Psuedo Seizures

Worked 16 hours. From 8 in the morning until four, did seven back to back calls.

1. a woman with chest and back pain
2. a woman with an anxiety attack
3. a woman who fell and didn't remember why, but had forgetfulness issues
4. a woman with the flu
5. a woman with pneumonia
6. a woman with pseudo seizures
7. An MVA with two refusals

The interesting call was the "pseudo seizures." We get called to a psychiatrist's office for a breathing but unresponsive patient. The psychiatrist is freaking out. She shouts "Hurry! Hurry!"

I see the patient slumped on the couch and it is apparent to me that the patient is having a psychiatric issue. Her eye lids are twitching, when I open her eyes, she rolls them into the back of her head. She fails the hand drop, etc. The psychiatrist explains it all happened when the woman was trying to explain what it is that happens to her. She gradually comes around, and opens her eyes. Her husband has arrived by then and explains that his wife doesn't want to go to the hospital because they think nothing is wrong with her. She's had all the tests. She is supposed to go in this week where they are going to put her in a room, take her off all her meds and see what happens to her over a course of days. She recognizes me as someone who has taken care of her before, including one time when she drove off the road and hit a tree at a very low speed. She says tearfully, "no one believes there is anything wrong with me, but something happens to me."

I don't know what to think.

She signs a refusal and her husband takes her home.

Yesterday

Three calls so far today. A lady with Alzhiemers battling pnemonia, an asthmatic in a doctor's office also battling pnemonia, and another 80 year old insulin dependent diabetic with low blood sugar. My preceptee missed all his attempts again on the diabetic patient, and I managed a 24 again on a tiny vein in the patient's hand. He is depressed about missing, but I explained to him the towns where I have now worked for many years are filled with obese Jamaican and African American insulin dependent diabetics with no veins. He has been precepting a month, I have been treating these people for over ten years. I really am not concerned with his IV skills -- they will come in time. Thought-process is much more important.

I didn't tell him I missed both my IVs yesterday.

Code Status

60 year old female with low temp this am (87.6) and low blood sugar(given 2 mg glucagon at 6 AM), now this afternoon (5 PM) has high blood sugar - 400 and a normal temp (98.6). Family wants her evaluated. Here is her medical history taken from the nursing home W10: HTN, CHF, dementia, IDDM, hyponatremia, dehydration, anemia, depression, PVD, seizure, GERD, acute respiratory failure, CAD, hypothyroid, UTI, mental status changes, agitation, dsyphagia, pancyoponia, bilateral urethra stents, chronic/acute renal failure, facial fractures, cellulitis, hematoma R hip, constipation, coagupathy, PE, GI bleed, hemolytic anemia, high cholestrol, mediastial mass, edema, high K, OBS, atonic bladder, DJD, hypocalcemia, hypoxia, sepsis.

Code status: Full

***

Did two false alarm medic alarms, then a realone for a patient who tripped in the bathroom, and had neck and back pain.

Our Backs

Three hundred fifty pound barely responsive diabetic with a blood sugar of 43 laying across her bed in a dark room at the end of a crowded hall at the top of some very narrow turning creaky stairs. Extremely poor IV access. No way are we carrying her down. Her family says she normally walks on her own. They think she missed breakfast this morning. My preceptee misses twice with IV attempts. I miss twice myself on tiny superficial 24 sized veins in her upper arm. I do not want to quit. We had given her some glucagon, but that didn't work. Finally I get another 24 in her upper arm and we push an amp of D50 through it. She wakes up and does not want to go to the hospital. Her family feds her and agreee to follow up with her doctor, and we walk back down the stairs with just our equipment on our backs.

We also did a psych and a woman short of breath on exertion.

Beta Testing

Worked 12 hours in the city. Did a wait and return transfer, a possible broken hip, a leaking diaylsis shunt, another hip injury, a prisioner with chest pain and old woman short of breath. I played around some with the laptops for the computer run forms. My preceptee did the paper run form and I did a sample computer form. The problem was one hospital didn't have a printer, the other's printer didn't work. Lots of little bugs in the program, but that's the reason for beta testing.

Not Good

Day off. I didn't really do much of anything and felt like I wasted the day. I wrote a little, but not particuarly well. There's days off where its good to do nothing and other days where its not. This one was a not good. I did call in and pick up shifts for the next two days.

