Days Off

I'm off to a poker tournament. No posts until Monday.

My Patch

Nothing for eight hours, then we get a call for an unresponsive. When we arrive, a man meets us at the door and he says, “They are not certain if she is breathing.” We enter the house and I see an officer standing in a bedroom doorway. I can hear the mechanical voice, “No shock advised.” I step into the room and see a woman on the bed, who looks like a corpse. I am surprised when I touch her that she is warm. Because of the kifosis of her spine, her head hangs suspended in the air. We get her down on the carpet. She is asystole. My preceptee has trouble with the tube, and after two tries gives me the blade. I look in and can only see the epiglottis. It is a difficult tube, but I have been anticipating this. I have been thinking what I would do when I encountered this situation again. I take a moment and collect myself, then extend my arm more and turn my wrist . The bottom of the chords are in view and I pass the tube. While the preceptee gets a line and start pushing drugs, I am already saying this is going to be twenty minutes and out, but we soon have some activity on the monitor. I am thinking it is just the epi and she will soon brady down, but the rate picks up. Soon she is cranking away at 170. On the capnography, my reading has gone from a 5 up to a 32.

At the hospital, the doctor asks why we have worked this person – this is futile. She seems to me more upset with the situation than with us. I don’t disagree with her -- it is futile to hope that we can bring this woman back to any kind of cognizant life -- but we have our protocols. The lady may be fixed and dilated, but she now has a heartbeat. My patch says the same thing it does everyday PARAMEDIC. It doesn’t say GOD. We had to bring her in.

I feel bad my preceptee didn’t get the tube – I explain it was a hard one – but I will admit to feeling good I got it. I had been frustrated lately. Even older paramedics can have confidence problems. The woman is still alive when we leave.

Our last call is for a fifteen year old vomiting. It seems he has gotten into some liquor. He is dizzy and can barely keep his eyes open. We run in a bag of fluid. He’s still going to have a whale of a hangover, but screw Bloody Marys -- nothing is better for a hangover than a liter or two of saline.

Alcoholic

I started precepting a new medic today. He is a nice young man who has already been cut loose in Massachusetts, so I don't expect it will take long. He seems to have a good handle on the job.

Dispatch was great today -- we got four decent calls -- no transfers in the eight hours he was with me.

We did a a syncope in the park, an unresponsive that actually was just a drunk, an abdominal pain, and a dsypnea.

The drunk was a guy I have done before. A couple years ago, he set his apartment on fire, by falling asleep smoking a cigarette. He had some serious smoke inhalation by the time the fire department pulled him out, but he was so hammered he was just laughing at everything going on. A year later we were called for an unresponsive on Main Street in an office building. We pulled in at the address along with the fire department. Eight of us all heading toward the main door. Standing outside an exit door about twenty yards from the main entrance is this guy with a cigarette dangling from his mouth, and one eye open, watching us, all the time, he has penis in his hand, urinating against the side of the building. I remember talking to him the first time. The guy is like a computer whiz, but he is just a serious alcoholic, who can't stay away from the bottle. He has been in and out of rehab, and he will eventually drink himself to death. He looks like crap. Today we found him laying on his side in front of the library.

After our preceptee left early -- he had a meeting he had to go to, we did another five calls -- two where there was no medical emergency -- a lift assist and a mother who's son had seizures, but hadn't had a seizure. She called because she thought he was about to have one, but he never had one and by then she had already called us. We did two psychs and a transfer back to a nursing home.

Younger Days/His Mama

We are sent to a nursing home to pick up a dialysis patient. They dispatch another unit to give us a lift assist. It’s a big patient. We get there first. “Let’s go in and do it,” I say. “We don’t need any help.”

I’ve picked this guy up before, but that was when I was working with a smaller partner. My old partner and I can handle it. In the old days we never needed a lift assist and we don’t need one now. We walk down the hall to the guy’s room. We look in. My partner looks at me. “He’s as big as a house,” he says.

I’m looking at the patient now too. Damn, he looks bigger than I remember. He looks to be about 500 pounds. “Yeah, maybe we should wait,” I say.

“In our younger days we would have done him,” he says.

“No doubt,” I say.

***

A couple psychs, a couple motor vehicle accidents, a little girl with asthma.

***

We get called for a drunk. We find a fifty seven year old man holding the fence in front of a house. An old woman comes out and says it’s her son and she wants us to take him to the hospital. She won’t let him in the house drunk as he is. He doesn’t want to go with us. “Lisen, lisen, lisen,” he slurs. "I ain’t going. I ain’t going.”

We can’t get him on the stretcher and his mother won’t take him into the house and he is going to fall if he let’s go of the fence. We threaten to call the police, and he says, “Go ahead, go on ahead. I ain’t scared. I ain’t scared. I ain’t going.”

We call the cops and tell them we need assistance with a drunk. He takes off then, staggering down the street. He is weaving all over the sidewalk. I am certain he is either going to stagger out into traffic or fall flat on his face. We follow him down the block where he veers into another yard and sits down on the steps. He says it is his other mother’s house. His mother who has followed us up the street, says he only has but one mama and she is his mama.

The cops come and the lead cop, looks at the man and declares, “Hey, this isn’t a drunk. Look at his pupils. They’re pinpoint.”

“He’s drunk,” I say.

“What are you using?” he demands.

“Huh?” the drunk says. “You talking to me?”

“Yeah, what are you using? You using illegal drugs?”

“Drugs? Now what kind of shit is that. What kind of shit is that. I don’t use no drugs. Looka these arms. I’m clean. What kind of shit is that?”

“Your pupils are pinpoint. See I used to work on an ambulance. I did that before this job. What are you using?”

One of the other cops looks at me. “It’s a drunk,” I say.

“Because I’m a black man, you saying I use drugs. What kind of shit is that? What kind of shit is that? Lisen, lisen, lisen. My mama taught me better than that?”

“Your momma?”

“He don’t use drugs,” the mama says. “He drink, but he don’t use drugs.”

Long story short, it takes fifteen minutes to get the guy on the stretcher, only after everyone has apologized to him for accusing him of possibly using drugs. “What kind of shit is that?” he says, as we finally plop him down on the stretcher. “I ain’t never use drugs. What kind of shit?”

“My boy don’t use drugs,” his mama says to the cop as he walks back to his cruiser.

Golden Acres Manor/Colostomy Bag

My old partner, who I work with regularly on over time has gotten a transfer to Florida. He’s leaving in two weeks. I’m bummed that he is going, particularly since it will leave me with partner de jour for the entire month of October M, T, W, when I would have been working with him. But I’m happy for him. He likes the sunshine. He was telling one of the nurses today he was going to Florida, and I cracked that he’d finally gotten into the Golden Acres Manor. “A Bed, a roof over my head and three squares a day,” he said. I think for a moment the nurse thought he was serious. “I’m only kidding,” he said, disturbed that she thought maybe he was really ready for the Manor.

Did a wait and return transfer for a psych patient – a young woman, who was fully ambulatory, but had to go by ambulance because she is a psych. A staff member accompanied her. We brought her into the doctor’s office. She hopped off the stretcher and walked over to the procedure table. We waited about a half hour then brought her back.

We got sent to a suburban town for a psych, only to find it wasn’t a psych at all, but a patient on the heart transplant list, who hadn’t been feeling well for a week and needed to go to a distant hospital beyond the range of the town’s service. That took up a good part of the day, seeing as we went at rush hour.

We did a dialysis patient with difficulty breathing.

A dead body. Neighbors came over and found lady dead, tried to start CPR, but she was stiff. An alcoholic, there was blood all over the bathroom, in the toilet, and hallway and bedroom and on towels. She must have been puking it up. There was a big open bottle of wine near her cold fingers.

We were sent priority one along with fire, two police cars and a fly car medic for a “burst colostomy bag.” I don’t think the dispatcher knew what a colostomy bag was. It turns out the guy just needed help getting into his wheelchair so he could wheel to the bathroom and clean himself and change the bag.

Last call was for a woman who passed out and twisted her ankle. I put her on the monitor and found her in a rapid afib. That could explain the recent falls, which she thought was just due to blood pressure.

Rest and Time

Slow day fortunately because I was beat down. I had a Diet Coke on the plane coming back and the caffine kept me awake till almost two in the morning. I was up at five to dress for work. I got a good two hour nap after checking my equipment, then spend most the day working on my blog entries and catching up on email.

The only call was for a nursing home patient with a CHF history who the nursing home gave extra lasix too. I think his problem though was pnemonia not CHF. His lungs were decreased, he had a nasty productive cough, and had no problem laying flat in bed.

I am working four straight 12 hour shifts in the coming days, three in the city, before getting a few days off at the end of the week for a poker tournament. I hope I will be able to get caught up on all my blog entries in that time, but it may be difficult. I also want to go to the gymn every day. Too many goals? No, just not always enough rest and time.

Day Eight - The Earth

I awaken shortly after midnight. The high winds of Hurricane Rita have knocked down one of the tents where sixteen EMTs and paramedics were sleeping. We need to push our cots closer together to make room for the temporarily homeless tent people.

