Overdose

Again, we're called on an overdose. Female, unconscious, breathing. Alcohol and heroin. Police responding as well.

My partner snorts as I manuver the ambulance down narrow streets with cars on either side, strobes reflecting from windows. "Unconscious? We'll see. Nothing a little narcan won't fix, in any case." She sighs. "I don't want to fight with someone, we just started the shift..."

The fire engine arrives a few moments ahead of us. I turn a corner and thump the steering wheel. "Go get 'em, boys! Make me proud!"

But when we arrive, parking in the middle of the street, one of the firemen sticks his head out the door before we're halfway up the stairs. "Grab your suction, we're working a code."

Oh, dammit.

She's sprawled out in a tiny living room. Nice enough house. A firefighter pumps on her chest; another squeezes a bag-mask. Two other people, friends of hers, I suppose, sit on a couch. They're arguing about responsibility, and who should or shouldn't have called 911, and so on and so forth. I try to tune them out.

My partner and I jump in. She starts an IV, remarking that she's surprised a drug user has such good veins. I get set up for the tube; take a look, pull back, confronted by a mouth much too small for the grandview blade. I stand up to swap blades. A couple of cops are standing at the door now, dark blue uniforms almost black in the poor light.

One of the friends is asking the firemen over and over, "What's happening? What's her condition?!" They've already told him that his friend's heart is stopped, that we're doing everything we can, please let us work on her.

Now he fixates on me. "Why don't you give her some narcan?" he asks, accusingly. "Come on, she was just breathing until right before you guys got here."

I look at him, look down at our patient. She's cool, mottled. She's been down for a while. Look back at him. "Narcan only works if her heart is beating, sir." I pop the old blade off, snap the new one on, click it open to test the light. "Which it hasn't been, since we got here."

"But, come on, she was just breathing, jesus, do something ... I mean, she's been like this for an hour, but she was breathing, come on, guys ...."

I look over at the cops, toss my head at the friends. "Them. Out of here. We need room to work." I turn my ball cap around backwards and nudge the fireman at the head out of the way, kneeling again, scope in hand.

The cops take the friend by the arms, out the front door, down onto the sidewalk, firmly but not unkindly. As he steps out the door I glance over. The lifepak faces me, yellow on black display glowing softly. The three lines are flat as the surface of a pond.

Empathy

We're called on an overdose. Wait for police. We sit around the corner from the apartment complex, fire engine and ambulance idling in the night. Before long the dispatcher came on the air -- "Engine 44, Medic 38, cleared in by police."

The man sits in a chair, nodding off. A few cops stand around, arms crossed.

"What's up?" I ask after introducing myself. One of the firemen wraps a blood pressure cuff around his arm.

"Nothin'," he says, slurring his words a bit. "'m fine."

"Then," I ask, a bit of sarcasm tinging my voice, spreading my arms to encompass myself, my partner, the firemen and cops, "why are we all here tonight?"

"I dunno," he said, obstinately. "Nothin' wrong w' me."

I sigh, put my hand on his forehead, flick my light into his eyes. Pupils tiny constricted dots, even in the dark room. I glance down at the monitor, showing the normal blood pressure and heart rate. I wave to the firemen. "Have a good night, guys."

As they filed out, I look down at the man again. "Okay," I tell him, not kindly. "We know why I'm here. What did you do tonight?"

He looks sullen. "Nothin'."

"Fine," I say, patience evaporating. "You can either go with me, or go with the cops. Which do you want?"

He mumbles something. I lean in. "What's that?"

"I said, I'll go with you."

In the ambulance, we get him out of his jacket. Track marks dot his arms. My partner looks the man in the eye, and says that if he has to stop the ambulance to come back and deal with any problems, he'll be angry; there aren't going to be any problems, right?

The man shakes his head. Tha ambulance jerks into gear. I take a deep breath, try to be less irritated with him, this stupid junkie who's wasting all our time, and lying about it to boot.