Laptops

Had training today for the computer run forms. This is a pilot for what will one day hopefully be a statewide standard run form. We each get a laptop that has the special software loaded on it. You use a stylus pen. Much of the form is pulldown menus and checking boxes, but there is also an windows keyboard and there is handwriting recognition software. You sign your signature and it appears in the computer. When you get refusals, the patient will sign on the laptop. The computer puts it all together and at the hospital, you hook up to a printer and it spits out the run form. It was very cool. We'll start using it on Friday or Saturday.

Dilemna

Busy Day. Started off with a man feeling weak who we discovered was in a rapid afib. Since the new ACLS recommendations for rapid afib are "seek expert consultation" and since he was stable, I held off on the cardizem.

We did an old woman not feeling well, a man who had a seizure, a nursing home fall, and this call:

Dispatched to a nursing home for a woman in respiratory distress. The nurse meets us at the door and says the patient's pulse SAT is dropping. "She was in the 70's, then we put her on a nonrebreather at 4lpm, and she is now down to the 30's."

Do'oh.

We try to explain that unless you have the 02 up to 12 or so, she is just going to be rebreathing her own carbon dioxide. You might as well put a plastic bag over her head. But she needed a mask, the nurse says, her SATs were dropping. We try to explain, but she doesn't get it.

I look at the patient and ask what her code status is. She is taking shallow gasping respirations. They say she is a DNR, but a do intubate. Out in the ambulance while she is still breathing I intubate her. Inside they had a BP of 50/20. We can't hear an BP or feel a pulse. She is now in full respiratory arrest. On the monitor she is in a bradycardia in the 40's. Her capnography is 20, then slowly goes down to 14. We should be doing compressions, but she is a DNR.

I find myself in a little bit of a dilemma. I intubated her when she still technically intubatable, but now that she needs resuscitation do I stop bagging her? I decide to call medical control for permission to cease, which they give me. I detach the ambu-bag. Her rhythm stays steady in the 40's. She has no pulse or detectable BP. I stare at her. My partner throws a sheet over her. But then it suddenly looks like she is moving imperceptibly or is it just the shaking of the idling ambulance? I pull the sheet back. This is very confusing to me. She is a pulseless, apneic DNR. Her pupils are fixed and dilated. But her rhythm holds steady and her capnography actually rises. Maybe if I had a Doppler it would show she had a BP, and maybe even though I can't see it she may be breathing imperceptibly. She has to be if she is generating a capnography of 14. I would think anyone with a capnography of 14 has to have some kind of perfusion going on. Admittedly I could use a course in capnography because I am still new to it and have a lot of questions. But what should I do right now? I am uncomfortable putting a sheet over the head of someone who may not be completely dead. I don't know whether to start bagging again or what. If she wasn't a DNR, I'd be doing CPR. I look at the monitor hoping for the patient to brady down, but she stays strong and steady at 40. I call the hospital back and say, "About that presumption..." I tell them I am uncomfortable putting a sheet over her just yet, and will bag her, but withhold compressions. Just then she starts to brady down, and by the time I am at the hospital, she is almost completely flat line. I have stopped bagging her again. The doctor calls her dead and that's that.

***

The doctor later tells me that he has just read her recent discharge notes from several days ago she was supposed to be a DNI/DNR. He says I had to go on what they told me.

What to Do

Two calls. A woman who tripped and possibly tore a hamstring and a man in a nursing home with altered mental status.

I was talking with a long time medic today, who is also precepting a new medic, and he says he is losing interest in the job -- both as a preceptor and a medic. He is thinking about going to a national conference or taking some special training, such as pediatric critical care transport -- something to get him excited again. He says even though he is doing some decent calls -- three codes this month -- he just feels like a robot. He is working a lot of overtime while trying to get money to start a small business.

He also mentioned the company is going to be requiring preceptors to take a special course as well as writiten and practical tests and that there is already a union grievance against it. He says most of the exciting preceptors want to be grandfathered in. I have mixed feelings. It does seem to be a violation of the union contract. Precepting was put into our union contract a few years ago, which I think was a mistake. We are chosen based on defined criteria. We get a $1 extra an hour when we are precepting and 50 cents extra when we are not. Precepting is also now done a rotating basis so you get whoever is next up on the list as opposed to preceptees and preceptors matched up for compatibility. While I like the extra money, I don't think precepting should be done the way it is. I now have to decide whether to join with others in boycotting the process by not resubmitting an application or going ahead and signing up for the training. What to do.