I am soon back to sleep, and awaken on the tired side. I have a late breakfast of pancakes and sausage. I'm on the afternoon plane out of town so there is no going on the road today. I get an early lunch of cheesesteak, macaroni and cheese spiced with crawfish and spicy sausage, and a slice of apple pie.

I am sorry to be leaving. I think it was a great experience to be down on the Gulf Coast and to witness the strength and goodness of the people as they rebuild their lives after the storm's fury.

While waiting for the bus, one of the local workers comes over and says, "Thank you for coming. We appreciate it."

He holds out his hand and we shake.

"You're welcome. I know you'd come up for us if we needed the help."

"You can sure put my name on that list," he says.

As he walks away, I call after him, the words coming to me now. "Thank you," I say, "For showing us what's important."

He smiles. "Sometimes the littlest things -- that you sometimes forget about -- are the biggest."

I understand what he means.

***

At the airport, I learn my reservation has been canceled. There was a mixup in the reservations and I was supposed to be on the earlier flight. The other nine head to Atlanta and I wait in Gulfport for four hours till I can get a later flight. To make matters worse when I go through security, they pull me out of the line and practically strip search me. It was funny on the way down, not so funny now. I admit to being tired. The guards try to make small talk, but I am in no mood. I just hold my arms up silently. My zipper makes their electric wand go off, so my crotch gets patted down with the back of a gloved hand. I know they are just doing their job. Next I stand there while they meticulously go through my carry-on bag. At last I am clear. I make a connection in Atlanta and arrive back in New England after ten. The company division head picks me up, which is nice, but after he drops me at my car and takes off, the car won't start, and I have to find someone to jump me.

Home at last, I have a cold beer and sit again in the quiet. I think again about Mississippi and also about my trip to the Dominican. I am grateful for what I have seen this year, grateful to be healthy enough to help others, grateful to be able to walk the earth.

Day Seven- Gators

I am working with a local girl from Mississippi. I tell her I need a diet coke to start my morning off so she takes me to a place called Sonic, which is an old time drive-up with rollerskaking waitresses. A woman with rather fat legs on roller skates brings me a can of Diet Coke on a tray. That wakes me up.

My partner tells me how she and her partner were lost for two days during the storm, having to take refuge in first a fire station than later in a sewage treatment plant as the waters rose. At one point she and her partner were joking about how their car was going to need a little more than an "Orangeline Special" washing at the end of the day. Not long after they were wading in chest deep water as part of human chain trying to get to higher ground. She also told me about being sent into KMART in the darkness with only a flashlight to get needed radio supplies to get the communications system running, and suddenly getting very scared by an strange foreboding, and then hurrying to get the supplies and get out of the store. Later she heard that six corpses were found in the store along with four alligators.

Outside all the shopping centers there are piles of wet clothes, the remains of donations.

I ask my partner whether people got many clothes from the donations. She says they did, but as one of her regular partners -- a large girl herself -- said. "What makes all these little itty bitty Yankee woman who ain't seen a sandwich inside the last three months think us healthy Southern women are going to be able to fit in anything they send down here?"

Our first call is for chest pain. We arrive outside a motel to find a young man hyperventilating. "He don't speak a lick of English," the firefighter tells us, then I start rattling off the Spanish with him, and they are somewhat amazed to see a paramedic talking Spanish. It turns out the guy is from Honduras and his baby sun died there three months ago. He works and sends what money he can back. This morning, all of a sudden he was having trouble breathing and his hands got very cold and he was scared. By the time we get to the hospital, he is feeling much better.

We spend most of the day on the shore. My partner takes me down to the WalMart which is now a see through WalMart.

She tells me how the security guard there always used to give them a hard time about parking in the fire lane, threatening to write them tickets. She said after the storm when they went down there, they drove right up to the fire lane and took pictures of themselves standing in front of the ambulance parked there.

By the water the wind is really whipping up as the hurricane approaches. Port-o-potties are getting blown over and knocked across the road.

We talk to a police officer who is on the lookout for waterspouts.

We give out some more tetanus shots to workers.

We do a call for a motor vehichle and find a woman with neck pain. What is funny is how down there everybody knows everyone. A firefighter introduces us to the patient by saying "This is Patty, John down at central fire's sister's cousin's neighbor's wife. She got four kids, two dogs and cooks a fine apple cobbler."

"Okay," I say, and I tell her my name and say it my pleasure to make her aquaintence, circumstances aside.

Our last call is in a poor neighborhood for a man feeling week. He has colon cancer and hasn't seen the doctor for awhile. He ran out of colostomy bags during the storm and hasn't had one one for three weeks now. His abdomen is stained with feces and there are flies landing all over him. His nail beds are white and while I can't get a pressure, he is only going at 96 on the monitor. We take him in.

The shift is over and they bring us back to the base. Dinner is country fried steak, and as always it is mighty fine.

The new people from our division have come down and I give them tips on what to expect. "Its just like up North," I say, "You do ambulance calls, except the people are very thankful and the scenery is mindblowing. And you need to play with the stretchers before you put your patients on them. You'll have a great time."

Eleven-o'clock I'm in bed.

Day Six - Resiliency

I have breakfast with one of the guys from another division in our state who came down a day before I did. We talk about how a trip like this can change you. Any time you can get outside your normal life, it can't help but make you different.

What impresses me is the resiliency I see in people's eyes and their voices. You ask people for their address and they say, "Where I used to live? or where I'm staying now?" Maybe they haven't hit the angry portion of the grieving process or maybe they have just blew right on by it. I imagine what I would think if I saw my house flattened into a timber, a mound of wet irrecoverable junk. What would I grieve for -- a crushed car? a smashed computer? a lifetime of collected books ruined by water and mud? Seeing it all piled together makes me see how little material possessions mean. These people have made it through their darkest of storms, and in the morning, they look at their homes, and what they see rising out of the rubble of their old lives is their families, their grandparents, their mothers and father, their own children. "I lost everything, but my family made it through, praise mercy." I hear that over and over again. "My family made it through."

Another think that has impressed me is the kindness people have showed us. EMS people often complain this is a thankless job, but I have never been thanked more than in this last week. From patients to store clerks to people on the street, thank you was all we heard. It made you feel good about your life's choice of work.

I'm glad for the opportunity to come down here, and I hope more of my fellow employees will get to come in future weeks.

I work again today with the guy from Portland, which is good because he's a nice guy and I like having a regular partner. We are posted down by the water. There is a good breeze blowing, and I try to imagine what it would like to sit there in the ambulance as a hurricane came in. I imagine the ambulance being picked up and whisked away like Dorothy in Oklahoma, ending up miles away in a big tree.

We examine the Treasure Bay Casino or what's left off it. It looks like a true shipwreck.

Compare that to the photo on the casino's website:

Treasure Bay Casino

We park next to what once was a Burger King -- only there is nothing there but one table and chair.

It is surreal down by the water. The area is blocked off by razor wire and then only let down rescue personnel, construction workers and residents looking to go over the shambles of their homes. It is not uncommon to see rescue workers walking around with cameras talking pictures of the destruction like we are in some living museum. I have so far resisted talking any novelty pictures. There is a minature golf course where someone has put Humpty Dumpty back on the wall and police and firemen line up to have their pictures taken with him. At one house that like so many is just a slab, someone has set up a porcelin toilet. I have heard of people having their pictures taken, pants around their ankles, reading a newspaper as they sit on that toilet with all the outdoors around them. I have such mixed feelings about taking any pictures at all. I put my camera away, but then fifty yards later see something so amazing I have to take another picture. I waver between respect for what happened and the natural human desire to laugh. I finally relent and pose for a picture drinking a Coke at Burger King.

We give out some tetanus shots, then a car drives up and worker gets out with a huge gash on his arm where he cut it on a piece of tile. We wrap it and take him to the hospital. There we talk with the nurses about the coming hurricane. They call up satellite photos and path projections on the hospital computer and give us a lecture on hurricanes that is quite impressive. It seems just about anyone who has lived ten years on the gulf coast knows enough to be an expert. They talk about the pressure systems and barometer readings and cite how Elaine bounced like this, and Ivan turned right like this. They all think the new hurricane will turn right and hit right on the Texas Louisiana border. The real tell they say is to watch the weather channel. One of the old guys on their is the one to watch. Wherever he sets up is where it will hit. Old so and so always knows where the hurricanes are going. If he comes to your neighborhood ahead of the storm, look out.

We sit around. It is a quiet day. I eat an MRE for lunch. It is very good. Jambalaya. You drop the package in a plastic bag that has some kind of heating coil in it that is activated by water. It steams the meal in just a couple minutes. The MRE package also includes wheat bread, cheese sauce, a powdered grape drink and a pack of MMs.

Around one, they call us back to the base. It seems they are going to be taking our car and sending it to Texas to get ready for the storm there. Since it is slow, they tell us to take the rest of the shift off. I want to go back on the road, but they say they have enough cars on. I'm not happy to be sitting around camp. I'm down here to respond to help, but what can you do if you don't have a car. I guess the afternoon off is good for some of the people who have been here longer than me or who are less used to working every day.

I watch them prepare the ambulances, loading them with supplies and a portable generator. Two of the people going to Texas are guys who lost everything in the storm here. It sort of a good will message. You helped us, we'll help you.