"Okay, friend. No cops here now. Just me, and I just want to take care of you. Can you tell me what you did tonight?"

A long pause. "Yeah, I did a speedball." A bit of shame in his eyes.

Alright. "Thank you. Coke and heroin, right?" He nods, and, the dam broken, readily answers the other questions I have. There aren't many, and presently I'm sitting writing my chart while he stares out the back window at the city lights.

Abruptly, he says, "I'm getting too old for this, man."

I look up from the paperwork. "I'm sorry?"

He looks over at me, obviously unhappy through the sleepy heroin high, and for the first time I really see him -- a man past 40, who hasn't been spared much, either by life or by himself.

A screwup junkie, yeah, but it takes a long time to get there. A lot of bad times, bad choices. There but for the grace of god ... Hell, and I'm not even a believer.

"I'm too old to be getting loaded," he says sadly. "I was trying to quit, man."

I set my clipboard aside, lean closer to him a bit, and smile. "And that's a good thing, trying to quit. So what happened tonight?"

And so he starts talking, telling me about his night, about how he's been clean, about how he fought with his wife, how he stormed out, about how he thought, well, everything sucks already, might as well get high. He tells me about how he wants to get clean, get into a program, but the lines are long, and if you relapse you lose your place.

By the time he's done talking we're at the hospital. I put my hand on his shoulder, tell him that he needs to keep trying, and that he'll get there. We put him in a bed in the ED. I shake his hand when we're leaving the room, tell him good luck.

Ten minutes later he walks out, AMA.

Cover

Out back of an apartment complex, one warm summer night, we find the man, pointed out to us by a concerned neighbor.

He's altered, inexplicably, unusually. Sweaty, staring into space, awake but not tracking, not interacting. Blood sugar, vitals, all fine. No track marks, no bottles, no evidence of substance abuse. No one knows him, at least not well.

We put him on the cot, put him in the ambulance. I wave off the firemen. Just gonna pop a line in. Take it easy, guys.

I set up a line, uncap an IV needle, grab a wrist securely, and poke the back of his hand. I barely break the skin before he jerks back sharply, groaning. The most response we've provoked so far.

I cuss, start to ask my partner to help me with the line. But even as we watch, his agitation level rises.

He goes from groans to an eerie yowling wail, and shakes his head from side to side. His limbs start moving, slowly at first.

I grab for the restraints. My partner starts getting the seatbelts on the stretcher lashed down tight. By the time I've got the zipties out, he's thrashing actively now. We're not going to make this work, not the two of us.

I rip my radio out, and shout over the screaming. "Medic 38, send fire back, code 3, we're fighting with one here."

However, this is what the dispatcher heard:

"Medic 38-- *GLAAAARGH!* --code 3-- *WAAAAAAAAAARG!* --fighting with-- *AIEEEEEEEH!*"

I toss the radio over my shoulder and jump back into the fray. I think I missed a few status check calls from the dispatcher. My partner is sitting on the patient's chest, trying to keep him from coming off the stretcher altogether. I am trying to get zipties around his ankles.

Ninety seconds have elapsed since I dropped the radio.

Suddenly I see, from the corner of my eye, a flicker of motion, out the back of the ambulance.

Motion, and lights.

I turn my head to see no fewer than six patrol cars sliding to a halt around the back of the ambulance, lightbars shutting down, doors flying open, and then a horde of grey-uniformed deputies are pulling our back doors open.

Shortly thereafter, our patient is secure, though still thrashing and screaming. One of the deputies pauses at the back doors, watching me draw up a syringe of chemical restraint.

"You gonna be okay?" she asks, concerned.

I reach down from the airway seat, swab the man's deltoid with alcohol, grab it securely. Slam the needle home and thumb the plunger down. "Yup," I say, sharpsing the syringe. "We're cool now. But thanks for the cover."

Bird

We carry the gear a few hundred yards down the dirt slope, to where the small group of people is clustered. The moon is just rising through the trees; it's a bit past one in the morning.