Before I have had a minute to ponder what to do, the tones go off and we are off to a stroke. Another late call, another 7:45 punch out.

Pain Away

No calls all day until 17 minutes till crew change. Hip pain going to a distant hospital. He didn't seem in a great deal of distress until we got on the road and started hitting the bumps. I gave him some morphine, and then after the call had to go to our base hospital to exchange narc kits. I got off an hour and a half late. But I felt good because I took the man's pain away and he thanked me warmly when we said goodbye to him. A good day.

Day off

Had the day off. Slept, went to the gymn and had a good workout, went to the Federal Express Delievery Pickup Place and got my tickets to the World Baseball Classic, played some on-line poker, worked on my writing, took my girlfriend's kids swimming and cooked a leg of lamb. I'm working the next three days, and expect to pick up several extra shifts as well.

Crash/ A Cigarrette

I was in a crash today. I was in the back, helping my preceptee with an IV. I had just repositoned it to get a blood flow, and pulled out the needle, occluding the vein with my left hand while I reached for the saline lock, when all of a sudden we were decelerating and I started sliding, and I kept sliding and the next thing I knew I was in the net at the end of the bench. Our patient who we had c-spined after a fall resulting from a seizure and who was complaining of neck pain, slid some along with me until the harness caught him. Through it all I managed to keep his vein occluded and not spill a drop of blood. I did lose the lock and my preceptee had to draw up another one while we waited for another ambulance to come and take our patient. Fortunately no one was hurt. A car had pulled out in front of the ambulance and our partner did the best he could to stop, but made impact.

I love that net.

***

We did a call for a psych today. The mental health team met us outside and said they had also called the police because the patient, a large woman had seemed anxious today and they had noticed a knife near her which wasn't there when they had talked to her a half an hour before. They said she was prone to fits of temper in which she would actually tear a door off its hinges. We waited for the cops.

Once they came and we walked up the three flights of outdoors stairs and then forced the door open because she would not come to it, we found a completely bare apartment. I am always surprised when I walk into what is a fairly common occurance -- a psychiatric patient living in an empty apartment. There was a kitchen table with no chair and in the living room, there was no furniture, except the single folding chair in which the woman sat facing the window sill, smoking a cigarette. She wore a dirty flowered robe and slippers. She was about two hundred and ninety pounds. When the officer started talking to her, she turned her head around slowly and said, "Don't you be talking to me in my house. I don't give a good god damned about any of you, so for all I care, you can all go ahead and kiss my ass. I ain't getting up, and I ain't going anywhere."

One at a time we tried talking to her, and she was just getting more agitated. When it was my turn, she turned full on me, and I could feel hot breath coming out of her flaring nostrils. I just let her rant, and whenever she stopped to get her breath, I'd start talking again in a real quiet, slow voice. It didn't get me far, but at least it wore her down some. I discussed with the cop the various game plans. He wanted us to get restraints. I offered chemical as an alternative, but suggested we just try to get her to walk first. They stood her up and she started yelling, but once they cuffed her she calmed down. We walked down the stairs with her, and she was yelling again at the top of her voice about what motherfuckers we were and how the world was corrupt. When we got her down on the stretcher, she said her wrists hurt. I started talking to her soft then, and got her to agree not to fight us if the cops took the cuffs off, and in return we would let her smoke a cigarette at the hospital. She agreed. The cops were a little dubious, but since my preceptee and I are both over six four and two twenty, they agreed. She was quiet the whole way in. We got her a cigarette, let her smoke it, then walked into the ER with her. While we were still in the ambulance, I had a vision of us pulling her out on the stretcher and letting her smoke while still on the stretcher, and a newspaper reporter taking a picture of us "ambulance attendents" standing around letting our patient have a cigarette, and what a storm of controversy it might cause. Since she said she would rather walk in, then ride, we had her step out of the back of the ambulance, and so she was standing when he gave her the cigarrette. People seeing a photo in a newspaper might not understand the power of a cigarette. It often works better than brute force, better than pepper spray, handcuffs, Haldolol and Ativan.