The only benefit to being in camp is they are serving fried catfish for dinner, and it is some fine eating catfish. I eat my first dinner at four, then have a second dinner at eight.

That night I talk to a woman from one of our state's divisions. She has traveled all over the world on humanitarian missions. She has enjoyed her week here, but is ready to go -- a week is enough. There are emergencies at home too. We work in an ambulance, we respond to calls. There are people coming down to replace us. There are more than enough calls waiting for us at home as well. Wherever they need us, we do the same work, up there or down here.

Day Five - Such a Storm

I tell myself no surprises today. I get in my ambulance an hour early and check it out from top to bottom, then set it up the way I want it. I am pleased to find this ambulance has Haldol in its jump kit -- a day too late. The ambulances are from many states as is the gear, so each day is an adventure in what you will have to work with. While the Haldol is the good news, the bad news is the intubation kit only has the crappy disposable intubation blades (We tried them a few years back and had several cases of the blades bending) and an old Life Pack 10 lacking even the hands off pads. If I have to shock someone it will be the old fashioned way, lubing up the paddles with gel, and pressing them hard against the chest. BAM! I do confess I liked doing it that way.

Our first call is to one of the relief centers where we were at two days before, the one with the army people. I get an awesome report from the army medic, top to bottom assesment, history, almost down to the color of the patient's last poop. I complimented the medic on it. I was very impressed. The patient is an obese woman in her late sixties with some breathing difficulty. She is supposed to be on oxygen at home, but since the storm has had no power, consequently no oxygen. She also has been out of her inhaler. I give her a treatment and she is doing much better. As we go to the hospital we have a bit of a dialogue, though I have a hard time understanding her deep Mississippi accent. Here's about what it sounds like:

##############Since I was a chile##############such a storm################our boys over there######that man.#######################Thought I'd never see the day#################################It done takes the cake.####

***

More traffic. Unbelievably slow.

***

We get called for a guy who fell off a roof. These calls have been going out all day. There is hardly a roof that doesn't have someone up on it, working to repair or replace it. The man has fallen through the roof and landed on concrete twenty feet below. He may have had a brief period of unconciousness, but he remembers falling and is complaining of pain in his side and back. He has some welling and redness on his left flank. When I palpate his pelvis he feels pain and he can't lift his legs without pain, although he is able to move them. I find it curious that he already has a c-collar on while we are the first unit there. We c-spine him, and take him on a priority to the hospital. He is grey, clammy and has a pressure of barely 90, yet he is thanking me for coming down to help, and asking me where I am from. A little poke, I say, as I put a 16 in his wrist. That wasn't a little poke, he says. Sorry. He keeps his good manner.

It turns out he has a broken pelvis, broken ribs, and later a hemothorax. My partner solves the mystery of the c-collar. It seems a fire truck came by, ran in, put a collar on the guy, then said they were actually on another call and help would be there soon. Interesting.

We get sent on a priority one for an unknown and I don't know whether they have us in the wrong area or all the other cars on on calls, but it takes us 40 minutes to get there through the traffic, through my misreading the map (our map books were by quadrants, so you had to keep flipping pages), and one street sign turned around pointing the wrong direction. Anyway, it turns out to be a psych. He is bipolar and we have quite a conversation. He is down on a mission to help people, but claims his partner is holding all the cash and he hasn't been able to afford his meds. I'm sure his partner has a different story. He is from Boston and we talk about the Red Sox and before the ride is over I am assured he is personal friends with half the most famous sports figures in New England History.

Our last call is for a possible stroke. It is a small ranch house on a street just a block or two from other streets where all the houses have been destroyed. We find a woman in her forties sitting in a chair like she is paralyzed. Her mouth is shaking, her eyes look very scared, and she is crying. She seems very spastic. But her pupils are equal and reactive, her skin warm and dry, her grips equal. She can answer me in brief words, that are not slurred. The neighbor who called us said they were talking about their lives and they were both crying, and then suddenly she started acting wierd. She tells us the woman's boyfriend in on an off-shore oil rig. There is a new hurricane, already named Rita that is threatening to be as big as Katrina. I don't know what to think. The woman's pressure is good, but her heart rate is in the 140's. I'm guessing it is some sort of psychological episode, but I work her up anyway. IV, 02, monitor. At the hospital, when I walk by her room, she follows me with her eyes.

We have spaghetti for dinner. Every one is talking about the hurricane and where it will hit. It is projected for Texas, but one big turn to the right and it will right at us. "I hope it hits us," one of the guys says. He lost everything in Katrina. "We're already destroyed. No one else should have to go through that."

There is talk of moving some resources to Texas. I think about what the company has set up here and I have to hand it to them. I don't know what kind of arrangements they have with FEMA, but whoever is in charge of seeing that things get done in Mississippi, can easily put a check mark by EMS and say, "We got it covered."

Day Four - Oh Well/Mississippi?

I heard someone say the other night that while there are some regional differences, a paramedic is basically a paramedic and the practice is pretty much the same everywhere. I agree, but also part of being a paramedic is being comfortable with your equipment, with your setting, with your routine. A good paramedic can improvise, but it does help to have a certain underpinning like a captain who knows his boat and his area of the sea.

First call is for an unknown. The fire department arrives at the church before us and we find them grabbing a skinny woman who is screaming "Its a lie! Its a lie! I didn't kill myself. I didn't kill myself!" She is out of her mind. I hear someone say she has been smoking the stuff. The firefighters who are both big men, walk her out to us. She is fighting and now starting to spit. They throw her down face first on our stretcher. I announce that I want to sedate her. One of the firefightres says we are close to the hospital. Maybe ten minutes away. The woman is creaming spiting and trying to bite. "Let's get her in the ambulance and I'll sedate her," I say.

Under my protocols, I would give her injections of Ativan and Haldol and in two minutes she would be snoring. The gear in Mississippi doesn't have Ativan of Haldol. All I carry here is Valium. The problem with Valium is I can't give it IM, I have to give it IV. An additional problem is they don't carry saline locks, so if I want to give the patient Valium, I have to hang a bag of Saline. Whiule my partner spikes the bag, I put an IV in the back of her arm while the fire guys hold her down as she continues to buck and shout and spit and try to bite. He hands me the line, and I try to take it down -- they have no Veneguards. The poatient is diaphoretic, the tape sticks to my gloves. I finally get it taped down. I draw up the Valium, put it through the rubber port, then open up the line. It won't run. I know my line is good, but I can't get the fluid to run. I examine the drip set -- it is foeigh nto me. The roller clamp is above the drip chamber. I try to trouble shoot, but can't get it to run. I then have to find a syring, drwa up some saline and flush the the Valium in through the rubber port. It flushes fine, but still the line won't run. The next thing I know the IV has been ripped out in the patient's flayling and the Valium I did get in doesn't seem to have made any impact. We finally get to the hospital where they give her Ativan and Haldol and there she is sleeping like a Baby. I examine my Valium and discover I only gave her 2 milligrams instead of 4. I was expecting to give up to 10 depending on how she reacted. My mistake comes from the fact the Valium is stored in a syringe similar identical to the morphine we catrry back home and here in Mississippi. Execept the morphine is 10 milligrams in 1 cc, the Valium in 10 milligrams in 2 ccs. In the heart of the battle, I thought I was drawing up 4 mg, but in fact I was only drawing up 2. Not enought bay any means to sedate a person.

Oh, well.

At the hospital I beg the nurses to give me some saline locks and they are happy to oblidge. I want to ask for some ativan and haldol, but don't think I will get anywhere with that request.

We do a chest pain, which I think is just an anxiety -- a local business owner under stress. He thanks us for helping him. His ECG looks good, his skin is warm and dry, good vitals. He has had similar pain and be told by his doctors it is stress. Two nitro don't help. I work him up, give him some aspirin, some 02, but stop the nitro after two.

We do a psych -- an 18 year old who has been told to move out by his adoptive father. The cop tells me there are some 10-80s in the family. I think he means some of the family died in the storm, but I am told later that 10-80 is local slag for an AIDS patient. Eighty. AIDy.

The last call is a fall at the airport. A man who has been obviously drinking has taken a tumble down about ten stairs. The fire department has a c-collar on him. We board him and get him out to the ambulance. The man has no idea why he is in Mississippi. He claims no knowledge of the hurricane. I look at his license and the photo there is one a bearded madman. One eye closed, the other cocked wide. He looks like he has just beat his wife, kicked the dog, downed a fifth of jack Daniels and walked into a pool hall ready to fight.

I don't know if he has a concussion or is just completely hammered, but I work him up. He knows his name, social security number and home addresses, but he has no clue why he is in Mississippi. "Mississippi?" he says. "What am I doing in Mississippi?"

***

It takes forever for us to get from the hospital back to the base. The traffic jams are horrendous with so many roads closed. In the passenger seat, it seems like I fall asleep, open my eyes, and we're only ten yards down the road. I fall asleep again, open my eyes and we are still not through the light.

***

At dinner we talk about the new hurricane, Hurricane Rita that is headed into the Gulf. One of the local guys, who lost everything in Katrina says he hopes it hits us. "Everything is already destroyed here. No one should go through that."