They've got a few blankets over him in an attempt to keep him warm. "My chest!" he says. "I can't breathe! Please help me!" Over and over, no matter what we say. His friends stay close, refuse to move, get in our way.

He's drunk. They're all drunk. They were playing around on dirt bikes and he crashed his. It landed on top of him, apparently. The offending machine lies a few yards away, dark and silent now. Sunday night was fun, but not anymore.

When I press on his chest he moans, but nothing crackles or scrapes or moves. We can't find any bleeding. He doesn't hurt anywhere other than his chest, but it's hard to get him to be quiet long enough to listen to his lungs clearly. He says he didn't pass out.

"Do you want the bird?" my partner asks. We're way out in the boonies. I think for a long moment, and look at her. "I don't know yet," I answer honestly. "Let's get him in the car, get him assessed better. I'm sure he's a trauma entry, but if there's nothing bad wrong, we could probably drive him..."

We board him, carry him back up the slope to where the waiting emergency vehicles sit, floods casting cool white light on the grass and trees, diesel fumes filling the night air. I cut his shirt off, ask the fire department EMT to get vitals, try and listen to his lungs again. Maybe a little less on the left, the hurt side? I listen again. Nah, they sound about equal.

But his fingers are cold, we can't get a sat, and even on a mask cranked to 15 liters he's saying he can't breathe. I throw the end-tidal on him, and though his CO2 is fine, he's breathing forty times a minute or more. The EMT says his pressure is a hundred by palp. I look down to my partner, standing at the back doors. "What do you think?" I ask. She shrugs. "Your call."

I look down at him, think for a second longer, let out a long breath. I can't find a big red flag, but he's obviously hurting, even through the ten beers. I look at the vitals again, look at him, look down at my dusty boots. "Hell with it. We'll fly him."

She nods, closes the door, talking to the fire department IC. Ninety seconds later, as I'm getting a bag of saline spiked, the portable radio -- forgotten on my belt -- beeps out tones. "Engine 305, respond for the landing zone..."

We bump and judder down the rough logging roads back to the nearest clearing, an opening on a hilltop. I hang on for the ride, get the IV in, try to get a sat, all the while talking to him and trying to reassure him.

When we pull up, I can see flares through the side window, and a firefighter in turnouts wetting down the dirt. My partner climbs in back. "Medflight is about five out. What do you need?"

"Well, I've got a line, and the EMT here is taking a manual pressure. I'd like a second line, but first listen to his lungs."

She listens, and goes from left to right to left back to right, and then to left again for a long moment. She looks at me. "How's his pressure?"

"Uh, one nineteen over sixty eight," says the young EMT. I'm already listening again, and now it's clear: the lung sounds on the left side are diminished, way fainter than on the right. I look at my partner. "Do we need to..." I ask, knowing the answer, probably, but wanting to have her years of experience behind my decision.

She reaches up over the patient, pulls open a cabinet, tosses me a paper-and-plastic wrapped package. "Get it ready, at least," she says. "I'll get you a second line."

I look at the package. COOK EMERGENCY PNEUMOTHORAX SET. God. I rip it open, dump the contents out. Get the valve set up. Put the catheter on the syringe. It's a three-inch twelve-gauge. It looks like a whaling harpoon. Jesus wept.

He looks up at me as I start counting ribs down from the midclavicular notch. I can hear the bird outside now.

"My chest hurts! Why don't you believe me?" He's almost whining -- but when I look in his eyes I can see the confusion and fear there, awareness that Something Is Wrong finally penetrating past the alcohol. I lean down to his ear. "I believe you -- that's why you're going to a helicopter ride! Hang in there. You're doing great, and we're going to take real good care of you."

I make the mark on his chest, a little X, and I'm relieved to see my hands aren't actually shaking. Outside, the helo is touching down. "Wait for the medflight nurse?" I shout. My partner nods, and a minute or two later a pair of red flightsuits climb into the ambulance. I give the nurse my report. She listens carefully to his chest and nods to herself.

