Face First

Another slow day. A refusal -- an old lady in a parking lot hit the gas instead of the brake and ran into a building. Air bags went off. She was sitting on a bench when we got there. Alert oriented with no complaints. Just wanted a ride home.

Other call was at a nursing home. Guy had been coughing up phlegm for three days. COPDer with a great big distended abdomen which he said was the result of gaining a lot of weight. His skin was warm and dry, good cap refill, but his BP was 78/48. Pulse was 104. Couldn't get an IV to save me. Couldn't see one. Couldn't feel one. Tried by anatomy, didn't even draw blood from the skin.

I'll have to follow up to see what what wrong with him.

***

I've had a few nagging injuries lately none of which have panned out into anything.

A few weeks ago, I tried trouble lifting my right arm up, but attributed it to working out. Couple days later, I was fine.

Then one day I banged the heel of my left hand against a bed at a nursing home. I was trying to pull an oxygen cannula off a portable 02 tank, and when I finally tugged hard enough, it came off, and my hand flew into the bed. I really thought I had broken something. For a week, everytime I had to hold my arm out to brace myself, it hurt. Then it went away. I guess it was just a bruise.

The last three days I have felt a cramp in my back on the right side, and when it cramps I get this lightning bolt of pain shooting into my spine. My guess is when the muscle cramps it hits a nerve. It happened less today than yesterday and hasn't happened since this morning. It was like getting these irregular electrical shocks that cause me to jerk and shout "Ow!" Maybe someone was poking needles in me with a voodoo doll.

I got 2 flexoril last night and by mistake took both at the same time, rather than one every six hours. When I got home -- it was a strange slow drive through the night -- I got out of my car, walked into the house, up the stairs, down the hall into the bedroom, and flopped down face first. Not to wake up until the morning.

Where Everyone Has Been

Slow day. A twenty-year old with a headache and a thirty-year old with gas pains. Both walked out to the ambulance.

***

The paper had a big spread about the accident. So far there are four confirmed dead. No names. The big story is about how the truck had past violations for faulty brakes.

I think part of the reason the story is getting such play(besides being a horrific accident) is that it occured in a place where many people have been. Just about everyone in this area has at one time or another gone over that mountain. We have waited at the light at the base of the mountain. And we all know people who travel that route everyday at rush hour.

It could have been me, we think. It could be someone we know.

When we hear someone describe watching helplessly as the truck sped toward them out of control, we can picture it clearly. My god, don't hit me...

Chaos

Got a call as soon as I walked in this morning. Obese black lady in her late forties having chest pain into her throat. She also felt nauseaous. Said she had an MI a few years ago that felt the same way. She was on no meds and didn't have a doctor. Skin warm and dry. Lungs clear. No pain increase on movement or breathing. Put her on the monitor. ST elevation in the inferior leads. Did a 12 Lead. Inferior with posterior involvement. Went on a priority to the hospital. Called in a cardiac alert. She ended up in the cath lab.

When we got back to the base we got a call from the PD asking if we could send a backup ambulance to a noncontigious suburban town (about 20 miles away) for a severe car accident. They won't let me go because we have a keep a medic in town. We had a EMT in the building and he called another EMT and they took off for the accident. A moment later we got a call in our town for a man with the shakes(probably from his vomiting and diarrhea.) When we got to the hospital there were already two patients in the trauma room from the wreck in the other town. I talked to one of the medics who brought one of the patients in and he said it was the worst wreck he had ever seen and he has been at it almost twenty years. He said a heavy dump truck carrying a load of earth lost its breaks coming down a hill and rolled several times as it plowed into a row of cars. He said there was a tour bus involved and cars on fire, and bodies in the road and bushes. There was one helicopter on the ground and another hovering overhead ready to land. He said the scene was complete chaos. Another medic said there was a bystander on scene doing CPR on someone who the bystander claimed now had pulses, even while he continued to do CPR.

When we were leaving the hospital we passed our BLS ambulance that was going lights and sirens to the hospital.

It was on the news when we got back. The scenes were horrific. An unknown number of people were incinerated in their cars. There were several dead and about twenty injuries altogether, many serious.

I talked to one of our EMTs when our ambulance returned. He said when he was there, a man was pulled out of one of the cars and was talking when suddenly he grabbed his chest and went down, and rescuers started CPR on him. The helicopters were both back at the scene on return trips. He said being there was like being in a war movie.

I guess a total of fifteen ambulances responded from all over the area. We are all waiting to hear the names of the victims, hoping we don't know any of them.

***

Later we did a lady with an episode of heart palpitations that had resolved before we got there.

After that things were quiet in our town.

Responsibility

Came into work this morning and was talking to the boss here about the call I did earlier in the week involving the suicide. He has a police background so I was interested in his perspective.

He was sympathetic to my decision making. The guy was dead, and had I worked him, I would have jammed up a lot of people, with no change in the result. We talked about how on one hand the state has protocols for EMS that suggest patients need to be worked regardless of fatal injury and on the other hand the average police department has no idea such protocols exist so they go on taping up obvious death scenes as crime scenes, and medics are slowed down on the way to presume bodies that may not quite meet the state standard. They wait outside the yellow tape while the photos are taken, then are given access to call the time. There was obviously no cross communication in the development of the EMS protocols.

Another example is the state regulation that requires a police officer to ride in the back of the ambulance if the patient is handcuffed. The police departments all have policies that allow the officer to follow in their cruiser. Now the reason for the regulation is in case the person becomes suddenly ill, maybe stops breathing and needs to be unhandcuffed, what do you do if you don't have the handcuff keys readily available (i.e. in your immediate hands rather than in the car following)? Answer -- you are screwed. The patient is screwed.

Now sometimes the cop will ride in the back, but most of the time, they follow. You can be a hard head and insist that they ride in the back, but then that jams them up, they need to get another officer to the scene when they may already be holding police calls. Sometimes they'll just tell you no -- this is how its going to go down. I try not to argue with people wearing guns -- unless I think it is really important. They are just not aware of the regulation. I doubt they were consulted when the regulation was written.

What do you do? You may only be a few blocks from the hospital. Why be a stickler when the only reason you are going to the hospital is because the patient needs a few stitches? They are fully healthy and alert. Why be an obstructionist?

They will tell you one thing in a class, but then there is the reality of the street.

I try to use common sense on a case by case basis. Sometimes I ask the officer to ride in back if I think there might be a problem with the patient being cuffed. If I don't think there will be a problem, I go with the flow.

You need regulations, but you also need common sense.

I will note that I raised this issue at a regional MAC meeting many years ago -- just pointing out that it was a problem medics faced -- being asked to violate the regs in the due course of the daily job. A letter suppossedly went out to police departments for a third time, but nothing changed.

Some would say the only way to do this job is to be black and white on everything. Others would say flexibility and common sense must rule. I am in the latter camp. Of course there is responsibility to be accepted whenever the issue is gray.

But I will accept that responsibility.

That's what being a paramedic is about.

In my opinion.

***

An interesting sidelight of our conversation was the officer mentioned he had recently been on a call where he and other officers got there. The person was in arrest. They put on a defibrillator -- no shock advised -- they started CPR. A paramedic arrived. Put the patient on the monitor. The patient was asystole. She told them to stop CPR. She said she was calling the patient dead. The officer left, leaving another officer on scene. He later heard from the other officer that a second paramedic showed up, and after CPR had been interrupted for ten minutes, for some reason the second medic convinced the first medic that they needed to work the patient. So they ended up transporting the patient to the hospital, doing CPR -- all after a ten minute interruption.

Now I wasn't there so maybe I have some of the facts wrong. It sounds like the first medic failed to follow the protocols that require you to do 20 minutes of ALS rescusitation on medical asystole patients before calling the patient dead. Did she not know the protocols? Was she lazy? Or were there other factors that I don't know about that led her to say stop? Maybe there was some rigor in the jaw? I have been on calls where the cops were doing CPR, but the patient had early riggor so I stopped. Like I have written before dead is dead. So what happened when the second medic showed up? Why did they start working the patient again, and not just working for 20 minutes on scene and then presuming dead, but working and transporting? I guess you would have had to have been there.

What does it all mean? There are many decisions to be made. Everyone has their lines of demarcation. Some are inside mine. Some are outside.