Day Three - "Dooh!"/EGO

I sleep through the night. In the morning I have a breakfast of sausage, grits, biscuit and fruit.

I work with a nice 27-year-old guy from Oregon who would like to go to medical school. He has been in Mississippi going on three weeks so he is familiar with the roads.

Right off the back we are sent for a chest pain at one of the red Cross Disaster relief centers. I have told him I am a good map person, but we shoot by the road because there are no street signs. I have to gauge by the map and what appear to be roads and I misgauge. We swing around, and the delay is only a minute or two.

The Red Cross center is in an industrial park. As we approach the road is crammed on both sides with cars for a great distance. People walk along the sides of the road as if they are walking to a sporting event. There is a huge line outside the gate, mothers carrying babies, trailed by children of varying sizes, old people holding each other up. A guard lets us in the gate and directs us toward a big open tent. Another man points us toward a table where three woman sit, none of them looking particularly well. I ask who is sick and I am directed to two of the woman, who are both pale and diaphoretic. Their stories are similar. Both have had bypasses, one has two stents, both have been taking nitro. Both refuse to go to the hospital. The heat is over 100 degrees and sopping humid. Its just a little chest pain,” one says. “I’m feeling quite better now that I am in the shade. I appreciate your wanting to help, but I’ll be fine. I don’t want to make any trouble.”

I plead with both of them to go to the hospital, but the closest I get is calling their physician. The line is busy, the woman says, though I wonder if she has not dialed her own cell phone number. While I am talking to one of the other women, the other woman says. “Doctor, I’m feeling fine really. I had a little chest pain, but its over, what you want me to come to your office, after I’ve got my check, well, twist my arm, okay. Bye.” I have turned now and am asking if I may talk to him, but she shrugs and says “Sorry. I hung up. We both are going to see him later when we’re done here. Thank you for being so nice and caring about us.”

Just then, a large man profusely sweating man is being lead over by two others. He is only 37, but he has a history of an MI. he too has been gobbling nitro. “You can check me out,” he says, “But I ain’t leaving until I get my check. I waited sixteen hours yesterday. I’m not leaving.”

Nothing works, I make every appeal possible. Think of your family, think of the future. I don’t want to come back and have to pound on your chest. No go. He isn’t leaving. After giving them all aspirin (and doing 12 leads) we end up with three refusals, and a probably empty promises that they will call if they start to feel worse. The nurse has asked us if we can post a unit at the center. My partner tells me there are relief centers like this all over town with lines as long. I tell dispatch I think we will be sent back here and they have me talk to a supervisor who says he will look into it. I think you could easily lay out fifty cots and start running Ivs on all of them. Walking out there are people leaning against each other, holding each other up. The sun and humidity are brutal.

They send us to a new location, but for the rest of the day we hear other ambulances dispatched back to the center – for chest pain, for dehydration, for asthma.

We are dispatched to another Red Cross center. This line is just as long. This one has an army medical team assigned. We are the second of three ambulances –all arriving lights and sirens for unknowns within ten minutes of each other. An army medic gives us a quick briefing. We have lots of dehydration. We’re in there starting lines. Just go in and help us triage, take the worst ones, and send another ambulance in. It’s getting out of control. The scene is surreal, people in fatigues, crowds of people, a helicopter sweeps low overhead. We go in, and a woman in fatigues says, "We have a baby who isn’t responding. She’s been in line since six thirty this morning. I put an ice pack on her and she doesn’t flinch." I see the baby, and snatch it from the mother. I give it a little pinch and it doesn’t respond. “Let’s go,’ I say. It is too crowded and chaotic in there to do a full assessment. One ambulance crew is loading a large sweating man on their stretcher, the third ambulance is just wheeling their stretcher in now. I’ll let them triage, I’m taking the kid. We race out to the ambulance and I have my partner hang a buretrol, then get in the front and drive. I strap a tourniquet around the kid, but I see no veins. I hold a 24 in my hand, but I don’t have faith to stick. I get out the glucometer, and poke the kid’s ear. Oh, to hear the noise. She wakes up and starts crying like a banshee. Now kids freak me out, and I always want to be safe rather than sorry, but I am regretting that I did not do my patented grab a piece of their skin near their belly pinch and twist hard when I first held her. I was freaked out by their setting. This is just a kid who was tired and sleeping soundly, and who really isn’t very sick. It is certainly no longer an unconscious child. I feel silly at the hospital explaining that I think the kid in fact is really okay. Now that we are in the air-conditioned hospital, and the baby is safely in his mother’s arm, the baby stops crying and seems quite normal. Baby and mother are sent to the waiting room.

Our next call is for an MVA. We arrive to find a woman lying in the middle of the road. The fire department is already there and they have put a collar on her. She is alert, and seems okay. When her air bag went off, the she got out of the car, but then lay down in the road because she thought that was the thing to do. I get the stretcher and wheel it over. I look for the release to lower it, but I can’t find it. I nod to a cop on scene and ask him to take the head end, while I pull the foot release and we lower it down. We get the woman c-spined, and over onto the stretcher. I am at the head end now, and a firefighter is at the foot end. Ready to go up I say. He pulls the release and I lift up, but the wheels don’t drop. “You have to pull the release," he says. I look at my end and there is a release there too. We both pull our releases and the wheels finally drop. My partner has to show me how to put the stretcher in the ambulance. The head end has to go into a load position, then a latch is pulled, then the foot end, pulls a lever and the stretcher is pushed in. Boy do I feel stupid. I have never seen a stretcher like this before. The worst part is my partner asked me in the morning if I never how their stretcher worked. My internal answer of “Daah!” in the morning turned into "Dooh!" when I had to work the stretcher. You learn something new everyday.

Next we are sent to another hospital to pick up a man who has been having increased confusion and falls for a week. They did a CAT scan and it showed he has a subdural hematoma. One of his pupils has just blown. He needs to be transported to a distant hospital where they have a neuro ICU. He is a 73 year old with a thick Mississippi accent wearing a white tank top tee shirt. Between his accent and his confusion, I have a hard time carrying on a conversation as we race along the highway.

On the way back, we stop at a highway rest stop to get a hamburger. Gas is a little expensive down there.

We're posted in the outskirts off the highway. A guy approaches us and asks us if we have any glucometer strips. He is a nurse with a team who's job it is to check on the welfare of other nurses working in the disaster area, and they have a diabetic nurse in the hotel there who isn't feeling well. They have glucometers but no strips. His glucometer isn't compatabile with ours so he ends up asking if we wouldn't ind going in and checking on the nurse with him. We bring all our gear, including the glucometer and the heart monitor. There is another nurse in the hotel room with the nurse who isn't feeling well and she is somewhat offended by our presence. I go to take vitals and she says she has already done that. She tells us she has fully assessed her, she is a nurse and all she needs is the woman's blood sugar checked. My partner and I both have the impulse to slam her, but we don't. I think we handle her with respect, while still doing what we need to do. There is no sense in getting into pissing fights when the goal is to just help people. The ill nurse refuses transport. I have the offended nurse sign the refusal as a witness. She puts a lot of letters after her name.

We go to a waffle house to use the rest room, and end us in a conversation with a retired army chaplin and his wife. The chaplin, who wears an oxygen cannula has come down from Michigan on his home to help counsel people. he starts telling us about World War II, while his wife sits there patiently. We hear about the time the Germans came over the hill at them. We shake his hand, compliment him on his life and his heart for coming down to help people, then make our exit.

I start to think about the issue of EGO and what motivates us to "do good." Why am I in Mississippi? Is it because I am "good person" or is it because I want to be able to tell people I went to Mississippi so they will gather around and hear my stories? Am I pure of heart or does my heart have other motives? And does it really matter what your motives are if you are doing the work? I always want stories. I like to be able to say "There I was!" When I was a kid one of my favorite cartoons was Commander McBrag. His catch line was "There I was tiger in front of me, lion to the left, a band of savages attaching from the rear, an alligator filled swamp on my left."

At the camp one night there was a big debate over people who come for the wrong reasons. One person said they came because they wanted to help people, not because they wanted to say they were there. I don't think the reasons you do what you are ever so clear cut. One one hand we can puff out our chests and say we are here helping the victims of the hurricane out of the goodness of our hearts, which we are, but at the same time we are not volunteering in the strictest sense. We are getting paid to be here. Few of us asked what we would be paid or how we would be paid when we volunteered to go. I would have gone for nothing (as when I went to the Dominican I paid my way). But even if I wasn't being paid, it wouldn't be for nothing, because I would be getting experience in return, and experience to me is as valuable as money. I also go because it makes me feel better about myself. Would I go if it made me feel worse? There is some hardship in leaving your life at home for a week and sleeping on a cot in a room full of snoring people, but it is only a week.

The people who impress me the most down here are not the people from FEMA or the Red Cross or the ambulance or the utility workers, it is the common people -- individuals or small groups who have collected supplies from their neighborhoods, loaded up trucks and come down and passed the stuff out -- food, water, clothing, even money. No bureacracy, no processesing or paperwork, just getting the work done. There is a purity there that I admire.

Our company has a plan where you can donate some of your unused paid time off to fellow employees who are sick or suffering hardships. I have never done it. Maybe I should. I definately should. I should do it and not tell anyone, except whoever I need to tell in order to do it.