"Needle him?" I ask. She shakes her head no. "His vitals are alright. We'll do it on the way, if we need to. Twelve minutes to the trauma center."

We roll the stretcher across the bumpy ground, crouching under the whirling rotors. Slide him into the bird, quickly get back out of the way. A minute later, as we huddle behind apparatus, the low whine ramps up to a full-throated roar. The wind and dirt and pebbles and twigs rip at us, and we close our eyes and try not to breathe. The pilot takes his time lifting off, and when I can finally open my eyes I see why -- he's done a Hollywood takeoff, straight up. Trees all around. The helo curves away, and I watch it go, blinking lights against the mountains and stars.

Behind me my partner swears. "We forgot to close the ambulance! There's dust everywhere."

Full Court Press

She was barely 50. Healthy.

Her husband woke up a little bit before 4am because she was snoring. He didn't say, but I imagine he nudged her, maybe asked her to roll over. And if this was a blog about something else, maybe she would have grumbled and flopped onto her side and everyone would have fallen back asleep and gone about their lives the next day.

But you already know that's not the case.

It's obvious when someone's coded out; there's nothing quite like the pale stillness that a lack of breathing and a beating heart brings. We georgia-lift her into the living room, and go to work.

Her heart was still quivering, a little bit, but not in any organized manner. After a minute or two of CPR, I push the yellow button on the lifepak. The whine is electronic, synthesized, a warning, rising. When it starts warbling I say "clear," unnecessarily, and thumb the red one. Unlike TV, when you shock someone in real life there's just a dull thud, as the capacitors discharge. Clunk. And they jerk.

I put a breathing tube down her throat. My partner starts an IV, and drugs start going in. The firemen keep doing CPR. Every few minutes I have them stop and look at the screen again. Every few minutes her family listens to the rising electronic whine, the "clear!", the clunk.

Eventually we go to the hospital. In the back, on the way, things change suddenly; the squiggling confusion is replaced with a familar, regular pattern, p-QRS-t, tight and clean. "Whoa," I say to the fireman who'd been doing CPR, and feel at her throat. Nothing. I press my fingers into the angle of her hip, feeling for the femoral artery buried there. Come on. There. A thready beat. I grab for the blood pressure cuff, grinning at the firemen. "Nice job, boys."

In the ER, she arrests again. More CPR, more shocks, more drugs. Back to a heartbeat. They do an EKG and see the heart attack we all expected. She needs the cath lab, Interventional Cardiology's Roto-Rooter. They come in from home. Twenty minutes or so.

She codes out again. The nurses are getting tired, so I do CPR for a while. The ER doc talks to me, as I do compressions, the quiet tones of one professional to another, talking about drugs and algorhithms. I make a comment or two back. Remind him what we gave her before we arrived.

As I sweat, pressing on her chest, the family watches from the corner of the room, and the doc orders more and more interventions, trying everything he can think of to keep her going. They take the dopamine off the pump and run it wide open. They hang dobutamine, levophed. Amio, lidocaine, mag, bicarb, vasopressin, boxes and boxes of epi. Antiarrythmics and vasocontrictors and buffers and pressors, as much as they can give.

Finally the cath lab team arrives. They take her. We clear, go and get coffee in the growing dawn, talking over the call. What an effort, we say. Full court press. I've never seen dobutamine hung in a code, I remark, and my partner nods. Rare, very rare.

It's our Friday, and we go home with the dawn. A week passes, days off, beers with friends, running with the dogs, sleeping next to my own wife. Holding her a little tighter, maybe. Sleeping a bit lighter.

On our second day back we return to the same hospital. The same shift of nurses is there. After we drop the patient, I go over to a couple. "You remember the code we brought in last week? The one we worked so hard? How'd she do?"

A pause. Their faces fall as they remember, and one sighs, ever so softly. The other nurse turns away.