I have argued against having medics have to call the physician to get permission to presume. I want to be able to decide for myself, but when I hear of people not working people who I would have worked, then I think maybe it is neccessary.

Bottom line is the State Medical Committee is working on rewriting the state guidelines and not only do they need to be rewritten, but each medic needs to know what is in them and how much leeway they have in interpreting them. Good guidelines would allow common sense to prevail. But what if people don't have common sense? That is a whole other problem, and a very scary one.

***

Only call today a cancer patient with chest pain.

Day Off Again

Two Days in a row. Whoo Hoo!

Expert

Had the day off today for a doctor's appointment in the middle of the day that didn't square with any of the open shifts. I wanted to get a mole checked on my back. My aunt died of melanoma. You're not going to die, the doctor told me. He sliced the mole off and said he was confident it was benign, but was going to have it biopsied anyway. He said if he didn't call me no news was good news.

It is interesting being examined by another medical professional, observing the routines they have. You can tell someone has done something thousands of times before. There was a quiet efficiency to the doctor's method.

I took the needle he stuck in my back (I think it was a 25) like a Indian. Well, maybe I winced a little.

Afterwards, I asked the doctor for some general advice on skin care. He said keep it clean and protect yourself from the sun. Now, you're an expert, he said.

Intubation Article

Interesting article in the Pittsburgh Papers about the trouble paramedics have with intubation.

Paramedics lacking experience
Intubation at issue in study

***

Paramedics lacking experience
Intubation at issue in study
Tuesday, July 19, 2005

By Jacqueline Shoyeb, Pittsburgh Post-Gazette



Many Pennsylvania paramedics don't get enough experience intubating patients, a new University of Pittsburgh School of Medicine study has found.

The report may help explain results from an earlier study that found that patients intubated in the field are more likely to die than those intubated in a hospital.

"I think we need to be worried as medical educators. We have this complex procedure, and we think it's critical for paramedics to perform this procedure. And we're finding out they may not be skilled enough," said Henry Wang, the study's lead author and an assistant professor of emergency medicine at the school.

The study, published in the August issue of the journal Critical Care Medicine, reports that two-thirds of Pennsylvania paramedics performed the procedure three times or fewer in a year. And 40 percent never intubated a patient within a year's time.

Wang said that lack of experience may be one reason for findings from a larger study done last November.

In that study, university researchers found that Pennsylvania patients with traumatic brain injuries who were intubated in the field were four times more likely to die than those intubated in a hospital.

But paramedics here and nationally say more training is preferred in any field, and that overall, emergency rescuers are doing a good job.

Endotracheal intubation involves inserting a 12-inch plastic tube down a patient's throat to pump air into the lungs.

In the 1970s, Pittsburgh paramedics were among the first in the nation to use the procedure outside a hospital to help keep trauma patients alive.

Wang and the other researchers gathered their information from the Pennsylvania Emergency Medical Services Patient Care Report, a database of all emergency medical service patients in the state.

They counted the number of successful intubations done by 5,245 rescuers in 2003.

The report doesn't record unsuccessful intubations.

From the database, researchers calculated that the median number of intubations done by a rescuer was one.

Wang said paramedics need more experience and training or find better methods of opening the airway.

But one of the challenges with that is agreeing upon the right number of intubations that should be done before a paramedic is declared certified, said Daniel Gerard, past chairman of the Paramedics Division of the National Association of Emergency Medical Technicians.

Gerard, a 20-year paramedic, said he estimates that rescuers need to perform it on mannequins or cadavers about 12 to 20 times.

U.S. paramedic students only need to perform five intubations before graduation. In comparison, nurse anesthetist trainees need to perform 200.

Gerard, who also is an associate professor at George Washington University, warned that Wang's study is only a one-year snapshot of one state. It shouldn't be applied to paramedics in the entire nation, he said.

"I would say for the entire profession, we're doing all right," he said.

Paramedic training officer Paul Sabol, with the Pittsburgh Bureau of EMS, said he has faith in the city's paramedics.

Sabol, a 23-year paramedic, said he can't argue against more training, but said that Pittsburgh paramedics get enough experience to meet certification requirements.

***

Here's the Abstract

***

Title: Procedural experience with out-of-hospital endotracheal intubation

Author(s): Henry E. Wang MD, MPH; Douglas F. Kupas MD; David Hostler PhD, NREMT-P; Robert Cooney MS; Donald M. Yealy MD; Judith R. Lave PhD

Objective: Out-of-hospital rescuers likely need regular clinical experience to perform endotracheal intubation (ETI) in a safe and effective manner. We sought to determine the frequency of ETI performed by individual out-of-hospital rescuers.

Design: Analysis of an administrative database of all emergency medical services (EMS) patient care reports in Pennsylvania.

Setting: Commonwealth of Pennsylvania from January 1 to December 31, 2003.

Subjects: EMS advanced life support rescuers (paramedics, prehospital nurses, and EMS physicians) who reported at least one patient contact during the study period.

Interventions: None.

Measurements: We calculated individual rescuer ETI frequency and opportunity. We evaluated relationships between ETI frequency and the number of patient contacts. We also examined the relationship with practice setting (air medical vs. ground rescuers and urban vs. rural rescuers).

Main Results: In 1,544,791 patient care reports, 11,484 ETIs were reported by 5,245 out-of-hospital rescuers. The median ETI frequency was one (interquartile range, 0–3; range, 0–23). Of 5,245 rescuers, >67% (3,551) performed two or fewer ETIs, and >39% (2,054) rescuers did not perform any ETIs. The median number of ETI opportunities was three (interquartile range, 0–6; range, 0–76). ETI frequency was associated with patient volume (Spearman's &rgr; = 0.67) and was higher for air medical (p = .006) and urban (p < .0001) rescuers. ETI frequency was not associated with response (Spearman's &rgr; = -0.01) or transport (Spearman's &rgr; = -0.06) times.

Conclusions: Out-of-hospital ETI, an important and difficult resuscitation intervention, is an uncommon event for most rescuers.


***

I am surprised the numbers are as low as they are. I was expecting them to be low, but not that low.

I have wavered back and forth on the issue of what is better more medics or fewer but more experienced medics.

I have to say I am more inclined now to go with the experience.

Dead is Dead

Guy goes into a gun shop, buys a gun. Goes next store, buys a coffee. Gets in his car.

***

We get dispatched for a man unresponsive in a car, covered with blood. Priority One.

My partner and I converse as we head in that direction. The address is on a street lined with cheap hotels. Its where many marginal people rent by the week. He's going to be dead, I say. I just hope he's been in the car a long time.

Maybe they shot him and left him there, my partner says.

It sounds like that, I say. He's probably been dead awhile.

Maybe its esophageal varices, my partner says.

In that case, I realy hope he's good and dead, I say.

Esopheageal varices are nasty. Veins in the esophagus burst and people drown in their blood. Very messy.

We get an update. Slow down to a two. Its a suicide.

We hit off the lights and sirens. A simple presumption. Put the electrodes on, run off the asystole, call the time.

It takes us another six or seven minutes to get there.

There are police cars all over, yellow police tape blocks off the parking lot. A photographer is taking photos.

Something doesn't seem quite right. This is a pretty public area. How did he go so long unnoticed? Maybe the car had tinted windows? Maybe people just aren't observant?

We have to drive up on the grass to get around the police tape. I get out, and take the monitor out of the side door. I approach the car. I can see a man slumped back in the seat.

Give us a minute to finish taking pictures, an officer says, holding up his hand. I am standing back. I am hearing some conversation, scattered bits about getting the names of patrons who were witnesses.

Did this just happen? I ask.

I don't get an answer, but I get a look.

I might have to work, this guy, I say. If he's dead dead, I am not going to work him, but the state regs suggest if he's fresh, he may need to be worked.

The cop says nothing.

I am still standing back. I'm looking around at all the cops, the cameras, the people in the restaurant.

I know what the state protocols say, they say you have to work someone in arrest unless they have rigor mortis with dependent lividity, decapitation, decomposition or body transection. We all used to think there was a line in there about injury incompatible with life, but it isn't in there. The state knows there are problems with the protocol, and the state medical committee is actively rewritting it. The line incompatible with life is getting put in.

The committee wants to require medics to call medical control to presume. I have been against this because what happens when the doctor tells you to work the person who you have not been working, who no one has been working because he is dead. I have been a big advocate of letting the medic use his judgement following a reasonable protocol. Dead is dead.

