shook hands like we always did at the end of the shift (after resupplying and washing the ambulance) and wished each other good night and a safe drive home.

We're working again together tomorrow night.

Eats

Five calls today -- a woman with diarrea, vomiting, facial numbness, body pain and an inability to see out of her right eye or hear out of her right ear, a minor MVA, a psych feeling anxious, a person with blood in their stool, and a transfer.

The first woman was a psych too. She had equal grip strength, no arm drift, no slured speech and no facial droop. I stuck her with an IV in her arm, and to hear her hollar and moan. I had to try hard not to keep from laughing. I apologized for hurting her, I said, but I've never really heard anyone make quite so much noise.

"But it hurt," she said, and put on a pout like a four year old. She was on lots of depression meds. I think it turned out she had a sinus infection.

My culinary highlight of the day was a cubanito, a sandwich in a fresh made baggette, ham, pork and cheese, toasted. I asked my partner how much she thought it cost. Four dollars, she said. $1.25. I had been to this bakery a number of years ago when my partner that day, a Hispanic guy went in and bought one and told me it was only a $1. When I was at the airport in Santo Domingo I had a sandwich with proscioto and cheese on the same kind of fresh made roll, and I remembered this place, so today I went in and bought one again. Outstanding.

Much of my day revolves around eating. I try to eat a small meal every two hours. I should write a Medic's guide to the city's best take out eats.

Cold water, Pork and Plantains

Worked two to ten in the city. I love Sunday shifts (except for th fact they are Sundays). No traffic, nice pace, most calls are legit. Did four today. A transfer, a seizure, a vomiting Abd pain, and a stabbing. The stabbing ended up in the trauma room, but I couldn't tell if the wounds went through the fascia or not. One was in the abdomen, the other in the chest. The patient was tachycardia, but aside from some belly pain, had no trouble breathing and didn't seem in much distress.

It was hot today, and I started with my usual diet coke, but then I filled up my big liter water bottle with ice and drank cold water for the rest of the shift. What a difference drinking cold water makes. I love cold water on a hot day. Tomorrow I will only have two diet cokes, then just water.

I also went to El Mercado today and had pork and plantains on a stick. Very, very good.

Saturday

All the cops in town were off on a multi-suspect foot chase -- a gang robbed Home Depot, then fled toward the city -- so they had no one to back us up. There is a man standing outside the house on his cell phone. He looks anxious. I grab the bag and go in past him. In the kitchen, a man is on the floor, seizing violently.

I have to admit -- I love being the first one on scene -- going into a house not knowing what to expect. Its a nice adreniline rush. It used to be like that in the city all the time. Then the fire department replaced the cops as the first responder and probably two out of three times they are there before us now. In the suburbs, the cops usually always beat us there. Now, I come in and go to the first responder and get the story from them. Its less exciting, although having them there to help carry is a benefit, particuarly when I am working with a smaller partner.

The man is seizing spastically -- not the tonic clonic seizing associated with gran mal seizures. I suspect he is a diabetic. I check his sugar. The glucometer reads LO, which means less than 20. There's the problem. I get the Iv while my partner tries to hold him down. I push the D50. He stops seizing, and shortly opens his eyes and is surprised to find himself on the floor. When we stand him up, he looks at the stove and says, "I guess I didn't get my eggs yet." We take him to the hospital.

***

Later we go down to the jail to examine one of the new prisoners. His only complaint -- he has mental problems and needs to go to the hospital. They can strap him down to a bed there, but he is going to the hospital. His vitals are all fine. I hand him a refusal. He signs it. I tell him to call back if he feels any change in his condition. We will be happy to evaluate him. I will be calling, he says.

***

Another nursing home train wreck. Oh Lord, this guy is deaf, blind, victim of a massive CVA, and is completely contracted. You cannot pull his arms away from his chest to get a blood pressure without causing him to scream in pain. And he is a full code. I can't get a BP or feel a pulse, but he is only going at 60 on the monitor and he has some cap refill so I just put him on 02. The complaint is abd distension and hypotension.

***

Watch the rest of Ocean's 12, except for the part I sleep through. I must have missed something important because while I liked Ocean's 11, this one was boring.

***

Go to the trauma room with a motor cycle accident -- stoic old guy with a broken clavicle and ribs and a big hematoma on his head. He has ropes for veins. I put in a 14, but could have put in a 6 if they made them that big. He is hurting, but not admitting it.

***

One of the guys working with me this afternoon just graduated from college. It seemed like just yesterday he was a new EMT graduating from high school.

***

The paper online says the guy struck by lightning is upgraded from critical to serious.

***

We get our usual Saturday night half an hour before I get off call. An old guy vomiting.

***

At least the prisoner never called back.

Not Again Rant

Two back to back calls to start the day. Nothing exciting. Routine ALS. A COPDer with belly pain and a possible TIA already resolved.

Came back, got on the internet, and did my daily morning surfing.

Boston Globe Red Sox Coverage

Boston Dirt Dogs

Marketwatch

Then I checked on fellow EMS blogger

the macmedic

His posting called my attention to an incident I hadn't heard about so I looked it up on the web.

State Investigating EMTs' Response To Lightning Strike


Bottom Line: A 48-year old man gets hit by lightning. His friend does CPR. A basic ambulance arrives. The EMTs stop the CPR and call the patient dead. They don't talk to medical control. They cancel the responding paramedics. They put a blanket over the patient. Ten minutes later, the patient is spotted by a police officer apparently breathing. Patient is alive with palpable pulse. Rushed to hospital. Patient is now in critical condition. State investigates.