"Oh," says the first one. "Her. Yeah. Well..."

Holes

"Okay, gonna be a poke here," I said, as the ambulance bumped down the road.

"Is it going to hurt?" he asked, apprehensively, looking at the IV needle in my hand.

I lowered it for a second, looked him in the eye, grinned wryly. "Bro," I said, "You just got shot."

"Oh yeah," he replied, carefully supporting his bandaged, grazed hand, adjusting his legs to avoid putting pressure on the superficial, in-and-out wound on his calf.

"Alright," he muttered to himself as the needle went in. "I'm strong. I'm strong."

"Yeah," I told him, smiling, trying to put him at ease, attaching the IV tubing. "Yeah, you are, and you're gonna be just fine."

Headaches

When the tones went off I'd been asleep for maybe an hour, in the recliner. "Ladder 12, Medic 38, an unconscious unresponsive..."

Goddamn. We already worked one code tonight.

Outside, my partner is sitting in the ambulance, doing his crossword. I look at the computer as I hop in the driver's seat. Female, unconscious, heavy breathing, the notes said. Good. Not a code.

When we get there a quietly anxious man in his thirties leads us back to a bedroom, where a woman about the same age is in bed, barely awake.

The husband describes, while trying to wrangle a pair of small children, what sounds like a seizure, and she's acting like someone who's just had one. Vital signs are fine, and she's starting to come around. We wave off the sleepy firemen who come trailing in after us.

History, we ask? None, he says, shrugging, a kid on each hip. No medical problems. Oh, but she's had these headaches, real bad, for the past week. Nothing else, though.

Well.

I take the gear outside, bring the stretcher in. She's awake and halfway alert now, and gets dressed enough to go.

The house is the kind of happy shambles a young family makes, with clothes and legos on the floor. The older kid bounces around a bit, pointing to her younger sibling and saying, "Baby!" and then to us and saying, "Medic!"

It's adorable.

The father loads them up in his car as we load her in the ambulance. I walk back over to the front door. You know how to get to the hospital? Okay. We're not using lights and sirens; you can drive easy too.

On the way, as I drive, my partner does the necessary procedures and checks -- IV, EKG, etc -- and talks to the woman. She wants to know what's going on, and he explains she's probably had a seizure. Why? Could be a lot of different things, he says. Maybe a metabolic imbalance, blood chemistry off, something like that.

He says that and I want so hard, so much, to believe it, to believe that it's just a little metabolic imbalance, that she'll get checked out and ok'd and sent home in a few hours.

I want to believe that a week of headaches and a new-onset seizure at thirty doesn't scream brain tumor, malignancy.

I also want to believe that the little bit of welling in the corners of my eyes is just exhaustion, the end of a long night, but I can't fool myself there, either.

De Profundis

They say you become cynical, working nights.

They say that you get tired and worn around the edges, trying to sleep fitfully through hot summer days and the lives of everyone else, waking up for dinner, saying goodnight to your kids as you leave for work.

They say that nights are ninety percent bullshit and ten percent ohshit, and that the former makes you tired and bitter towards humanity while the latter takes years off your life and puts white in your hair.

They say, they say, and all of them are correct. (With apologies to David Drake.)

And yet ... every night you get to watch the sun rise.

And for every drunk who wants to fight, for every idiot who needs an ambulance for a tummyache at 3am, for every stupid nursing home that has to "send one out" at the end of your shift, there is a poor dumb scared kid who just wrecked dad's car and just needs their hand held. There is a sick, sick, bad sick old man who has been waiting and waiting, hoping his chest will stop hurting or his breathing will get better.

And sometimes, usually when you least expect it, there is someone who truly needs an ambulance and truly needs advanced life support; not just a ride to the ER but all the care you and your partner can give them.

And that, I suppose, makes the cynicism and trying to sleep in the light and the endless parade of big white taxi rides -- it makes all that okay.


(Welcome back, folks.)

Epic

Saturday morning. The whole call is like a movie.