They finally let me have access. The man has a gun in his curled left hand. His head is back against the headrest. His mouth is closed. There is a hole in the back of his head -- not exactly what I would call gaping. He is pulseless and apneic. He is not cold.

Look there's some brain, my partner says.

There is some, but not what you would call chunks.

I hook up the monitor and attach it. The officer is watching my eyes. I look back at him.

I think he is thinking don't you even think about working this guy.

I am thinking this strip better be flatline.

I can picture the scene, me yanking the body out of the car, all ten of the cops, going what the f... And all hell breaking loose.

It is flatline.

I run a long, long strip, then detach the monitor. I write my name down a piece of paper along with the date, time and my licence number. I give it to the investigating officer. I walk back to the truck.

A supervisor has arrived and I explain the situation. She thinks I should call medical control just to get it on record. What if he says I have to work it? I say. The guy is dead. He's not coming back. He's been dead for at least twenty minutes.

They won't make you work it, she says. You need to cover yourself.

I call, hoping I don't get a moonlighter. I explain the situation. We were slowed down, delayed access, bullet through head, brain matter, asystole.

I'm think this is going to be something now if all of a sudden I have to go back, and say sorry the doctor wants me to work him.

He grants his concurrence with my decision, but from his tone it sounds like he is thinking "Why are you even bothering me with this?"

It all leaves me slightly uneasy.

***

Twice before I have been slowed down to a not breathing, told it would be a presumption, only to find the patient did not quite meet the standard. They were dead -- no doubt -- dead and not coming back, but not dead enough if you follow the protocol.

Picture the scene, officers offering the family condolences, the family calling relatives to tell them that granny has passed on. And the medics come in with their monitor only, then suddenly they go throw granny on the ground and start doing CPR and yelling for their gear.

And what does the family think after they've talked to the lawyer. The police did nothing. They slowed the ambulance down. Maybe granny would have lived.

No, granny was dead.

Sometimes its a matter of interpretation.

I guess I have to fall on the side of doing the right thing for my own conscience.

Dead is Dead.

***

Did a couple transfers. A lady with numb hands, A refusal.

The Will

Day off. Slept late. Went to the gymn. Cleaned the house. Played some on-line poker. Watched the Red Sox lose.

This evening I had a cook out. I made some fried green plantains and onions, and opened up my liter bottle of Presidente I brought back from Republica Dominicana.

Put on some Dominican Bachatta music.

I admit I was feeling a little homesick for my friends there.

Later I'll get in the hot tub and look up at the night sky and think about how big the world is, and how possible it is to shape your destiny if only you have the will.

Seizure History, Had a Seizure

Fifteen hours down, only one call. Nursing home patient. Seizure history. Had a seizure. Wasn't seizing when we got there, but was a little postictal. We took her in.

***

Half hour to go and we get called out for a sprained ankle. Woman has been drinking vodka collinses. She tripped. Her laughter tells me I don't have to get the morphine out.

Time to go home.

The Check

Well I wrote out and mailed off my check to buy into the company. There were several forms to sign and the instructions for signing them were very confusing. I hope they don't reject it if I filled it out improperly. There was no phone number to call for clarification, and I didn't look at the paperwork until last night. If all is approved I will own 25 Class B units.

I decided to buy in for the following reasons:

1) I like the idea of employee ownership, even if the amount I am purchasing is miniscule.

2) I feel if I do speak up against the company or offer suggestions for improvement, I will have more credibility for putting my money where my mouth is.

3) While I believe EMS should be a municipal obligation (and I would love a municipal pension) I believe that done properly the utility model (government regulated private EMS) may be the most efficient (at least in this state--which lacks county government) -- the key being that there be sufficient commitment to and safeguarding of the quality of medical care delievered. Efficient financially and in use of medical resources.

4) In all likelihood if I am to remain in EMS, I will remain working for the company. I have seniority, the opportunity to make good overtime pay, and am getting too old to start over somewhere new.

Now that the check is mailed, I am glad I did it. I feel good about it.

***

Slow day today. One nursing home call for the woman with dsypnea and declining SATs, who felt better with some 02, and did not want to go to the hospital. Her vitals were all fine. She had no shortness of breathI think she was another case of pulse oximter inititated transport. I took her in, then got my breakfast in the hospital cafeteria -- oatmeal, a banana, and a Diet Coke with Lime.

A construction worker cut his leg on some wire.

A ninety year old had a slow irregular pulse when the nurse at the residential community was conducting a routine exam. We took her in. She had a sinus arrthymia with a rate from 20-80. She was asymptomatic aside from two recent dizzy spells.

Pain Survey, New Law, A Sandwich

Doctors at the University of Buffalo are conducting a survey on prehospital analgesia. Hit the link below to participate.

Prehospital Analgesia Survey

Providing sufficient pain relief to patients has been probably my number one concern or area that I have been trying to improve in in recent years(aside from trying to provide optimal airway care). I feel that while I am very aggressive with pain relief, I still don't give the patients enough.

I give an initial standing order dose, call for a specified additional amount. For instance, I may give 5mg, call for up to an additional 5 more, but then when I find that insufficient, I don't bother to call back again. I think what I need to do is ask for an opened ended amount titrated to pain. I could say, I've given the patient 5mg, their pain is down to an 8, I'd like to give them an additional 2mg every five minutes titrated to pain and provided their blood pressure is maintained.

I want to go beyond just taking the edge off, I want them to feel no pain, while still being alert. I want them to know their name, but I wouldn't mind if they were singing The Farmer in the Dell either.

***

The state recently passed into law a new statue that allows the state Medical Advisory Board authority to allow prehospital providers to perform new treatment methods (provided their sponsor hospital allows them) without having to rewrite the state laws to include them in their scope of practice every time they want to let people do something new. People from many states will say what's the big deal. Here it is a big deal because it is constantly an issue that doctors want someone to do something, but they can't because the law doesn't allow it. A number of years ago, first responders couldn't use defibrillators because the law specificed that only EMTs could use them. Basics could not use combitubes or even give aspirin.

Sec. 5. (NEW) (Effective from passage) Notwithstanding any provision of the general statutes or any regulation adopted pursuant to chapter 368d of the general statutes, the scope of practice of any person certified or licensed as an emergency medical technician-basic, emergency medical technician-intermediate or emergency medical technician-paramedic under regulations adopted pursuant to section 19a-179 of the general statutes may include treatment modalities not specified in the regulations of Connecticut state agencies, provided such treatment modalities are (1) approved by the Connecticut Emergency Medical Services Medical Advisory Committee established pursuant to section 19a-178a of the general statutes and the Commissioner of Public Health, and (2) administered at the medical control and direction of a sponsor hospital, as defined in section 28-8b of the general statutes, as amended by this act.

***

Started the day with a two person neck and back transport following a low speed MVA.

Later was sent on an MVA which turned out to be in the next town over. We were canceled en route.

***

Seizure at a nursing home. Lasts two minutes, involves left side -- typical for patient. She had a seizure on Sunday after which they did lab work that showed her Trileptal was low. The lab results just came back this afternoon. The doctor ordered her Trileptal up, and before she could be given the pill, she had the seizure. A-O on our arrival. I suggested the nurse call the doctor, since they knew what the problem was, and they already had the order to up her meds. Maybe he wouldn't think it was neccessary to take her in. We want to to go, the nurse said. Okay, fine. I happened to want to go in to the hospital anyway and get a sandwich in the cafeteria because I was hungry. I was just trying to make the system run a little smoother.

Powers of Observation

The following was adopted from a post I read on a poker bulletin board. Thanks to Edward Hutchinson of Mississippi for his post. I have adopted it to relate to EMS powers of observation.
***

Try this psychology experiment.


Go to this site: http://viscog.beckman.uiuc.edu/grafs/demos/15.html


run the tape excerpt and try to count the number of times the basketball is
passed.


That's it. Just count the number of times the ball is passed.


DO THIS BEFORE READING FURTHER

Then to learn more about your results, come
back here and scroll way down.

DON'T LOOK BELOW until you have counted the
number of passes.


keep scrolling down......


Have you counted the number of passes?


OK, fine. Did you notice anything unusual while counting the passes?


If you didn't, then go back and watch the tape again. This time don't worry
about counting anything, just watch.