In the ER, the nurse told her she had to pee into a cup. "I'm going to need a bigger cup," she said. The nurse said it was to see if she was pregnant. "I ain't pregnant," she said. "We require this of all females," the nurse said. "You're wasting a cup on me."

**

Did two other calls: a nursing home patient with pedal edema and a syncope with an elbow lac.

***

I was picked today to be one of the medics trying out the new laptop computer run forms. I'll get trained in a few weeks.

Feet Up in the Air

Worked in the city for the first time in a couple weeks. Did two transfers, a maternity, a motor vehicle accident and a lethargic Alzheimer's patient. I worked with two different people as my first partner went home sick half way through the day.

They sent us in at 9. I put my stuff in my car, we washed down the ambulance, and then since there was no supervisor there to take my narc keys, I tossed them through the window of the supervisor's locked office and plopped them down on his desk. This is common practice. Then I sat down and read the Newspaper to take up the last fifteen minutes of my twelve hour shift. Then my partner comes in the EMS room and says, the dispatcher says not to punch out yet. They just got a rash of calls and we are now the only ambulance they have available. Sure enough, five minutes later, my pager goes off. Priority One Call for a stroke. I can picture the woman as we arrive, seizing uncontrollably. I recall a news article I just read on an EMS news wire about an ambulance company paying several million dollars to a family who's loved one died because the responding medic didn't have the keys to the narc box in his ambulance. (Our narc box houses our morphine, Ativan, and Versed. Ativan is the drug of choice to stop seizures. If you can't get an IV to use the Ativan, we can use the Versed IM). I can't go on this call without the narc keys. I look at the window of the supervisor's office. I guage whether or not I can fit. The next moment, I am diving through, hands hitting the floor, feet up in the air. I get to my feet, feeling just like a cat burgler, snatch the keys off the desk top, and get ready dive back out when it occurs to me, why not just use the door, which I do, making sure it is locked behind me. I run out to the ambulance, where my partner waits, and just as we get ready to sign on, another closer car clears a refusal, and then get the call. We end up punching out on time.

Precipice

I'm working 12 in the city tomorrow. With all the days I've taken off in recent weeks, I am on the precipice of getting out of the habit of working. I'm looking forward to going in.

Slow

Two calls. A man from home feeling short of breath and weak with a low grade fever and a nursing home patient who was lethargic. It has been for the most part pretty slow out in the suburbs on my new days: Sunday to Tuesday compared with the Thursday through Saturday shift. I don't mind.

I expect to work some in the city this week although I am not on the schedule yet.

A Full Life

The call is in an exclusive retirement community up on the mountain ridge. Up here are half million dollar condos with BMWs and Lexuses in the attached garages. When we appear lost trying to find the address in the maze of roads with names like Winchester Park and Essex Manor a maintenance crew in a white truck with an attached snow plow asks us where we are going and then leads us to the address. They unload a snowblower and promise to widen the path for our stretcher when we are ready to come out with the patient.

An elderly woman meets us at the door and says her husband is upstairs. We do the best we can to wipe our boots on the Persian rug inside the door, but we still track dirt up the white carpeted stairs.

A small frail emaciated man sits on the bed making about as much impression into the mattress as a large pillow. He has big round eyes that show intelligence but lack liveliness. He has cancer and his doctor wants him brought in to the hospital due to his severe weight loss. While my preceptee evaluates him, and our other partner goes out to get a stair chair, I look at the pictures attached to a mirror that show the same man in better health: He stands with other men on a Western Prairie with high beautiful mountains in the background. He kneels smiling by a child who has mounted a tricycle. In a tuxcedo he has his arm around a glowing bride in long white dress. There are pictures of the same woman with a man of her age and three young children. A picture of a smiling woman -- more vivacious and twenty years younger but with the same features as the wife who met us at the door. On the walls are a golf flag that reads "U.S. Masters Peeble Beach 2004," a framed poster "Hal Holbrook as Mark Twain for One Night Only" and then, and I can't help but smile when I see it, a baseball pennant "Boston Red Sox World Champions 2004."

We carry him gently down the stairs, and place him on the stretcher and bundle him against the cold. As promised the sidewalk has been widened by the maintenance crew.

And that was our only call for the day.