*BEEP* *BEEP* *BEEP* "Engine 401, Squad 402, 4809, Engine 95, Medic 105, an echo response, cardiac arrest, across from Fargone Park, 49600 Wayout Road. Map page 6295-D, working Tac 2, time out eight thirty two."

We're a block from the fire station, going on a non-emergent walk-in sick person. My partner grabs the radio microphone. "Medic 105, we're diverting to the echo response at Fargone Park."

I hit the red EMERG MASTER switch, twist the siren knob to WAIL, and off we go. It takes us about eight or nine minutes to get there, hauling butt, and we beat all the fire responders (volunteers and paid from two rural departments).

About halfway there we get the expected update that CPR is in progress.

It's an area I don't know well at all, but my partner directs me; left turn, right turn. I drive hard -- either the gas or brake is all the way to the floor, the whole time.

We scream across a bridge, and we can see three or four people gathered around a man lying half in a mud puddle, doing CPR.

My partner bails out almost before the car is stopped, shouting to the bystanders, "Don't stop!" He grabs the monitor. I grab the hard plastic medkit and skid it across the pavement towards the patient, then sling the airway bag over my shoulder and run over. My partner drags the patient out of the mud puddle and the bystanders start compressions again.

They're doing good CPR, damn good in fact. They've taken a class recently and know the new standards.

Great. Keep going.

I pop an OPA in and start bagging. My partner gets the patches on -- "Check a pulse! None? Okay, we're in PEA. Continue CPR!" and starts getting stuff ready for a line.

I hear a growler siren and glance over to see the first of the calvary -- the squad and the duty officer -- pulling across the bridge. Brilliant.

A moment later we've got four or five firefighters eager to help. They take over compressions and bagging. My partner has an IV in, and starts pushing drugs. I rip open the airway roll and get my stuff set for a tube.

When I'm ready, I nudge the fireman aside, twisting my baseball cap backwards so the bill is out of the way. Drop to my knees in the mud, wipe rain off my face. Everything tunnels down to the narrow world of laryngoscope and mouth.

Suction.

Slip the blade in.

Look. See the cords. Lose them when I go to pass the tube.

Esophageal. Crap. Out.

Fireman bags. Adjust the tube.

Suction again.

Look again. A hint, a glimpse.

Lift his head all the way off the ground with my other hand. There. Bullseye.

Get a fireman to support the head. Cric pressure from my partner.

Perfect. Pass the tube, pull the stylette, inflate the cuff. Attach the BVM.

I bag as my partner listens. Good tube. My first in the field, after a frustrating series of misses and failures.

And the code goes on. I drop a second line and we start a fluid challenge. The PEA goes to v-fib and we start shocking him. We push the drugs: amiodarone, lidocaine. The v-fib continues. At some point the two engines, from different departments, show up. We keep rotating compressors for good CPR. At some point I run to the car for more epi.

The v-fib keeps going, and we've got to transport. Load him on a board, to the gurney, to the car. I get an escort by the duty officer's SUV out to roads I know. Manage not to throw my partner and the firefighters around too much.

By the time we're at the hospital he's in asystole, and been down over an hour. I code-surf the gurney in to the ED, doing good hard compressions. About eight minutes after we arrive the doc calls it.

My partner, running out immense code summaries, tells me they pushed twelve rounds of epi. We have to go out of service to quarters to get more drugs.

As we're leaving, I note that one of the bystanders seemed very emotional, on scene. "Yeah," my partner says, "it was his brother." They were enjoying some Saturday morning fishing.

I don't know if I could do CPR on my sibling.

And it was good CPR, too.

The Apartment Fire

It was about 9am, on a quiet morning just before the winter holidays. I was driving. My co-trainee rode shotgun. Our field training officer (FTO) sat in the jump seat in back. We were headed for a station in the southeast part of the city. Then the radio crackled to life.

"This is fire dispatch calling box 8513, report of an apartment fire..."