Did you see it this time?


Scroll down further for the answer as to what you should now be seeing


You will see a gorilla walk into the covey of players, stop and beat his
chest, and then walk off the scene. Go back and replay the tape if
necessary. The gorilla is certainly not hidden in any way.


Now the real question: Why do most people not see the gorilla?


Ponder this question the next time you are confronted with eye witness
testimony of how what occured at an EMS scene.

Beautiful Day

Day started off with a guy with his foot stuck in a conveyor belt. We were downgraded to nonemergency when they said they got his foot out. My old partner and I were just chatting away on the way to the call. I was reading the paper at the same time. Next thing we know they are updating us that we have gone by the call. We both totally tuned it out. I forgot we were even on a call. It was a beautiful day and we were just driving down the road. It happens sometimes.

The guy was fine. There was no deformity to his toe, no crepitis, no point tenderness. He could walk on it. One guy was saying he would take him to a doc-in-the-box. Another lady was saying he should go to the hospital. As far as I could tell there was no injury. "It is up to you," I said. "We are here to offer you a ride to an emergency department." They ended up taking him to the doc in the box.

***

We took an old man from one nursing home to another where he was suppossed to be with his wife. He was dying of cancer and I guess they arranged it so they could be in the same nursing home to spend their final days. He had to pay by check because insurance won't pay for non medical transfers. We get him to the new nursing home, and they tell us the room, and there is another man in the room. No wife. I ask about the wife, and they don't know anything about it. They just work there. This is the room for the new admit. I hope they got it worked it out later.

***

We get sent on a long-distance out of town transfer. It sets me off on a range of emotions. There are plenty of basic ambulances on. Why are they sending a medic out of town for what will be a 3-4 hour round trip when all is said and done? At first I am ticked off. This just burns me. It shows no respect for me or for paramedics. What happens if a code comes in and all the medics are tied up? A basic car will go. How many times has it happened that I am on a transfer and I hear basic cars screaming for medics. None available.

I have two days to decide if I want to invest $2500 in the company. We are being offered a chase to buy "units" of the company. A paramedic can invest only $2500. No more. No less. I am inclined to buy because I want to feel like I am a part of the company, invested in more than just punching the time clock. I feel if I speak out at any time, I have my money where my mouth is. So on one hand, I am thinking if they are so screwed up that they are going to send me on a long-distance out of town transfer, then I'm not investing. But then I think, well if they are running the company this badly, then it can only get better, so my money will grow when it gets better. And then I think, well, maybe they are running it okay at least from the business point of view. The customers and the public don't know the difference between a medic and an EMT. The hospital just wants someone to come pick the person up and get the room clear. Since we may be the closest ambulance, we get there the soonest. This pleases the hospital, it pleases the patient. They are happy, business is good. They call us again. The money rolls in. So maybe from a financial point of view, this is all good.

We pick the guy up, and head out of town. He has dementia and really can't carry on a conversation. As my partner says, "lights on, no one home." It is a beautiful day. A nice drive through the country. The Red Sox game is on and they are winning. I am thinking, hey, what am I so mad about. I'm not carrying a four hundred pounder down the stairs. No one is puking on me. I'm not working a baby code. I'm getting paid. Overtime rate. I've got a cold diet coke in the drink holder.

Here's what it is. Everyone wants, needs to be special. You need to feel you are in some way different, that your life has meaning. When you are send as a medic to do a basic's job, when there is greater potential work for you, you feel diminshed. You feel like you are just a cog in a wheel. You are easily replaceable. You don't matter in the individual sense. You live long enough, and you realize you aren't immortal, you aren't particuarly special. You're not going to be President of the United States. You are not going to play right field for the Boston Red Sox. You are not going to be the center of everyone's life.

The first steps toward humility is recognizing that you need to find your own specialness in small places. Whether is is loving someone, doing your job well, or becoming really good at one small thing or just learning to enjoy a beautiful day, you find specialness where you find it.

I still love this job even though there are times when I feel devalued.

We dropped the man off at his nursing home, got him comfortable in bed, joked some with the nurses there, then headed back to the city.

They posted us in a suburban town and we did nothing for a couple hours. We drove to a park and I laid down in the back and got a good nap in. Then I finished reading my book, The Farming of Bones.

It was an very moving novel based on the 1937 massacre of Haitains on the border of the Dominican Republic. The Dominican President Trujillo, in an attempt to get Dominicans to ignore their economic problems, blamed the Haitains in the country for causing all the problems, and ordered them killed. Over 57,000 Haitians living on the border were hacked to death with machettes, their bodies thrown in the river. The Haitians were in the country to do the work the Dominicans wouldn't do, chiefly work in the cane fields. The Dominicans are poor, but the Haitains are like Mexicans to the Dominican's poor Americans. They are the poorest people in this Western Hemisphere, scorned by their country and by the Dominicans.

The book was told by a young woman who survives the massacre, but loses her lover and most of her reason to live. While she is one of the forgotten, she has her story to tell.

Here's an excerpt:

"It is perhaps the great discomfort of those trying to silence the world to discover that we have voices sealed inside our heads, voices that with each passing day, grow even louder than the clamour of the world outside.

The slaughter is the only thing that is mine enough to pass on. All I want to do is find a place to lay it down now and again, a safe nest where it will niether be scattered by the winds, nor remain buried beneath the sod.

I just need to lay it down sometimes. Even in the rare silence of the night, with no faces around."

***

And what does that mean? I guess what I feel is that everyone is special. Some people have very hard lives. Mine is relatively easy. I'm not dying of cancer. I'm not suffering dementia, at least not yet. I'm able to carry a four hundred pound person down a crowded stairwell -- with some help. I may be a cog in the wheel, we all are, but we're all special in our way, and we all are probably going to meet ends that we won't like. All I can do is say what I feel, tell my stories, and try to enjoy beautiful days like today. Days made all the better when the Red Sox win, which they did 9-4. Whoo Hoo!

***

Finished the day with a two year old allergic reaction to peanut butter. A little Benadryl started clearing it up. We got his car seat out of his mom's car and mom and I rode in with him in the back. They just moved to the country from Germany and she is due with another child in August. She used to work in a chocolate factory there. She loves the U.S.A., and loves her baby boy, whose screams at being hit with a needle gave way to peals of laughter at the Children's Hospital when he saw all the toys.

Satisfaction

Eight calls, eight transports. Busy on a hot humid day.

I did three back to back allergic reactions. A baby who ate eggs and had hives around his mouth, throat, and scattered on his torso. A man who just recieved IV dye while getting ready for a Cat Scan who had hives, and a 500 pound lady stung by a bee who had hives all over her body and who was itching like crazy. I gave the baby 10 mg of Benadryl IM and it pretty much cleared up. The medical staff at the Cat scan place gave the man epi, and benadryl, and two puffs of an inhaler. I followed it up with a treatment. He had wheezes, but I think they had more to do with his smoking than the reaction, although he said the treatment made him feel better. The lady I gave .5 epi SQ and 50 Benadryl IV. It stopped the itching, but didn't do too much about helping the hives. I think at her weight, she needed a double or triple dose.

We took a suicidal man from the community health center back to the hospital which had just released him after an overnight stay in their psych ward. I'm going to kill myself, he said. I just need help. Keep me away from a gun.

We were called for a fall. An old lady who fell last night and had a hematoma on her head. The response was on a priority one to a suburban town, and they kept us coming all the way on a one, but it was not a priority call. There was a visiting nurse there, who said the doctor wanted her evaluated because she had been falling a lot lately with no explanation. I worked her up as a syncope.

We did a fifteen year old in labor, contractions two minutes apart, lasting two minutes. She was huffing and puffing and occasionally screaming, but her water hadn't broken yet and it was her first child.

We did a seizure patient, who stopped taking his meds. He was extremely postictal, a three hundred fifty pounder, big strong guy. We had to carry him down a narrow staircase, and he was still moving unpredicatably. He started leaning to the left, and we bent the stair chair trying to keep him upright.