I echo the macmedic's concerns that once again we all look like idiots because some members of our profession don't follow presumption of death protocols. It seems particuarly egregious in this account because victims of electrocution, unless they are incinerated, have a much better chance of being rescusitated than other victims of arrest. State protocols would dictate that CPR should have been continued on this patient until paramedics arrived, and then the paramedics would need to perform at least 20 minutes of ACLS, including intubation and ACLS drugs, and even then because the patient was a victim of a lightning strike, the patient still should have been transported, unless the medics spoke with a physician and all agreed further efforts were futile.

Now I have screwed up in the past and will do so again in the future, but there are levels of screwup that just aren't acceptable.

I am not blaming the individuals on this call, but if you don't blame the individuals, you have to blame the system that trained them and put them out on the road to operate independently.

The fact is all too often, not just here in Connecticut, but all across the country, EMTs are put on the road, not because they are qualified, but because warm bodies are needed to make legal crews -- to fill the duty schedule. "Meat in the Seat." Bodies are needed so the towns and cities can say they are providing ambulance service for their people. No experience? Not a clue what you're doing? No problem. You have a state card, don't you? And hold on a minute, let me feel your wrist. Ahh, there you go, you have a pulse! Let me show you to the ambulance. Step right up, buckle yourself in. Here's the switch for the lights and here's the knob for the siren. Go nuts!

Now I didn't really know diddle when I started, and I had plenty of calls that I can truly say I was completely unprepared for. I had a 130 hour class behind me, no street experience, and a $6 an hour pay check. Many people don't even have that. I was lucky most of the time when I started I had a senior partner, who did know something, but sometimes, my partner was as green as me. You have to get cars on the road. This isn't a volunteer issue, and it isn't a commercial issue, it's a competence issue. And like all things it is a financial issue.

People want EMS on the cheap. Many services provide too little pay, or no pay. Training is minimal. Oversight is minimal. And the result is viable patients get blankets thrown over them when they aren't dead. And worse things happen.

I desperately want to be respected for the work I do, for the years I have put into the job, the time I have spent trying to improve, to master a job that is not masterable. I look in the mirror and see who I am, but sometimes I look in that mirror and see with other people's eyes. I'm a yahoo ambulance driver village idiot, who probably does what I do because I can't get a real job.

Why do some people see us that way?

Read the article above again. And read this one from February 16. Questions Surround N.C. Man Presumed Dead. And read it again when it happens next time, and the time after.

Now keep in mind that these are just the people who have the blanket pulled over them, and are later found alive. What about all the ones who have the blanket thrown over them while they are still alive and /or salvagable? Who aren't discovered while they are still alive, and who no one will ever know about.

What if the cop hadn't seen the guy breathing under the sheet? Maybe he passes away a half hour later. The crew who called him -- they write their run form. Who sees the run form? Who reviews it to see that they failed to comply with procedures? Do they even write a form? If they do, does it just get stuffed in an old file?

The entire EMS system needs accountability. It has little. That's a dirty secret.

And that's my rant for today.

Forgive me if I am a little pissed off.

***

Did an MVA, a fall at the supermarket, and an abd pain -- possible diverticulitis.

White Clouds and Goat Meat

Had the nurse paramedic student riding with me today. The poor girl. This is the third time in a row she has ridden and we have done nothing for the eight hours she has been with me. Not a call. This on Thursday which is usually my busiest day. She was off for several weeks, busy, busy, busy. She shows, up nothing. She leaves, the buzzer sounds.

Some are known as dark clouds for bringing death and destruction to their shifts, she is a white cloud.

But all streaks change.

I know one medic, couldn't buy a call when he was precepting, day he gets cuts loose, the shit hits the fan, as they say, code, code, major trauma, major trauma, another code.

Her day will come.

She'll be back in two weeks.

I don't mind that it is quiet when she is here, but I do feel like a bad host.

***

The one call we did do after she left was for a nursing home train wreck. A train wreck is someone with everything wrong -- insulin dependent diabetes, renal dialysis, dementia, multiple infections, amputee, etc. The man is shouting "Gooooat Meat. Goooooat Meat!" The nurse explains he wants goat meat, but it is not on the menu at the home. They called us because one of the aides thought he had stopped breathing for a brief period, but he seems fine now. He is satting at 100%, his pulse is 72, his skin warm and dry. The head nurse says she spoke with the doctor, and since they hadn't been able to get any lab samples from him in the last week, they decided to send him in to get evaluated even though he seems fine now.

We take him in. As we leave he is shouting "Goooat Meat! Goooat Meat!"

They don't have goat meat at the hospital either.

Someday

Had the day off, which was a good thing because my back was stiff. Oh Lord. I don't know whether is was from three days of sitting in the ambulance for 12 hours or from the last two days working with a woman half my size, and having to overcompensate on the lifts or just plain old age and being out of the gymn, not stretching and maybe my tight hamstrings causing a pull in the lower back.

I emptied the water in my hot tub, and refilled with clean water, then heated it up to 102, and sat in there with the jets on my back and neck, and a cold Presidente in my hand, but it did help some.

And it wasn't like I was completely disabled. I did a lot of house and yard work -- everything except that kitchen floor that is going to require me to get down on my knees. I would have, but I spend a good amount of time, doing that weeding the back patio.

I cut the lawn the other day as night was falling and so left several patches of uncut grass I had to touch up. I also mixed some total vegetation killer in a watering bucket and spread it against my house all along the sides, and then around the mailbox. My goal every year is to kill more grass so there is less to mow.

Having a house is a bit of a trial, but it makes me feel like I belong to society. If I was living in a $500 a month efficiency in Hartford, coming home at night to a dark room, and having to hear the neighbors fighting and worried about getting mugged everytime I went out, well, that wouldn't be a good thing.

Someday I will retire.