I admire anoynmous donors.

It is sort of like the old saying If a tree falls in the forest and no one hears it, does it make any noise? Of course it makes noise.

I read an article in USA Today about the guy who founded Domino's Pizza, then sold it for $1 billion. The guy gave up his yachts, his mansions, his rich life, and has very quietly been living a simple life, and giving all his money away to charitable causes, and giving it away without fanfare.

What would most churchgoers do when faced with this decision? Every week, you put a twenty dollar bill in the collection plate as all your fellow church goers look on. You have the choice now, of giving God or whoever $20 on the sly, which he will match also on the sly with the only sticking point being when the plate is passed to you, you have to pass it to the next person without putting any money in. So the church is getting $40 instead of $20 because of your choice, but all your neighbors now think you are a cheapshake, but you can't tell them why you don't put anything in. What do you do? It should be an easy choice.

I'm working on trying to be the best paramedic I can this week, and aside from screwing up with the stretcher, I feel I'm doing okay. I am besing excellent at using my name and the patient's name. I am also slowing down my talk, which I think is a good idea. Years ago I was a telephone soliciter for a national company, and when I would come to work each day, I'd get a new list of numbers to call. Some days I called people in big Northern cities like Pittsburg, others, I'd call customers in small towns in the South. I learned that what worked in one place, didn't always work in the other. In Pittsburg I used my best rapid fire TV/used car salesman voice "LetmetellyouDaisyHaveIgotaDEALforYOU. IamofferingyouTWOthat's rightTWOTWOsilkpillowsforthepriceofONLYONE. If I used that voice in the the small Southern towns they would hang up on me. I had to slow it down. "Well, hello...there..Daisy...How are you...this fine morning...Let me tell you why I am calling."

In addition to tyring to talk slower, I am asking myself in each situation, what does this person need from me. How can I leave them better than when I found them? The old chaplin in the Waffle House. We listened to his story about the Germans that he has told a thousand times, we complimented him and his wife. We tried to show that we valued him and appreciated him, then we left before he could tell us another story.

Dinner is over before we get back, but they have set aside meals for the later crews. Tonight there is pork and it is good.

I have no trouble falling asleep.

Day Two- Hellhound on My Trail

I sleep well thanks to the foam earplugs that drown out a room of snoring EMSers.

I shower, have a breakfast of sausage patties, poppyseed muffins and apple juice, then collect the truck keys, radio, and narc pouch(a fanny pack that included 20 of morphine and 20 of valium), then check out the gear. The ambulance has a life pack 10, a 02 bag and a medic bag with the drugs and IV supplies. I am disappointed to learn they don’t carry saline locks.

My partner is a woman with a thick Mississippi accent. I can’t make out what she is saying and when I tell her my name, she thinks I am saying something about a computer. I ask her how she fared in the storm, and she says her house made it okay, but she lost many trees. She looks tired, and tells me she overslept and had to rush to get in. She tells me a story about someone, but I have trouble following it – something about a relative wearing a life preserver to keep from drowning in a hot tub they are so drunk.

As we drive to our post, we pass a huge tent city and a sea of utility power vehicles lined up as far as the eye can see. The traffic is slow due to a convoy of Army vehicles. At least half the cars on the road are ladder trucks. We stop to get coffee and the parking lot is full of telephone repair vehicles.

Our post is in the north part of the county. The sticks. My partner says its no the best post for me to see anything. It’s slow up there and we could go all day without a call. A half hour later we get a call for an accident on a long country road and find everyone out of the cars. No one wants to go to the hospital, not even a young woman with a pretty good seat belt abrasion. We go back to our post.

We sit engine idling. Its 100 degrees and humid out. At least our AC works.

I read a book about the blues legend Robert Johnson, who was from Mississippi. He can’t play a lick, then disappears for a few years, comes back and is so good everyone believes he has made a deal with the devil to play like he does. He is the man who wrote “Crossroads,” “Love in Vain,” and “Me and the Devil.”

I watch “Love-bugs” on the windshield. I don’t know what the deal is with these two-headed insects that are everywhere. The bigger end drags the smaller end around. They appear to be two insects attached to each other at the but ends. I contemplate cutting the head off one to see if the other end will die. My partner tells me they are in fact two insects, and this is mating season. The bugs are everywhere. It is not unusual to see two or more couples going at it at the same time. The grilles of trucks that pull into the country store – a feed and saddle show -- are black with the bugs.

We get some walkup calls. A kid stepped on a nail. I ask him if he wants a tetanus shot – they give us a bag of the shots in the morning to give to anyone who needs one – but he got one yesterday from the car that was posted out there. Another young man asks me to take a look at his foot. He dropped a cement block on it two days ago. He has what looks like an infected wound on the top of his foot, and a swollen ankle. I press against the bone and he winces. “YOU need to go to the hospital,” I say. “I think it’s broken.” He just shrugs and says he isn’t done working for the day. “I’m not kidding. This isn’t going to fix itself. You don’t get care, you’ll be limping for the rest of your life.” “I got two more hours of work today. Can’t let the boss down.” He says he may go see a doctor when he gets off. A mother with a baby with a fever of 103.8 asks for directions to the hospital. It seems people are on the stoic side in this state.

We eat lunch at a gas station/food mart that has a small grille in the back. I order fried oysters, but they say since the hurricane there have been no oysters. Instead I get a fried catfish “po-boy” which is the catfish served on French bread. I also order fried okra and corn. While we are eating, two young men come in looking dazed. They are not from the neighborhood. They say they both lived down by the beach. “There’s nothing there,” one says. “Its all gawn. It’s all gawn.” They say they are living in a car.

I give the waitress a tetanus shot. Everyone else has had them. We go back out and sit in the ambulance. The sun is beating down hard now. The AC barely holding its own. On the radio, other cars are getting called. Nothing going on in our area.

There are some interesting bits in the paper. A family five miles inland has a three-foot shark in their front yard pond. The areas gold courses are chewed up, but a few have opened for nine holes. The local birdwatcher says birds are just now starting to return to the beach. The third oldest house on the Gulf Coast was completely destroyed.

The radio is reporting another hurricane brewing in the Gulf that by Wednesday should be due South of us.

At four my partner requests a post change and they send us down to a central area. The stores here are battered. On the main road, which is lined with strip malls, shopping centers and gas stations and fast food stores, there is hardly a tall sign that is now blown out. I see a chick-Filet Restaurant, which they do not have in the North. I savor their sandwiches, but they like most of the restaurants are closed.. An hour passes with no calls and they send us in. Instead of going right back to the base, my partner takes me down to the shore and it is there where I see what it is all about.

The destruction, particuarly along the waterfront was astounding. Miles of beachfront homes, apartments and businesses were no longer there. Further inland were homes crumpled into piles of lumber, others with roofs torn off, windows blown out.

It wasn’t the wind, my partner says, but the tidal surge. I later hear a tale of a man who tried to ride out the store in his newly built mansion. He had to climb to the fourth floor, where in the middle of the howling a neighbors boat appeared, and he and his wife got in it, and when they rode out, they were above the telephone wires.

I have often fantasized that is I lived in a shore town, it would be interesting to ride out a storm, to say you had withstood a hurricane, but a force like this – my lord. I think of people whose houses exploded in the surge and of those farther inland that filled with water drowning them in a matter of minutes.

The remaining houses were spray painted with Xs by searchers, noting the time and what was found. If a number appeared under the X, it stood for the number of bodies found in the home's rubble. A medic found a regular patient, known and loved by the local crews, drowned in her home. That house got a "1" under the X. They took a house sign from her destroyed home and posted it back at their headquarters with a note in loving memory of the woman they all had cared for.

No one picture could describe the devestation. The lense isn't wide enough to encompass the breadth. What you need is a video camera, and a slow drive along the beach road, recording the miles of destruction. A casino was ripped in half, with one half ending up a half mile down the road in the middle of the street.

Giant hundred year old trees ripped out of the ground, crushing cars. Entire apartment complexes obilterated.

Where banks once stood were now only concrete slabs and the giant cement vaults. Nothing else. A church showing only its beams and steeple.

As we drove along the road, my local partner pointed out what was once there: a good place to get $1 breakfasts, a bar that people went to on Friday nights, an expensive condo complex, a historic home. All of it vanished.

In thinking about what kind of force could make that damage I thought of Robert Johnson's famous blues line. "A hellhound on my trail."

Back at the base, they have dinner for us. They have hired a chef from one of the destroyed casinos and his lasagna is fantastic. As other crews come in from the road, I learn it was a slow day all around. The local operation normally handles the area with 14 cars. They have had upwards of 40 on post storm. People are worried things will start to get busy as people with chronic diseases run out of their meds, and when rebuilders come in and start getting on roofs.

The schedule comes on. I’m on 9-2100, which will give me a chance to sleep until I wake up. I stay up watching the news on a TV with bad reception. The sports is all about college football. No baseball scores and only two NFL games.

Day One - Special

We meet at the office and a chair van driver takes up up to the airport. There are five of us: two medics, two EMTs, and a mechanic. When we go through the ticketing the airline agent puts a red mark on our tickets and says, we're all special. I am thinking, isn't this nice. They are recognizing our efforts and are going to be upgrading us to first class or maybe giving us complimentary access to the VIP lounge while we wait for the flight.