And we got called for an unresponsive in someone's backyard. It was a guy on a Lark -- one of those motorized scooters He was GCS of 3, skin cold, clammy, more than clammy, he was drenched. It took me awhile to realize, he had been out in the downpour, we'd had earlier. It occured to me he might be a diabetic. Blood sugar was 26. I gave him an amp of D50 and he woke up, although he was still groggy. In the ambulance, I mixed 25 grams of D50 in a 250 bag of saline, and ran him on a D50 drip or techincally a D10 drip. He gradually perked up. I read an article where they are studying replacing D50 IV with 250 cc of D10 IV Drip. It is easier on the patient's veins and brings them about more gradually.

While I was at the hospital today, a medic from one of the volunteer towns brought in an asthma respiratory arrest that he intubated and got back. A young woman. What was so great about the call was not just the medic's skill on that call, but this medic is in charge of their service, and he basically turned their BLS volunteer service into a small but well-run medic service(The service is still technically volunteer, but the medics and day staff are paid.) He has to take enormous satisfaction that he was responsible for getting medics to that woman's side, and being the medic who saved her. He said, when he arrived at the house, the little kid answered and said, "I think my mommy's dead." He found her purple with an inhaler in her hand. Now she's pink again, and her kid has a mommy that's alive.

Nice job.

Air Freshener

Some days I love my job; others are tedious. Today was hot and humid, and we were steady without much of a break.

Day started with a chest pain and the fire department was there before us, and there were so many people in the room, I couldn't even get to the patient for awhile. They had to get a blood pressure, and it was taking awhile even though the guy was alert. I felt like saying, look I'm going to have to do it myself anyway because I'm going to give this guy nitro and I need to know the pressure is okay. I was getting so many different reports and the guy was being besiged with questions so I just told my partner to get the stair chair and I did a quick 12-lead.

He was a heavy guy and a tough carry down. My partner and I did the lift, although I have no doubt if I was working with a female, the fire guys would have helped me carry. Once we got out in the ambulance, I started my assessment from the top. The guy had a good story for an MI, although the 12 lead wasn't too bad. Basically he was having chest pain similar to pain he had when he had an MI a few years ago.

I was hoping to followup to see how he did, but we were too on the go. Every time we went to a hospital, they gave us a transfer coming out.

I guess the most frustrating part of the day was getting sent as we often do "Priority One" for "the sick" or for "the medical." They are supposed to have EMD. The call comes in, it gets sent to the dispatcher who gives it out as a 1 with little or no info, then once the calltaker further EMDs it, the update just doesn't get passed along. The priority one for the medical at the substance abuse center turned out to be a drunk with two week old fire ants bites that they wanted evaluated and medically cleared before they took him into their program. No way should that have been a priority one.

We did a baby who was dropped by his mom, but was asymptomatic. We were in the saem town, but at a far end so it took us awhile to get there. The address was just a few blocks from one of our posted city cars, but they still sent us. It didn't matter -- the kid was fine.

The last call was a medic alarm. We needed a key to get in the apartment. Lots of times when you get a medica alarm, it turns out there is no one in the apartment. We are walking through the place, when the cop goes in the bathroom, and we hear her call. "In here," she says. She sounds a little startled.

I go in the bathroom and see a lady white as death, laying across the toilet with her head against the sink, motionless. My initial thought is she is dead. I touch her head, and move it open her airway. She makes a sound, and that startles me as much as seeing the body startled the cop. She is very cool and clammy and has vomited. We get her on the stretcher, and she pukes again. She is alert, but her pressure is low. I give her some fluid on the way in. It turns out she was constipated, took a laxative, felt sick, went to the bathroom, puked, passed out, woke up enough to hit her alarm, then passed back out. When we got her in the room, the laxative really took hold and she lost her bowels in a big sudden way. When I brought my run form back to give to the nurse, the nurse was spraying the air with air freshener.

Four emergencies, four transfers.

That Weather

A full day off at home. Slept late, worked at my desk, went to the gymn, went out and ran some errands. I'm looking ahead at five straights 12's and a following 16. Making some resolutions for the weeks ahead as far as working out and eating right. When I was out today driving on the interstate, it was pouring rain, pouring so you could barely see out of the window. On the other side of the highway was an overturned van and one of our ambulances on the scene. I was glad I wasn't out in that weather.

Poodle

It is early in the morning on a rural road. A car has gone over the guardrail. The driver is in the police car and is refusing treatment for her minor injuries. A passing car slows as the man behind the wheel tries to inspect the scene. The officer turns and glares at him. Another car approaches. A old woman who can barely see over the wheel is driving by slowly, looking straight ahead. A large white poodle its paws up on the open passenger window looks curiously at the wreck and then at the officer, as the car slowly inches by. "Let's go," the officer says to the poodle. "Move on, nothing to see here, nothing to see."

***

Did a man feeling weak and took a prisoner in who needed medication. Saturdays I always do a lot of prisoners. They are caught in the slammer until Monday. This guy is a diabetic, who needs insulin, and no one is at his house to get it. I tell the officers, they can go to the drug store across the street and buy insulin for him without a prescription, but they have no petty cash. So we transport him shackled in the ambulance, along with a police officer down to the ER where he can get a shot. Later they find a relative who retrives his insulin from home, and we get called down to the jail to observe him giving himself a shot.

***

The only other call is for a man who has been jumped. He is fine, just a few abrasions. The officers just wanted us to check him out. He checks out fine.

Out of Place

Drove back from Boston, and have spent the day doing chores. Mowed the lawn under the blazing sun, cleaned the hot tub, have been doing laundry, cleaning the kitchen, just generally taking care of the neglect from working so many hours.

Its funny when I am out driving see an ambulance whirling past, or even in my yard and I hear a siren go by, I feel out of the loop, like I don't belong. Don't get me wrong, I love my days off. I just feel a little out of place. I don't know if that is healthy.

Back to work tomorrow.

Just a Game

Had the day off. Slept till ten. I needed the rest. My lawn is overgrown and needs mowing, but I didn't get around to it. I drove up to Boston, left my car at my friend's house, then took the train in to North Station, then took the T to Kenmore. Met my buddy at Boston Beerworks, and we drank several pitchers of beer while we got caught up.

We do this two or three times a year. We tell each other what's going on in our lives. Today after I've told him about my trip to the Dominican, and my job, and events in my personal life, he tells me me a story about his father dying.

His father had Alzheimer's and he was his Dad's medical proxy. He gets a call saying his father is dying and he has to come right away. Its a snowy night and he tries to drive up the hill to get to the hospital, but his car keeps sliding down. He finally parks his car illegally, and walks up the hill through the blowing snow. He gets there and even though his Dad doesn't understand him, he tells his father all the things he's wanted to say, but has been unable to. He kisses him and tells him he loves him while he cries.

His Dad doesn't die. He hangs on. But my friend routinely gets calls, you have to come see your dad, he's really dying this time. He keeps hanging on. In the meantime, there is a nasty court case going on with his Dad's ex-wife, who basically stole millions from him while he had Alzheimer's, divorced him, and concocted a scheme to make it look like he had an affair so she could activate a bad boy clause in their prenup that would give her all his estate. A judge has ruled that she defrauded him, and is requiring her to pay back millions. She and her lawyer are stalling because if he dies before their appeal is heard, she gets to retain 1/6 of his estate. So his lawyer is telling my friend, he has to keep his Dad alive until the appeal is heard.

My friend gets a call from his father's doctor saying he needs an emergency trach -- right now --you have to decide. All these calls come at the worst times. He's in his car on his way to a criminal case -- he's a lawyer himself. He pulls over, talks to the doctor, then calls another doctor because he's required to get two opinions. One doctor is saying he needs it -- he's choking to death, the other is saying let him die. He decides to let him have it -- as a comfort measure. Then it turns out, he doesn't need it -- its just a nasal tumor that they remove and he is back breathing okay.

The calls continue to come. He is always pulling over to the side of the road to have to make these decisions. He calls his sisters and says, "I can't do this alone, you have to come see him, we have to decide together." His sister's come. His older sister walks in the room, sees their dad naked strapped down to the bed, with mitts on his hands because he is always scratching at himself, and makes the universal cut sign across the throat. "This ends now," she says. They put him in hospice. He looks very peaceful, and dies within the week.

My friend ends up having to pick up his ashes at the funeral home and they are in a paper bag. So here we are having beers before a Red Sox game like we do every year and have for the thirty or more years we have known each other, and he's telling me about how it feels to carry your father around in a paperbag. His father, just like mine, used to take him to Fenway Park ever year, as he now takes his own kids now.