White Out

Spent the night at the ambulance barn so I wouldn't have to drive through the snow coming to work this morning, and a good thing. There was a foot already on the ground when I woke up this morning. We took the ambulance out to get breakfast and encountered a woman who nearly rolled her SUV because she simply lost the road. She ended up in a ditch on the railroad tracks.

Coming back from the hospital after bringing in a woman with the flu, we lost the road ourselves briefly. Suddenly the snowbank was kicking up snow completely obliterating our windshield. It was white out conditions, snow fall at two feet and still piling.

We did an unresponsive diabetic and had to wade through four foot drifts to get to her house. She was a Jamaican woman in her eighties who lived with her sister. Her sugar was less than 20. We gave her an amp and a half of D50. She woke up slowly. We tried to tell her her sugar was low. "No, my sugar is high," she said, "I write it right down dere in de book."

"No, it was less than twenty."

"No, it isn't low. Me write it down in de book."

Finally her sister said, "Dis is anothder day now dear."

We finally got her straightened out and had her sitting at the kitchen table eating a big Jamaican meal of stew chicken and rice and peas.

She was amazed when we opened the door and showed her all the snow.

**

Two late calls -- a nursing home difficulty breathing and a thirty-nine year old with abdominal pain after shoveling. She checked out fine other than having abdominal pain when she made a shoveling motion. The call came in right at crew change when we were coming back from the hospital and it initially came in for some reason as not breathing. The patient wasn't done with the shoveling so we had to wade through deep snow drifts to get to the house. The patient was laying on the couch with her eyes closed moaning. We worked her up, but everything came back normal -- vitals, 12 lead, appearance, only the pain on the shoveling motion. She insisted on going to the most distant hospital so I got off late.

When I got home I couldn't pull into my driveway. The drifts were up to my waist. My driveway is thankfully short, but because it has high railroad ties on each side, it tends to collect the snow drifts. I was out there for about an hour and only got two-thirds of the driveway done. While I was shoveling, I thought about complaining about pain from the shoveling motion, but there was no one else home to shovel, and
I didn't think the local responders would appreciate it if I called 911.

Family

Went to the awards banquet for the volunteer ambulance. It was a nice event. Everyone dresses up -- men in suits, some in sportcoats, others in sweaters or simply clean shirts. The women do theirselves up to. It's amazing the change from uniform to being done up for the night. They all look really good.

The volunteers come from all walks of life: insurance, welding, housewives, retired computer people, engineers, government, nursing, sanitation, military, corrections, electricians, college and high school students, small business, retail, etc. One by one they are called up to get their certificates for years of service and recieve handshakes from the presenter while everyone applauds. 20 years, 21 years, 23 years, 26 years, 27 years.

I've been affiliated with the service for 13 years, first as a volunteer, then later as a medic. These people are like a family to me. I've been to their weddings, watched their children grow up, seen them battle cancer. I've taken many of them or their family members into the hospital. We've gone to funerals together.

We have a good time at the banquet, tell jokes and stories. Everyone takes a lot of pictures. When the music comes in, we dance. Every year my first dance is with my old Thursday partner Anita, who is seventy-eight and has two artiifial hips. She still rides the ambulance. Then I dance with Rosie, another old partner, who is half my height. Someone always brings out a chair for her to stand on.

It's a night for comraderie, a night to get to know friends better, a night that makes you glad you do what you do and grateful for the people you ride with.

Drove By

Not scheduled to work until Sunday. Drove by the gymn today, but didn't stop. Spent most of the day writing. Next week I expect to be back to my six day a week schedule.

A Truck

Another day off. Went to the gymn. I felt like everyone was looking at me like I was a recovering drug addict back at work for the first time in months. Look at him. He's emaciated. He used to lift the big weights, now he can barely lift the puny weights and he looks so out of breath. I came home and lay down. I felt like I'd been run over by a truck. Got to go back tomorrow.

Yeah, Right

I heard this on the radio today and then saw it on the internet.

***

Mouth-to-Beak Resuscitation Saves Arkansas Chicken
This chicken had lips, just not her own.
The Associated Press


ARKADELPHIA, Arkansas (AP) -- A retired nurse saved her brother's chicken, Boo Boo, by administering mouth-to-beak resuscitation last week after the fowl was found floating face down in the family's pond.

Marian Morris said she hadn't had any practice with CPR in years, but she was interested to see if she "still had it."