When we go through security, we find out what the red mark means. We have been tagged as security risks (probably because we bought our tickets at the last minute). We stand with our feet spread, arms held out while we are beamed with electronic wands, and then frisked, and have to watch as they painstakingly go through every item in our bags.

The flight is uneventful. We are met at the airport by two company employees in a big yellow school bus. We find out both of them lost everything in the storm. The guy driving the bus has a tee-shirt that says "Everything is Good." The young woman tells us that the storm in their area hit rich and poor alike. People have empathy for each other.

As we head to the coast we begin to see the effects. At first it is just a few bent trees, some blue tarps on roofs, torn highway signs. We see a WA MART, a Burger King underneath a sign that has been blown out. The traffic is brutal as some regular bridges are out. In the water we see what was once a railroad bridge, but is now just unconnected trestles. We see uprooted trees. Boarded up stores. Some stores have "Open" painted on the boards or whitewashed wre windows remain. We see stores with caved in roofs. A motel appears open, but several rooms have no doors or windows. We go by a marina where a shrimp boat sits up on top of the supply store. It is not a sign boat, but a huge working shrimp boat. The woods are scattered with lumber and trash. We pass a large shopping center and see huge tents with a line or people standing outside. Small trucks pass us loaded with supplies, signs taped to their doors "Disaster Relief." They come from church groups. Volunteer fire departments. Some are just unaffiliated families who loaded up supplies from neighbors and headed South. The licence plates are from all over the US.

Another shopping center has a long line of cars in rows waiting to recieve supplies. I see pallets of food, bottled water.

People carry large bags of ice. Nearbye an entrepenuer sells t-shirts. "I survived the Big One - Katrina August 28, 2005" for $15.

We arrive at our base in an industrial park. The company headquarters has sprouted a tent city, rows of port-o-potties, decon showers, a mess, and supply areas. We are greeted and get a tour.

We are told not to drink the water. Don't even use it to brush your teeth. There are pallets stacked high with bottled water, and coolers of ice. We learn we will bunk inside in a large converted training room that now has rows of military cots. We get tetnus and hepatitis A shots, make copies of our licenses, and then are told we won't be going on the road until the next day. They are running 12 hour shifts. We will be paired with a local EMT. In disaster conditions we have full reciprosity and can practice under our own state's protocols.

It is now about four in the afternoon and they are serving dinner. I feel bad about eating without having done any work. The food is great -- steak, mashed potatoes, crawfish pasta, biscuit and turtle pie. I hear later they have hired a chef from one of the casinos that was destroyed in the storm.

I am wishing they would send us out on the road even if only for a few hours. I don't like feeling like the new guy in camp. I ask myself what am I anxious about. How different can it be? You're a medic. A call is a call. You're at home in an ambulance.

It is hot. We drink lots of water, sit about. There are people from all over the country here: California, the Northwest, Texas, Miami, Georgia, the NorthEast.

They give us tee-shirts to wear with the company logo on the front and on the back "Disaster Team Gulfport 2005."

Your car will be gassed, 02 changed, gear checked and ready to go for you in the morning, I am told. I get my shift assignment 530-1730. That suits me fine. The sooner the better.

I stay up till 10, have a good conversation with a doctor from out west who has recently been appointed the company's national medical director. He is a cheery, excitable man, passionate about his work. The medics at the table share some of the frustrations with the systems we work in. He promises the direction of the company in the future will be clinically driven. Clinical Excellence will be the focus. It sounds good to me. I know things move slowly in EMS, but I feel better about the direction of the company now. I hope the company gives him the backing he needs to reach his goal.

Many people in camp are going through caffine withdrawl. I hear something about a FEMA mandate against caffine in a disaster area because it dehydrates workers. So everyone now has intense headaches. I am going to need my Diet Coke in the morning.

Waiting

We were supposed to leave today, but just as I was getting ready to go out the door I got a call saying to stand down, the flight had been changed to tomorrow. I spend the day, cleaning the house, making last minute prepartions. We will be going to Gulfport, Mississippi where our company has a base of operations. I don't know exactly what I will be doing. It sounds like just responding to 911 emergencies in the area. I am told to bring a sleeping bag, an extra set of boots, suntan lotion, bug spray, and uniforms. I am going to prepare just like I did for the Dominican Republic, except I will make sure to bring ear plugs this time. I haven't really had a chance to talk at length to anyone who has gone down there. I'll see when I get there, I guess. I am just happy for the opportunity to go.

Mississippi

I'm headed down to Mississippi for eight days. I will post about it when I return.

Samples

Started the day off with a couple transfers, including another wait and return with a paraplegic, who had to go to a distant town because he couldn't get an appointment at one of the doctor's nearer sattelite offices. His complaint was he'd been having spasms. We get to the doctor's office, wait, wheel him into to a room, the doctor -- a personable older man -- comes down and talks to the guy for two minutes, tells him, he's going to order some blood work and send him for a scan. He wants to make certain there's not an infection. He writes the stuff up and that's it. he tells the patient a dirty joke. They both laugh, then we take the patient back. It seems like the whole thing could have been handled with a phone call. Total trip time two and a half hours.

One funny thing happened. While we were getting ready to go a pharmacuetical rep comes in and leaves the doctor five sample packets of a popular erecile dysfunction drug. The doctor makes a crack about how the company must be losing money if that's all it can afford to leave, so the rep goes back to his car and brings in another four sample packets. The doctor is extremely pleased.

Long day. I am working with a nice women, who is very short, which makes our lifting hard. My back is on the sore side by day's end.

Nothing really memorable. A syncope, a lacerated finger, a baby who spit up some blood, most likely from a bloody nose, a back pain, a man hearing voices and some transfers.

Empty Tray

I wasn't on the schedule but when I saw there were a lot of open shifts I called in and told them I could work, but then would have to let me go to the regional EMS meetings from noon to four, drop me off, pick me up, and they said fine, they needed people.

At the meeting we discussed intubations. We've been requiring all medics to complete a form documenting all intubation attempts, and we discussed early results and whether or not we were getting an adequate sampling. For instance, if you missed an intubation would you fill out a form? The guy reporting said while we obviously haven't been getting every form, some people have been honest. We even had one medic who wrote down, he tried three times. I'm remembering I just filled out my form, recording how I'd put the first attempt in the esophagas and didn't get it until the third attempt. I had to create my own box for the third attempt.

Intubations were easy for me in the OR. I nailed my first nine attempts, then missed like four in a row, badly shaking my confidence. I struggled my first year as a medic, then didn't have a problem for the next ten years until lately. I'm intubating less now even though I work more. I just don't feel comfortable. Maybe I've just had some tougher airways. It hasn't been -- in open up, see the chords, slide it in. Wham Bam done. I feel like a hitter in a slump. I'm getting the tubes, just not easily. I feel like I'm looking around, okay, let's see how do I do this? There's the epiglottis, lift up, no, the head positioning is wrong, how about some cric pressure, I think I see them, no, hold on, let's bag some more and I'll try again. Maybe I need some manniquin practice, or maybe just a couple people with easy airways to get back in the flow.

***

Did transfers most of the day.

We go into this room in the hospital, and the guy in the first bed is like 300 pounds and he has a tray piled high with food, and he is chowing down with a big smile on his face. "You're coming for him," he says. He points to the next bed, where there is a rather emacitated man with vacant eyes. His food tray is empty.

We get sent to a locked down unit for a transfer. We find a tiny blind old lady with no legs -- not even stumps -- sitting in the middle of a bed. She is so small, I could fit her in a backpack. We go through four security doors to get back out to the ambulance.

***

Right before we are set to get off, we get an emergency call for a difficulty breathing about two blocks from where we are posted, which is only about five minutes from the hospital. My partner is upset to be hit with the late call, but I say don't worry, we'll bang this call out quick, and still get off on time.

The house is cluttered with furniture and cabinets blocking doors, all of which will have to be moved if we are to get the stretcher in. I'm hoping this will be a very walkable respiratory infection. In the house are nine obese women. No men, no kids, just nine obese women, not one under two eighty. The biggest maybe three sixty. I ask what is going on, and am told the woman in the bed room has had pneumonia, but I can't go in the room because she isn't dressed yet.

"You called 911," I say. "We came lights and sirens, is this a medical emergency?"

"Yes, yes it is," one of the women says.

"Okay," I say then, "I'm going in."

"Okay, then, go on in. It's okay, its okay. He's a paramedic, he done seen naked ladies before."