Quite a story.

Around seven, we went over to the Park and took our seats. Right field box by the bullpen. The game started off well. Trot Nixon hit a three run homer into the bullpen right by us to give the Sox a 4-0 lead. But then things slowly unraveled. A bad throw by the third baseman, a poor scoop attempt by the first baseman. The slumping second baseman striking out again with runners in scoring position. A terrible reliever getting shallacked again. Then the final ending was brutal. Tied 6-6 in the ninth. The Red Sox brought in Curt Shilling, their injured ace, making his comeback as a reliever. Gary Sheffield, Yankee Villian #1, hits a double. Next A-Rod, Yankee Villian #2, parks it. 8-6. We got up and left.

There is a ritual to going to Fenway Park. I've been going for over forty years now. I find as I get older I enjoy the park less. It is overcrowded, the seats are uncomfortable. I resent paying $6 for a watered down beer. I don't like getting caught in the human traffic when the game ends.

Still it was good to see my friend, even when the home teams gets beat so badly in the end. When the Red Sox win, I feel a little happier, when they lose I feel a little bluer. When they lose like they did last night, I feel beaten down. Still I tell myself, it's just a game. It doesn't mean anything really. It's just a game.

Labs

In one of the towns we cover, the following people respond to an emergency. 1)The ambulance(usually with a paramedic. In today's case -- me), 2) a paramedic fly car, 3)two police cars, and 4) a fire engine with at least five firefighters. We get sent to a doctor's office and arrive after fire and police are already there. The paramedic fly car medic arrives at the same time as us as we were parked together talking when the call came in. We have a difficult time getting in the doctor's office with all the people standing about. As it is there are three firefighters with the patient in the tiny room. The nurses and doctor's have fled the commotion. I get a quick report from fire. Chest pain, chest tightness for a couple days, hurts when he breathes. A police officer hands me the demographics. I just nodd and get him on the stretcher. I figure I will get him outside in the ambulance, and then assess him from the start. He is alert and oriented and only forty.

When we get in the ambulance, I talk to him on the way in, while I take his vitals, do a 12 lead and put in an IV. Well, it turns out the concern in not "chest pain" but the fact he might have a PE. He became short of breath on a plane a couple days ago, and has been having pain on breathing, and difficulty catching his breath since. According to the doctor's notes he had a SAT of 89 when he walked in.

The point to all of this is sometimes too many responders is too many. If just the ambulance responded, I could have actually gotten to talk to the doctor in the prescence of the patient, and been clued in a little quicker. It is hard for the doctor to figure out who has to give the report too, when various responders keep showing up.

***

Took a prisoner from a hospital to another hospital where they have a lock down unit. He was in severe hyperglycemia. The nurses was rattling off all his labs, his Sodium, White blood cells, BUN, creatine, etc. I was just nodding. I didn't know what the numbers meant. I looked them up in the ambulance. They meant he had an infection and was dehydrated. I gave him some more fluid. I guess I was pleased that she respected me enough to think I knew what all the lab numbers meant. I took a class in it along time ago, but since we don't use them every day, its hard to remember what all the numbers mean.

***

Ate pork and tostones for lunch.

***

Took a 500 plus pound intubated lady to a rehab hospital on a portable vent. I don't care for long distance critical care transports. I don't mind arriving when the bad stuff is happening, but a complicated patient, who has been in an ICU, and is deemed stable enough to transport, but who requires constant monitoring, I am a little uneasy. Rarely does anything happen. I watch all the monitors, and gages as well as eyeballing the patient, and every little gag and flutter spooks me.

It was a 40 mile trip, but everything went okay.

***

Had a guy with an unexplained swollen cheek who lived .4 miles from the hospital, call the ambulance. He walked out and meet us at the curb.

***

A nursing home dementia patient with a history of falls, slipped and bruised her cheek. the nurse was concerned because on pupil looked different than the other, although she admitted she didn't know the patient's baseline. The patient seemed fine and did not want to go to the hospital. I looked at the patient's pupils. She had a cataract in one eye.

A Remarkably Heroic Feat

It was on TV, on the radio and the following article in the paper:

Officer Praised In Saving Baby

July 12 2005

City police officials are praising one of their North End beat officers, saying his quick actions saved a baby's life over the weekend.

Officer X, an 11-year veteran of the Police Department, was on foot patrol about 9:30 p.m. Saturday in the 2600 block of Main Street when the child's grandmother approached X with the unconscious boy in her arms, police said.

X, who was training probationary Officer Y, performed CPR on the baby, who regained consciousness after about three minutes. The boy, reported Sunday to be 1 year old, was taken by ambulance to Children's Medical Center, where he was treated and then released, police said.

"It was just a remarkably heroic feat by Officer X," Assistant Police Chief Z said Monday.

X was in a police-sponsored training course Monday and was not available for comment.

Information was not available about the medical condition that caused the child to lose consciousness, but police said he had a high fever, was not breathing and was turning blue at the time the grandmother found X.
Copyright 2005,


***

Okay this happens about once a year. A police officer "saves" a baby not breathing. Gets a lot of PR, picture on the news, etc. In a couple days, they'll have a TV crew filming as the baby and officer reuinite in the thankful parent's home. Etc. Etc.

Of course anyone whith any medical training can see what really happened. The baby had a typical febrile seizure. Their eyes roll back, they can turn slightly blue and it can appear briefly that they are not breathing. Don't worry, if they don't seem like they are breathing, they will be breathing soon.

No baby who ever truly suffers respiratory or cardiac arrest is treated and released shortly after.

But its good PR. Happens all the time. There is never an article about EMS saving people. We get paid to do it. And of course we don't have publicists like police and fire do. A couple years ago the police had a similiar call. The ambulance wasn't there so they threw the not breathing kid in the back seat and drove like crazy to the hospital. Of course the kid was breathing by the time they got there. Maybe a little battered from being tossed all over the back. He too was released a few hours later. The department basked in their glory and ambulance bashed for a few days after that.

Enough complaining.

***

Worked double medic for 12 hours with the company's most senior medic -- the two of us both on overtime. You're talking an expensive car. We did a chair car assist, and two BLS transports, including one of 50 miles, and ended our day with a heavy person assist, helping another crew load a patient on their stretcher.

Again, I'm not complaining.

I got paid.

***

"Remarkably Heroic Feat" = Doing mouth to mouth on an inner city baby, then washing your mouth out with Vionex at the hospital worried that the baby gave you some kind of disease, which purportedly is what the hero was spotted doing at the hospital

A Good Man

Last night I watched a great movie, Hotel Rwanda.

Here's the review from Amazon:

Editorial Reviews
Amazon.com
Solidly built around a subtle yet commanding performance by Don Cheadle, Hotel Rwanda emerged as one of the most highly-praised dramas of 2004. In a role that demands his quietly riveting presence in nearly every scene, Cheadle plays real-life hero Paul Rusesabagina, a hotel manager in the Rwandan capital of Kigali who in 1994 saved 1,200 Rwandan "guests" from certain death during the genocidal clash between tribal Hutus, who slaughtered a million victims, and the horrified Tutsis, who found safe haven or died. Giving his best performance since his breakthrough role in Devil in a Blue Dress, Cheadle plays Rusesabagina as he really was during the ensuing chaos: "an expert in situational ethics" (as described by critic Roger Ebert), doing what he morally had to do, at great risk and potential sacrifice, with an understanding that wartime negotiations are largely a game of subterfuge, cooperation, and clever bribery. Aided by a United Nations official (Nick Nolte), he worked a saintly miracle, and director Terry George (Some Mother's Son) brings formidable social conscience to bear on a true story you won't soon forget. --Jeff Shannon

I bring it up because the lesson of the movie for me is that you can do many things in your life, but what really matters is being a good man -- doing the right thing. It's not an easy thing to do. But worth being reminded of. I recommend the movie to everyone.

***

Typical day. Four calls.

A chest pain -- a man who had an MI seven weeks ago and refused to have a quadruple by-pass. He's been having chest pain for two days, so his wife finally called.
I don't think he was having another MI, just residual angina from his clogged arteries.

An asthma -- woman left her inhaler at home, and needed a treatment. The nurse was having her breathe into a paper bag. Double take. Say what?