"I breathed into its beak, and its dadgum eyes popped open," Morris said. "I breathed into its beak again, and its eyes popped open again. I said, 'I think this chicken's alive now. Keep it warm.'"

She said she did not know how to find a pulse on a chicken.

Boo Boo's owners, Jackie and Becky Calhoun, put her in a large cardboard box containing a grain feeder and water. They also placed a heater nearby.

The chicken is called Boo Boo because she is easily frightened. The Calhouns thought Boo Boo was startled and flopped into the pond.

***

All I can say is this is probably the most ridiculous thing I have ever heard.

Fishing Pole

16 hours. Three calls. An 80 year old diabetic with a blood sugar of 22 who amazingly was still talking, although clammy as can be and very lethargic. A 90 year old lady with a fever of 102. And a man feeling dizzy and nauseous at work.

The diabetic was my partner's old grammer school teacher. After we'd woken him up and he was back to normal, my partner reminded him of the fishing pole he used to whack his inattentive pupils with. The teacher just smiled. He was known for that fishing pole, his wife said.

Drug Seeker?

Two calls. A syncopal episode and a person feeling dizzy. While at the hospital I got the chance to ask a nurse about the guy we brought in a couple weeks ago -- the young heart transplant patient with the diagnosed dissecting aneurysm who was experiencing sudden tearing back pain, and who was extremely anxious. The nurse said he was very squirelly with the doctors. They called the other hospital in town and found out he had been there the night before. They felt he was drug seeking. He ended up walking out of the ED and taking a cab to a third hospital. Going back and reading my entry about the patient, I can seek the drug behaviour. I'm guessing maybe he got hooked on pain meds post surgery.

Super Sunday

Super Bowl Sunday. I’m hoping for a quiet day, but we are busy right out of the box.

The first call is for a lift assist. We find an eighty-year-old woman sitting on the bedroom floor, unhurt. She says she just slipped off the bed, but can’t get up. She says she thinks her sugar is low. We check it and sure enough it is only 34. I give her some Dextrose, and then we go down to the kitchen and sit with her while she eats toast and jelly and eggbeaters. She says we used to come pick her husband up off the floor all the time, and took him to the hospital many times. Now we are coming for her. She says she hasn’t been eating enough lately. Being a diabetic and a dialysis patient, she has a limited diet. Her daughters want her to leave the house for an assisted living housing, but she is reluctant to move. It is after all the house she has lived in since they were babies. “I don’t know what’ll do,” she says. She eats a mouth full of eggbeaters, and then takes a bite out of her toast. “I’ll survive,” she says.

Call number two is for a man who has cut some fingers off with a table saw. We are at our headquarters so it is very easy for me to grab a big Ziploc bag load it with ice, grab a smaller Ziploc bag, and en route to the calls, put some sterile gauze moistened with saline. I also get my narcs out of the lock box, anticipating needed pain relief.

I should know better in EMS not to anticipate. When we get sent for a motor vehicle, and I toss a board on the stretcher before we leave the bay, it is never a transport. When I first started sometimes on the way to a cardiac arrest at a nursing home, I used to start getting my gear ready as we rode up in the elevator, attacking the defib pads, putting a stylet in the ET tube. Every time I did that, it turned out not to be a code. Preparation is good, but sometimes, you have to just wait until you get there. Today, even though we are updated that at least one finger has been cut off, when we arrive, all five fingers are there, along with their tips. It’s just a few lacerated ends.

As soon as we get back, we are sent for a fall at the hardware store, young child bleeding from the head. The young boy tripped and got a suturable lac on his forehead.

While we were out on these calls there were at least four other calls in the town that the commercial ambulance responded to. I’m hoping people are just out doing their business early so they can be safe at home for the Super Bowl. I get out at six and hope to be home in time for the kickoff.

***

4:30 I get a call at a group home for a 87-year-old man with extreme retardation and quadreplegia. He is barely four feet tall, completely contracted and with kifosis to such a degree that his head seems closer to his bellybutton than his shoulders. He is sucking pretty hard. I ask what his code status is. They don't know. They hand me the big blue book that has all his history in it. Normally, they are very reluctant to even let you hold the book to look for info, but today they send the book with him and no accompaning aide. This is a first. I think they are required to send an aide. I do see a TV on -- the pregame show. On the way to the hospital, after doing the 02, IV, monitor routine, I try to read through the book, but can't find anything about code status. They have pages logging the man's BMs, notating size, shape and color, but nothing about his code status. It is the first question they want to know at the hospital. Code status? I tell them I don't know. I tell all that I do know. While they are debating what to do. The doctor says anything done for this patient would be futile, we are suddenly aware of a smell. "Well," the nurse says, "At least I can chart his BM."