I get a sudden horrible vision that inside the door will be the queen bee of obese ladies -- a naked Lady Jabba the Hut on her throne of matresses, surrounded by empty buckets of fried chicken and McDonald's wrappers, but it is just an ordinary regular sized obese lady -- maybe two sixty, and she is mostly dressed -- she has a bra on, and just needs a top. She feels hot, and her lungs are decreased. I ask her if she will be able to walk out to the living room, and she says, yes, but she keeps delaying getting up. She needs her cell phone. She needs her fan turned off, she needs someone to bring her someone's number. When I finally get her to stand, she seems already out of breath, so I have my partner bring the stretcher even closer, which requires more furniture moving. We finally get her in the ambulance, and I put her on the oximeter before I put her on the oxygen to get a room air SAT. It's 72. Her heart rate is 168. I try a cannual at 5, but that only gets her up to 90%. A nonrebreather brings her up to 98%. I do a twelve lead and it shows an SVT. I think the tachycardia is caused by the pneumonia, but it could be an SVT. It is an chicken or the egg question. I have her bear down, and the rate drops into the 140's with clear p waves. (When my scanner gets hooked up, I will put the strip in). I give her fluid and we head into the hospital.

We punch out forty-five minutes late.

Computer Woes

Still getting my computer fixed so yesterday's, today's and probably tomorrow's post will be delayed until Thursday most likely.

Sore Throat

We’re standing next to our patient on a stretcher in the waiting room of a clinic with 49 other patients. Our patient, paralyzed from a motorcycle accident, has a fist-sized bed sore on his bottom. We wait for forty minutes. There are no magazines to read, there is no TV to watch. I try to entertain myself by listening to the Spanish conversations going on around us. We are in fact twenty minutes early for his appointment, and then we are seen twenty minutes late. We take him down to an exam room where we wait another twenty minutes. A doctor finally comes in, asks us to leave the room while he examines the patient, then a moment later asks us to return so we can help him move the patient on his side so he can get a better look at the sore. We stay and watch him pack it. It looks good he says, no infection. Good? I wouldn't want one on my backside. It is nasty looking. We wait another twenty minutes for the doctor to come back with a pain prescription. He tells the guy that he’ll see him next week. Bt the time we have the guy back at his house – where we have to move a refrigerator a neighbor dropped off at his house, leaving it right in the middle of his handicapped ramp – two and a half hours have passed.

***

It’s a transfer kind of day.

***

Right before we are set to go home, we get sent for a choking downtown. We find the fire department standing around a guy on a low cement wall that is part of the landscaping. A tree looms over him. Even in the dusk I can see the man is purple. He looks dead. I am about to say, check for a pulse and start CPR, when on a sternal rub, the man takes one big deep gasp. I pull out the ambu bag, and hand it to my partner. I look at the man’s eyes. Pinpoint. Okay, I’ve got it now. It’s a heroin OD. I draw up 1.2 mg of Narcan and jab him. I am expecting him to wake up fairly quickly, but I get no reaction. Well, now his respirations have gone from 1 a minute to maybe 8. But he is still out of it. I draw up another .8 and hit him again. Still no response. He does have some alcohol on his breath, maybe there are other pills on board and his color is crappy. I decide to intubate him. I go in and can’t see the chords; I think I see them, when my partner gives me cric pressure. I try to pass the tube, but he says I am in too deep. I use the bulb syringe detection device and it confirms I am in. I bag once listening to the belly, and I hear the rumble of air down there, and quickly pull the tube. So much for the bulb detector device. I go in again, but can’t quite manipulate the chords into view. I reposition his head, and go in a third time. This time I see the chords, but no sooner have I passed the tube, then I look down and see his eyes are open, and he starts fighting me. I think what an idiot I am for tubing him before I have given the narcan time to work. I pull the tube. He raises his head, and mutters something. A passerby goes, “Good bless you people, you are terrific” I am thinking “right three tries to get a tube on someone who doesn’t need one. Impressive.”

Down in the ambulance, he drifts back off and starts snoring again. I try to rouse him with no success. I put in an IV, and give him an additional .8 of Narcan. That does the trick and he is alert and able to carry on a conversation. He did heroin, percocets and alcohol. He says it is only the second time he did heroin. He is very apologetic.

When I describe the call to the nurse, she tells the man, these guys saved your life. He thanks us again.

I am thinking. It is true we saved his life, but it was one of those calls where any paramedic with some narcan could have saved his life provided they recognized it soon enough. Not every paramedic will leave him with a sore throat, however.

I was surprised at how long it took the narcan to work. I did find this recent article suggesting that alcohol combined with heroin requires a larger dose of narcan.

The relationship between naloxone dose and key patient variables in the treatment of non-fatal heroin overdose in the prehospital setting.


I talked with a doctor about it later and he said maybe the initial narcan just didn't hit the receptors quick enough because the patient was so shut down. Maybe.

The sad thing is it isn’t the first heroin overdose I have intubated and had wake up on me with the tube in their throat. You are supposed to be aggressive with the airway, but sometimes patience is prudent. Years ago I used to always give Narcan IV, then I ready a study, which said IM was a better route because it worked just as fast as IV (when you allow for the time it takes to get an IV)and it is easier on the patient's system.

Intravenous vs subcutaneous naloxone for out-of-hospital management of presumed opioid overdose.


Not to mention the number of times I have given Narcan IV, had the person wake up and rip the IV out of their arm before stalking off. Some would argue, better to put them in the ambulance, and then wake them up as they are coming in the hospital door so you don't have the problem of the patient's walking off, and then later succombing to the heroin when the narcan wears off. But again I read a study that suggests the reoverdose just doesn't happen all that much if at all.

Assessment for deaths in out-of-hospital heroin overdose patients treated with naloxone who refuse transport.


***

Even though I work all the time, sometimes I feel rusty and off my game. It's definiately a drawback of spending so much time hanging out in waiting rooms for hours at a time instead of doing emergency calls.

Straps

50 year old male insulin diabetic found by staff with blood sugar of 53. Given glucagon, still out of it. He is still cool and clammy when I get there. I know the patient, having transported him many times over the years including this past Thursday. His sugar is 63. I give him an amp of D50. He wakes up, but is still groggy, almost postictal. He does also have seizures so maybe that is also involved, although no one saw him seizing.

He is alert enough to open his eyes and mumble some answers. We put him on the stretcher and take him to the hospital. On the way, he complains of back pain, which was bothering him earlier in the week. I undo the straps so he can can turn over. I go to call the hospital, and as I am giving the report, the triage nurse suddenly hears me shout "Hold on!" as I watch my patient do a sudden violent log roll, right over the side rail and down to the ground between the stretcher and the bench before I can reach him. Since my partner can't lift, and the man has no legs to grab, I have to reach under his arms and lift up, squeezing his chest at the same time he is grabbing the stretcher with both his hands resisting my lifting him. I finally get him back up on the stretcher and strapped down. I have rechecked his sugar and it is 300, so I am thinking he is maybe still postictal. Either that or he did too many pain meds or maybe even got some street drugs as has been known to happen at his particular nursing home.

In the hospital he thrashes around, calls the nurses "bitches" and the security guards who restrain him hogtying his stumps, "cop wannabees." The doctor ends up having to give him ativan to sedate him.

We are supposed to place three horizontal straps on each patient, and off the top strap, attach two vertical straps. In the suburban town the other medics had tied those straps under the stretcher so they are out of the way. While at first I was resistant to them, I do sort of like them, as they are not in the way too much and do hold the patients in better, particuarlly c-spined patient's (when the driver stops too suddenly) and stroke patients ( who tend to lean toward one side). This is the first time I have ever had a patient flop off my stretcher. I will try to be more vigilant with the straps in the future.

***

Brought in an old woman with weakness in her legs, having increasing trouble walking.

***

A man hit by the side view mirror of a passing car in a parking lot. He was more outraged than hurt.

***

A man with high blood sugar.

***

A woman with abdominal pain.

***

Another woman with abdominal pain.

***

After that one guy, none of the others hit the floors. I had them strapped tight.

I See Dead People

We took in a former EMT with chest pain. The man, only in his forties, has a history of multiple MIs, pacemaker, HTN, high cholestrol, IDDM. He stopped taking his meds a couple weeks ago. He has been known for being noncompliant with his treatment plans. I was surprised to see him. There was a rumor a few years ago that he had died.

At the time we had a number of EMTs who had recently suffered life-threatening health events. One had a brain aneurysm, another had attempted suicide. All three had either suffered cardiac arrest or at least were not expected to live. I was sitting in the base office one morning when all three happened to come in. None of them were working at the time -- they had all come in for various paperwork reasons. It was very strange sitting there in the room looking at them. I felt like I was in that movie where the kid says "I see Dead people."

***

A lot of EMS people don't take care of themselves, eating crappy, smoking, ignoring warning signs.

***

Took in a 76 year old man feeling weak. Guy had COPD, skinny barrell chested, on home 02.

***

I don't understand health professionals who smoke.

But I guess I should talk, I just hate a pepperoni and onion pizza.

Boots: End of an Era

I just retired my third pair of EMS boots in over ten years a medic, and put on my fourth new pair. The left boot ripped from toe to heel on the outside, seperating from the sole. I knew they were weak so I was carrying a new pair in my car. I just couldn't take them off until they had given it their all. Let it be said they died on the job, limping through their last call. Me and them, we walked some miles together.

***

Two calls so far today. A 230 lb young woman, stumbled coming down the stairs and hurt both her ankles. One was badly swollen, the other had a smaller hematoma. Her pain was 8 out of 10. After 10 of morphine, given incrementally, she was down to a 1.