An unresponsive -- a woman from a nursing home with dementia and every other diagnosis was found unresponsive for a few minutes, and was back to normal by our arrival. One nurse thought she was playing possum, the other thought she might have had a seizure. This happens to her frequently. Since she is a full code, both nurses agreed she needed to be checked out.

A hypovolemia -- man just returned from foreign travel, vomiting and diarrhea for two days, went to his doctor's office. Had a BP of 60 and almost passed out. After a liter of saline, he was feeling better and up to 110/60.

A Hammock

Worked till ten last night, got up at five to come back to work. Slept for two hours, then got up ate some breakfast -- a Diet Coke and a Cliff Bar. An hour later we got a call -- for a dizzy old woman. An hour after that a man with asthma.

It is a gorgeous day. Bright sun, blue sky, not too hot, just a soft breeze. There have been a lot of nice days this summer and I have worked through most of them.

Don't get me wrong. I love my job. My commute is easy. I love doing calls and I love having time to pursue other interests. I write, I'm studying to improve my Spanish, I practice poker with simulation software. There is plenty of overtime so I am bringing in good money. And the stress is relatively minor.

But sometimes I can't help but think when I see days as nice as these, that I am missing something. A hammock, a cold beer, hamburgers on the grille, a bag of potato chips, the ballgame on the radio.

But you can't have everything. And I will not trade what I have.

***

Just did a call for a guy worked all day in his delievery truck, came home to a nice day and family of about six kids. Walked in the door and passed out. Hot diaphoretic, hypertensive, exhausted. he didn't want to go. I pressed him and pressed him. Right after he signed the refusal, and his wife and the police officer signed as witnesses, he started puking, and he finally realized maybe he should go.

No hammock for him today. A hospital tray instead of burgers and chips. Ginger ale instead of Budweiser.

A New World

We get called for a lift assist. We find a man lying face down on the carpet on top of a pile of papers. He is naked except for a dirty purlple bathrobe. His wife is sitting in an armchair.We ask him if he is hurt, but he starts jabbering about how long he has been down. I am not quite following him. He says something about how as a boy he used to milk the cows. When we try to get him up, he keeps saying "holdon holdon holdon." I get tired of him stalling, and since he doesn't appear hurt, we get him right up to his feet. He looks at me with a gleam in his eyes. "I know you, you're that guy. That's right. I could have sold you my car, but then where would you be?" He has a shake to his head and outstretched hand that reminds me of Kramer from "seinfeld." "Yes," he says. "Its all written down. It's all been recorded."

While my partner starts asking him questions, I turn to his wife. "Is he always like this?"

"Since Wednesday," she says, "It's been getting worse."

The man is completely insane. "Don't tell them a thing!" he shouts at the little terrier that runs by his legs. "They have their ways. Run, Rosco, run!"

The wife is elderly and can barely stand up. I look in the refrigerator. There are a couple of cartons of jello. That's it. She says she hasn't eaten for two days.

I ask if they have any relatives who check on them or does a visiting nurse come in. The woman says the closest relative is in Pennsylvania. No nurse has ever been to their house.

The man looks at me and declares, "It's a new world!"

We end up taking both him and his wife down to the ER. We leave a bowl of water and one of food for the dog.

***

A chest pain, sciatica, and vominting to round out the day.

Funeral

15 month old not breathing. Okay, so you rush out to the ambulance, buckle yourself in, and as you flip through your field guide to read the recommended ET tube size for the age and the epi dose, you wait for them to update you. Child is breathing. Child choked on some milk, but is alert and crying. Child had a seizure, but is now breathing. Nearly every time they call you back and tell you this. Like clockwork. You hit the lights and sirens. Forty-five seconds, maybe sixty seconds later, you get the update. Its okay. Take it easy. False alarm.

This morning, they update you with these words: "Starting rescue breathing. Continue code three."

A woman is screaming and two police officers are on all fours like giants over a doll. I have already told my partner to set up in the back of the ambulance, my plan is to snatch the kid, and do walking CPR out to the ambulance where we can work it.

I pick the baby up. It is cold, its skin white mottled in places with livitity, its limbs stiff. It feels just like a mannequin, except it is much smaller. The baby isn't fifteen months, it's fifteen days.

I ask the woman, when she last saw the baby moving, while I raise it's mouth to my lips, and press my fingers against it's chest. All I can hear from the woman is noise. I don't know what she is saying, but there is no answer for my question. I turn and begin the hurried CPR walk out to the rig, out of that too small house.

"The baby is dead," I tell the officers and my partner on our way out. I give it another breath. "We're going to the hospital, but the baby is gone."

In the back of the ambulance, I lay the baby on the half board and we put in an oral airway and bag the child while we do CPR. An officer drives. We go lights and sirens. I tell him to drive slower. Drive like you are in a funeral, I say.

I radio ahead. I say "15 month old found not breathing. I mean fifteen week old, no -- day old. It's got some rigor and livitity. Aystole. We're doing BLS CPR."

When I get to the hospital, I am expecting a quiet room with doctor and clock on the wall that he can look at and call the time, but they have heard baby not breathing and they have paged soome sort of code Blue. I have never seen so many faces standing around expectantly.

"The baby's dead," I say. I show the stiff legs and arms, the lividity.

The doctor understands now. He examines the baby briefly, then asks for the time. The word is passed to all the people crowding around trying to get into the small room. The baby is not workable. There are still questions asked. When was the baby last seen? What happened? What is the history?

I don't know. All I know is the baby was dead, and we had to get it out of the house. I couldn't just say. "Time of Presumption: 8:02. Here's my name, license number, date of birth, car number. You can call the ME now."

I suppose I could have called medical control on the way in and said the baby's dead, may I presume it here, call the time, shut down the sirens, pull a sheet over its head.

I don't mind calling the time on someone whose time has come, but for a baby, you sort of have to go through the steps. How can you ask a doctor to presume a 15 day old he hasn't seen? Isn't it better to say. We did what we could. I don't know. I may be callus, but I have a hard time calling the time on a fifteen day old. Let the family know we did what we could -- CPR, transportation to the hospital -- while at the same time not violating the corpse with IV and bone needles. But everyone has their own limits on what they feel they should do.

This is the third stiff baby I have brought to a hospital. The first one was ten years ago. When we got there the fire department was there. I remember them swearing at me with tears in their eyes, big grown men crying. "Where the fuck have you been? What took you so fucking long? The baby's fucking not breathing!" That child was ice cold. The other was a baby expected to die. The mother crying to the child, "No, no, not yet, I'm not ready yet. Don't go. Don't go!" We transported him, with the mother in the back, wailing in grief the whole way to the hospital. She wouldn't let go of the baby's cold hand.

Today I don't remember what the mother or grandmother or anyone else in the house looked like. I could see them in the supermarket later and not recognize them. The same with the other parents, I could sit next to them on a bus and talk for hours and have no idea who they were. I remember each of the babies though, exactly how they looked -- like cold lifeless dolls.

On my way out of the hospital, I hear the howls coming from the family room down the hall.

***

Busy morning. A lady with a swollen tongue. Ate some soup last night, and the tongue swelled up so she could barely open her mouth. Later a golfer with a broken hand.

Full codes

Two calls today at nursing homes, both frequent flyers, both with lengthy medical histories, both full codes. One patient, aphasic due to a CVA caused by a brain absess, had a seizure. The other, a patient with dementia, IDDM, CAD, HTN, CVA, renal failure, and every oither diagnosis you can thing up, woke up with her entire left side bloated with edema. Her left eye was completed closed shut like a fighter or someone with a bad case of posion ivy. Her left arm was twice the size of her right arm. She had no IV access at all. The other woman I managed to get a 24 in. Both had foley catheters and G-tubes. I have taken each woman in at least four or five times each. I hope they don't code when I'm on duty.

Also did a chest pain and a dsypnea.

A Twenty on the Dashboard

I'm sitting here at the end of a twelve hour shift, trying to remember my day so I can write about it, but even though before I turned in my envelope of trip cards I glanced at the list of seven calls so I could remember them when I sat down to write, I am having a hard time remembering, particuarly the first call of the day -- it just won't come to me.

What do I remember from today?. I had lunch at El Mercado, arroz ammarilla, puerco, y tostones. Muy bueno. Las mujeres de la restaurant le gustan hablar conmigo en espanol. Son mis professoras. Hoy tambien, hablo con muchas personas que hablan espanol. Leo un Libro -- Jorge, el curioso.