I don't get back until after crew change. I hear the opening kickoff on the way home, which is okay because at least my head is still on my shoulders and no one is keeping a blue book on me yet.

Again?

Worked eight hours today in the suburbs today. Did two calls. A 79 year old woman at a retirement community with chest pain whenever she took a deep breath. Had a low grade fever and was vomiting. And an 80 year old female with a trach that always gets plugged up. The nursing home panicks, calls 911, and then they suction her or she clears the mucus on her own. By the time we get there, the patient is back to normal. They still have us transport. We get to the hospital, the doctor sees the patient and asks sarcastically, "And why is Mrs M here today?" "A mucas plug." "Again?" He shakes his head. She'll stay long enough for them to listen to her lungs, take a set of vitals, and walk to the phone to call for a commercial service to take her back.

It was nice having three days off.

The Day

Interesting experience. I went to a naturalization ceremony at the federal courthouse. 52 people, including a friend of mine, were sworn in as US citizens. They were from all over the world: Albania, Argentina, Bangala Desh, China, Cuba, Dominican Republic, Ghana, Greece, Guatamala, India, Iraq, Italy, Jamaica, Laos, Nigeria, Pakistan, Palestine, Poland, Russia, St. Nevis, Somalia, South Korea, Sudan, Yugoslavia, United Kingdom. Very simple ceremony. The judge read a short speech, welcoming them all to the United States, encouraging them to vote and participate in our Democracy where they all now had equal rights and opportunities. Together they took an oath, recited the Pledge of Allegiance, and then one at a time went up and got their naturalization certificates and shook hands with the judge. There were many smiles in the room. Outside the courtroom, they were given a small US Flag. It was pouring rain outside. A person driving might notice the flags in the hands of the people hurrying to their cars or to the bus stop.

I imagined the celebrations that went on afterwards, all the different kinds of foods being laid out on tables as family members and friends gathered to celebrate the day.

First Hand

Had a very productive day. Rewarded myself in the evening by permitting myself to play some poker. The first hand -- the very first hand -- I won back all the money I had lost the previous night. Played for another hour and was up slightly more.

Poker, Beer and Life

I'm off for a couple days. Slept late, did some chores around the house, even some landscaping work in the backyard. Tonight I treated myself to a six pack of beer after dinner. I don't usually drink that much, but since I'm not working tomorrow, I thought I might just chill a little. Listen to some music, play some poker.

I finished the beer a couple hours ago, tried to get to bed, but couldn't sleep.

So I'm back up at my desk. I'm a little annoyed with myself because I have a long list of projects to take care of, and I know I will be tired in the morning.

I'm all for having fun and enjoying life, but as much as I love drinking beer, playing poker and listening to music, I can think of some things I might have enjoyed more.

At my age I don't like wasting time anymore, and that's what I felt I did tonight.

Maybe if I had played better I would have felt differently. I know I would have because I played rather poorly.

I didn't get very good cards and over time I became impatient which is a sin in poker. The cards don't go your way, you start thinking the dealer owes you, and then instead of putting your money in when you are ahead, you gamble and the cards still don't hit you.

I am not a big gambler. In fact, I am not a gambler. (At least not when I play smart). I play poker mostly as an exercise in discipline, but I did not have the discipline tonight. Blame the beer I guess. I actually like playing sometimes while drinking because it is test to see how you can handle yourself under adversity. Can you stay focused, even when distracted?

Not tonight.

It seems to me in life, you can be anything you want to be. You just have to put your mind to it and commit. You can't get lazy, you can't be undisciplined and you can never feel that life owes you.

I play poker to remind me of those things.

You have to work hard, be patient, stay focused, and when opportunity appears, put your chips in. Give it your best shot. That's not gambling. That's the way to live.

So maybe if it took an evening of drinking beer and playing poker and losing a few bucks to remind me of that, well, then maybe my evening wasn't wasted.

Tomorrow is a new day.