The other call was very interesting. An elderly man is found on the sidewalk of a retirement community with a small abrasion on his head and a couple cuts on his elbows. The security guard says he was initially hypotensive, but is now normotensive. He is alert, denies any pain, has equal grips, talks coherently. He says he tripped. His wife arrives just then, says he has some dementia, and a history of both hypotension and falls. She doesn't want him to go to the hospital. I convince her to let me get him in the back of the ambulance, check him out, and if he checks out okay and she still doesn't want him to go, we will take him to their apartment and put him in bed. I am thinking he will probably check out okay. He is falling a lot recently, he probably just fell, and didn't even hurt himself.

She sits in the front and directs my partner to where their apartment is around the backside of the complex. The man is hemodynamically stable. I start asking him some questions, but he won't answer me. I try to open his eyes, and he keeps them closed. He will squeeze my hands, but will not say a word. I get the wife in back and ask her if this is like him. Not at all, she says.

He is now not responding at all. We go to the hospital on a priority. He starts to vomit so we roll him on the board. By the time we are in the hospital room, he is starting to posture. They knock him out and intubate him.

I'm glad we didn't leave him at home.

***

Did a cardiac arrest at a local nursing home. 92 year old male. Found not breathing. Staff started CPR. Called 911. The first responders applied the defibrillator. No Shock Advised. We got there. Patient asystole. Continue CPR. Intubated the patient, got the IV. 4 epis, 2 atropines. 20 minutes of ACLS. No response. Presumed the patient. Left.

I will give the nursing home staff credit. They did good CPR, helped bag the patient, were helpful and never got in the way.

***

Finished up the day with a decent asthma call -- I gave the patient two treatments and some fluid and probably should have called for solumedrol, and a refusal AMA of a prisoner with chest pain, who was expecting to be released and wanted to wait until the release was processed. She had a legitamete cardiac history and was having chest pain and was very hypertensive, but she wouldn't go.

While I was at the hospital with the asthma patient, I saw the doctor who took care of my earlier patient -- the guy with altered mental status and she said he had a massive subdural bleed.

People and Stuff

Well I'm at work and have a computer so I feel attached to the world again. Tomorrow I am hoping my partner out here will be able to take a look at my computer and fix it -- in addition to saving my files.

I feel bad whinning about being without a computer and having to pay a couple grand for some new front teeth in light of the situation down on the Bayou. It all demands a certain perspective.

I just read an excellent column from USA Today

"Stuff" Doesn't Matter

I mentioned before that I brought a lot of clothes down to the state armory the other day, and am regoing through my house to find anything I don't truly need that I can donate.

I have been upset by the government's priorities in recent years and by its complete bungling of the situation in New Orleans and the area both before and after the hurricane hit. By misusing resources, appointing unqualified people to key posts and just plain not showing needed leadership -- it has failed the American people. But I have to say my faith in the country has been renewed not by the politicians, but by the common men and women of the country. The number of people volunteering and giving freely is staggering, and being down at the armory, you couldn't help but be swept up by it. Clearly the storm has taught us that people matter. I'd like to see this lesson passed on beyond the moment and imbedded in our government policies permanently.

Here's a few other editorials and articles that I have found interesting.

New Orleans Growing Danger -- an article from the Philidelphia Inquirer last October forecasting the threat and possible damage from a killer hurricane.

New Orleans Crisis Shames Americans -- an early (September 4) BBC view of the crisis.

United States of Shame -- a scathing indictment of the government's bungling.

Americans Give Record Amounts -- an account of American's generosity.

Before the Flood -- a column about how Americans responded to the 1906 San Francisco Earthquake.

***

Two calls so far today. A syncope that turned into an AMA refusal, and a nursing home chest pain that seemed to be skeletal. The memorable part of the call came for me was the interaction between one of my partners and the patient. On Thursdays one of the people I work with is a wonderful 78 year old grandmother with bad hips who is sceduled to get another hip replacement next week so this could be her last call. The patient was a 50 year old double amputee, who used to be a big time colleg e football player and still has a strong upper body, residual from his youth and maintained by using his wheelchair. His back hurt and he was only comfortable on his side, so my partner asked him where he hurt and she started rubbing his back there. He basically rested his head in her lap and moaned softly while she rubbed his back. A 78 year old Italian lady who can barely walk herself and a tough guy from the inner city, who's had more than his share of hardluck. I'll never be a cynic when it comes to believeing in the inherent kindness of human beings.

***

Did a diabetic with a blood sugar of 25. Took an amp of D50, and then 12.5 grams of D10 (D50 in a 250cc bag of NS -- pt got 125 cc) and he was back to normal by the time we got to the hospital.

***

I just read a very interesting and thoughtful article in the morning paper, which I hadn't got to until now. The basic premise is that where have all these kind souls(donating clothes, food, and shelter) been when in our own city people are drowning in poverty. Shelters are overflowing, people are homeless and needy here.

"It's easier to drop off a check, a case of water or a few bags of diapers for the victims in New Orleans and feel like we did our part. Easier to avert our eyes when the calamity is just the daily drip, drip, drip of poverty all around us."

Sort of puts a damper on my self-congratulatory clothing donation at the armory. The writer has a point.

Drowning in Poverty Closer to Home

Sweaters

I'm posting this from a Kinko's work station for .20 a minute so I'll keep it short. Got my teef fixed yesterday. Good news was I didn't need a root canal and won't have to go to a peridontist, but the bad news is the bill was still huge. Still, if you are going to spend money, I guess your front teeth have to be high on the priority list.

Last night I went to the Red Sox game, and Big Papi hit a walkoff home run in the 9th. A great game. You have to enjoy moments like that.

I was going to do some chores around the house today, but they paged out an open shift so I am on my way into work. I just stopped at the State armory and unloaded five bags of clothes for the hurrican victims. I was ruthless going through my closet. Every Christmas I get a sweater from my father and his wife. They sit in my closet because I rarely wear anything besides my work clothes and then jeans or workout clothes when I am off. I piled a bunch of them into the bags. When I got to the armory, I felt good, but thought I should go back and get the rest of my clothes and bundle them up to.

I'm on a list at work to be sent down to Mississippi/Alabama to help out, but don't know if I will get deployed. They are sending five people every five days. I think the problem with me going is I work six days a week so it is like having to replace two people. We'll see.

***

Did five calls today.

An anemic lady from a nursing home with CHF history. Her H and H was low.

We got called to a local nursing home that also calls itself a "Hospital" for a patient unresponsive with a low BP and bradycardic. They had the patient in Trendelenburg and had two tiny bore IV's running (curiously one through an IV med pump, the other had a BP cuff wrapped around it). In the room were two nurses and a doctor. The doctor was giving a fairly long winded report to our fly car medic who had just gotten there. I got out the atropine and the flycar medic asked the doctor if he had given the patient any atropine. He looked befuddled. I gave the lady the atropine and and that picked her pulse up and got her BP up to the 90's from the 60's. She was hemodynamically stable after that, but still sluggish. We took her in and the hospital said she was hypothermic. Other than that, she was okay.

Did a similar syncope questionable vagal call later, a lady passed out on her way to the bathroom, and was hypotensive, but not bradycardic. She was unresponsive when we got there, but soon was back to alert and oriented. A little fluid and her BP was fine.

We were sent from the far northern part of our territory to the far southern part for a wait and return transfer. I was working with a small woman. We got out at the address and the door opened and out hobbled this man walking with two canes. He looked sort of like a giant dwarf with a long white beard. By giant I mean close to 600 pounds. The two canes and the shape of his body made it look almost like he was two people fused together. There was no way we were going to be able to lift him up on the stretcher, much less get him on it and into the ambulance. I guess there was a screwup and he was supposed to be sent the big ambulance we have that can accomadate out larger clients. Because it was already late, he had to reschedule his appointment.

The last call was "difficulty breathing" which turned out to be a Russian Lady who is on portable oxygen and was worried she didn't have enough oxygen to get home. The call took place outside a limmo company where the woman was involved in a shouting match with the limmo driver who was also Russian. Let's just say she was getting plenty of air to be able to shout at the limmo driver, who she has been having long running disputes with, the police officer and us. We cleared it no medical emergency as it looked like she had at least a two hour supply of 02 left.

***

I heard a third hand report about the conditions in Mississippi where some of our division employees have been sent. Our company has been deploying employees from across the company to help out down there. I guess a lot of people are getting sick from the water. They have been told to wash their hands with commercial sanitizer only. The devestation I guess has to be seen to truly understand. Hurricane victims are walking around like zombies -- they have no jobs, no homes. I also heard that the five day deployments are going to be changed to ten day.

Labor Day

Worked 13 and a half hours at holiday double time and a half pay. Slow day. Spent most of the time covering a suburban town.

1st call was a COPDer with dsypnea and dizziness. She turned out to have a rapid afib at 170. I gave her Cardizem and that worked well, knocking her down to 70.

Later we did a kid who had a sparkler blow up in his hand, and he had 2nd degree burns over his hand and all his fingers. I put moist dressings on the hand and gave him 5 of morphine.

Last call was for a woman with the flu.

The one thing that was nice about today was all the patients and their families were very appreciative of our help. Each time we said good by, they thanked us and they said it in such a genuine way that I really felt they meant it.

It was nice.

Plus we got paid.