In other words, my mind lately has been consumed with learning Spanish. Everyone I see who can speak Spanish, I make them speak Spanish with me. I eat Spanish food all day. I was in triage today at one hospital and they had a spanish speaking guy in the wheelchair ahead of our stretcher and they needed a Spanish interperter, so I volunteered and conducted the interview, and did well, got the neccessary info. I read a book Curious George in Spanish and copied down each word I did not know, and wrote down the definition.

What llamadas did I do? What calls?

Still drawing a blank.

I worked with my old partner and he was his usual fussy, complaining, but somehow likeable self. One day I am going to tape a twenty to the dashboard and tell him it's his if he goes the whole day without complaining. This morning he gets in the ambulance and the first words out of his mouth are "You didn't think to fill up the gas tank when you came in yesterday?' He is staring at the gas guage which reads 3/4 full. Before he is done speaking, the needle has risen to full.

The calls, the calls...

We did a lot of driving all over town, covering one area, then being moved to the next. That wears you out more than anything.

Maybe if I write about the calls, but not in order, they will all come to me.

We did an MVA. A seizure. A diaylsis transfer, a transfer from the ER back to a nursing home.

What else?

A canceled call for a violent psych.

An old woman who was dehyrdated.

And the first call of the day.

I'm drawing a complete blank. I know it was ALS.

Oh, I know, a lawyer with chest pain walking into court. He had a stressful job, he said.

I was tired today, but not stressed.

Taxi Driver

80 year old lady has belly pain so her doctor tells her to go to the ER. She calls 911. "I can walk," she says when we arrive. "I just need to get my coat."

"You don't need a coat," I say. "We have blankets, plus I need to get your into a johnny."

"Oh, heavens," she says, "Is that neccessary?"

I always like to get my patients into a johnny top. It helps me assess them better and it makes it easier at the hospital. I get her sweater and shirt off, but then she has a full body bra on, and I give up at that point and just drape the johnny on her over the bra. I tried. We make her lay on the stretcher.

"You take a taxi," she says, "You wait ten, twelve hours and still they don't see you."

I tell her I need to do an IV. Whatever, she says.

I miss the first attempt. It is a very makeable IV, I just miss it. Well, I don't miss it, I think I have it, but when I flush it it blows up.

I try again. "Maybe you better let them do that at the ER," she says, as I fish around.

"If you'd have called a cab, you wouldn't be getting an IV right now. Cab drivers, don't do IV's." I continue to probe.

"You don't look like you know what you're doing."

"I am a professional," I say.

She laughs. "You get what you ask for huh?"

I get the flash, and the line flushed. "There done," I say.

She shakes her head.

"Now I need to examine your abdomen," I say.

"Why do you need to that?"

"A cab driver would not examine your abdomen. If he did, he would get arrested. If I don't, they'll rip the Paramedic patch off my shoulder and tell me to go back to being a cab driver. I used to drive one, you know."

"Why am I not surprised?" she says.

"I've stepped up in the world."

"I get a comedian."

"I have a license to do this," I say.

"Just so long as I don't have to wait 12 hours," she says.

***

Six calls. CVA, dehydration, psych, dislocated shoulder, seizure, and the above.

Holiday Pay

Worked 12 hours at double time and a half, plus since it was overtime it was really triple time. Did three calls. Two transfers and a psych.

Open Sesame

Most ER doors require you punch in a code to get in. The usual code is 911 * or 911#. At one of the hospitals they have set up a security station just inside the door and the security guard has a switch that enables him to automatically open the doors when he sees someone approach.

I laugh myself silly standing outside the door and declaring "Open Sesame!" when people approach. I have it timed so that as soon as I say it they are coming into view of the security guard inside who opens the door. Sometimes I clap my hands and say "Clap open, the clapper!" Others I simply say, "allow me to open the door for you," and i extend my arm to allow them to pass as the door opens.

My timing is something that needs to be seen.

Perfect every time.

I kill myself sometimes with the simplest amusements.

Today I see this volunteer ambulance pull up and park across the street because they can't fit their big box rig in the drive. I'm guessing that the driver is new because he could have pulled up on the sidewalk instead of parking on the other side of the street. He and his partner pull their very large patient out of the rig, and try to come up the steep end of the driveway. They can't push the patient up the hill, and for a moment I am worried, they are going to flip the person. Someone closer than me comes to their aid, and helps them go around to the more level end. Next I see them coming around the ambulances in the drive.

"Can you get the door for me?" the guy lugging the front says.

I am not standing in my usual spot. I gauge where he is, then say, "Just say 'Open Sesame!'"

"Hey I have a patient here!" he says angrily.

"Open Sesame!" I say again.

And the door opens just like that.

Everybody watching cracks up, but I think the guy is pissed off at me. I think he is so busy trying to pull the patient along that the joke is lost him. Maybe he thinks someone else opened the door and I was being a wise guy.

I think about finding him to apologize and explain, but then I forget about it.

***

Did five calls today. A transfer, a crazy lady, a homeless man, a dsypnea and fall.

Hurt

Lady had a syncopal episode on the toilet, hit her head and sustained a lac above her eye. She crawled to the phone and called her neighbor, who came over and helped her call her doctor, who said she should go to the hospital.

She checks out okay. Vitals are good, skin warm and dry, no deformities, just the lac above her eyebrow. Is she in pain? Yes. Anywhere you touch her body. Her response is disporportionate to the light touch. She whines and moans. "I don't feel well. I don't feel well. I hurt all over. I hurt all over. My face hurts, my feet hurt, my legs hurt." Her words are interrupted only by fits of crying.

"Mary come with me! Mary come with me!" she cries to her neighbor, who shakes her head at me as she leaves and closes her own apartment door.

All the way to the hospital, we hear it. She hurts. She hurts. The blood pressure cuff hurts. The torniquet hurts, the Iv hurts. "Ow! The bumps! The bumps! Why don't they fix the road! I don't feel well. I hurt!"

She is eighty-eight years old.

"I don't feel well. I don't feel well."

I try to imagine her as a child, as a teenager, as a young woman. As a mother, a grandmother.

I can't.

I try to imagine how her life left her like this -- living alone in a small apartment with her walker, and a neighbor, who helps her because that's what neighbors do, but who wants no more part of her than that.

I am unable to do so.

"I don't feel well," she says again and again.

Tell me how you really feel, I want to say.

I hurt, she says. I hurt.


***

We take a ninety-eight year old woman in for delerium. Her son removes her hearing aids because they are emitting a high-pitched sound. No matter what I say as we travel in to the hospital, she can't hear me. She mumbles to herself.

***

A fifty-seven year old woman from a nursing home hasn't spoken since her stroke. We take her in for high blood pressure. Her eyes follow us, but she has no words.

Fat Lip

What is the role of EMS? Is it to take people to the hospital or to treat and release or examine and release?

I have to say in most cases it is to take people to the hospital, or more specifically the emergency department. I will accept there are some circumstances where it is our job to respond to an emergency, and sometimes our treatment is such that no transport is neccessary. For instance, doing a lift assist or even in some cases, giving a hypoglycemic patient D50. Some hypogylcemics clearly need to go to the hospital, others you can make the case that they don't. They forgot to eat, they dropped their sugar, we gave them D50, they're back to normal. Provided they eat, have someone to watch them, and follow up with their doctor, it may be okay to leave them at home.

What I am uncomfortable with is when the ambulance is used to just check people out. A woman is punched in the face and has a fat lip. They call us to "check her out." Maybe it's because I'm tired today, but I feel like saying. If you think this is an emergency that merits an ambulance to take someone to the hospital, then we will examine the patient on the way to the hospital. But what it looks like to me is she just got punched in the mouth and has a fat lip.

Too many people seem to think the ambulance is a traveling doc in the box.

***

Besides the woman with the fat lip, we did a man with chest pain and a woman in an MVA.

***

The woman who was in an accident, didn't have a licence, and was trying to pretend she had altered mental status when she didn't. She had no injury, her vitals and surveys were fine. Her sugar was fine. There was no seizure activity, no neurological deficits. She spoke in whispers, pretending at times to be unresponsive. She answered some questions, and not others in a manner inconsistent with how an injured person would act.

I hate it when people don't cooperate.

***

As I said, I was tired today.