East of us, in a large suburb. We heard the assignment go out and clicked our second radio over to the operations channel. The first-in engine arrived and sized up what sounded like a decent fire. More apparatus arrived, and then --

"Dispatch from Command, start us a code 3 ambulance."

My co-trainee and I looked at each other. "Are we closest?" I asked.

"I don't know," he said. "Maybe? Levels are low..."

A few more seconds went by. "Huh," I said. "We must not be--"

Five things happened at once. Both of our radios alerted, an unmistakable BEEP BEEP BEEP BEEP. The computer bleeped a priority tone, doo-doo-doo-DEEP. Three pagers started vibrating. A screenful of information came up on the computer with the highlighted text ASSIGNED in the middle. And the dispatcher told us we were going out to the fire.

I looked at the address, asked over my shoulder to my FTO, "Straight out this street, right?"

"Yup," he said. A second later he added, "Only about a hundred and ten blocks away." The gas pedal was flat to the floor before I even hit the switch.

Forty blocks later, fire command updated us: "You have one patient, he'll be in front of the truck company on the east side of the complex."

Oh good, we thought. One patient. Three of us, we should be able to handle it, even if he's badly burned and needs tubed, or whatever. We got it.

"Additional for the medic unit, your patient has lacerations to his arms from glass."

Oh, jeez, we think. No problem at all. We're golden. We got it.

In thinking this we forgot the cardinal rule of emergency medical services, and indeed any 911 response: The radio always, always lies.

* * *

It wasn't hard to find the complex. Usually we respond to medical calls with a single piece of fire apparatus, and if they've arrived first the last directions from the crew member with the mapbook go something like, "Turn right on 42nd and look for the marker truck." A thirty-thousand-pound red truck covered with flashing lights is an excellent indicator of where the call might be.

In this case, there were six or seven such vehicles (five engine companies, two truck companies), plus a few command SUVs. We found the specified truck company and parked behind it. It was beginning to rain a bit. As we're climbing out, a firefighter comes hustling up. In all his turnouts. With his airpack on.

"Hey," he said, sounding a bit worked up, "we need your airway kit over here!"

Airway kit? I thought. For lacerations? Maybe he got some smoke too... I asked my co-trainee to grab the kit and I followed the firefighter. He led me right past the truck, and across the parking lot to a small SUV with the back hatch open.

Standing next to it, wrapped in a blanket, in pajamas, was a woman in her twenties, with soot on her face, darker under her nostrils and around her mouth. Tear streaks cut across the black.

Inside the back hatch, also wrapped up in blankets, were three kids -- a two year old, a four year old, and a six year old -- all with soot-darkened faces. One had a cut on his forehead, and dried blood streaked his face.

I'd like to say that in the five seconds before my partners caught up with me I thought something like, okay, four patients, we'll need at least one and maybe three more ambulances, and we'll need them all on high-flow O2 for CO poisoning, and we need to first off evaluate them for airway burns because we may need to tube them early, and we should probably declare a Multiple Patient Scene and get fire medics to help...

But the truth is, in the first few seconds, I could only stare at them and think, very loudly inside my head: Oh, sh*t.

* * *

My training officer took one look and came to all the conclusions I didn't. "Give me your radio," he said to me, "and get them to the car." He turned away, looking for the command officer for the fire, and said over his shoulder, "High flow o's, and check their airways!"

I looked over my shoulder. It's just me and my partner trainee. I ask the kids, "Are you okay?" and get solemn nods in return. "Okay," I say. "We're going to go over to the car now." I picked up the smallest one and handed him to mom. We got the other two, and all of us walked in the light rain to the ambulance.

We got everyone settled inside, and then it really got fun. A firemedic hopped in (fortunately she'd ditched most of her gear) and so there were now 3 paramedics and 4 patients in the back of the ambulance. Thank god we have the Type III boxes, but even so it was cramped. Everyone's airway got evaluated. Things looked pretty good for the kids, but mom had some soot in her throat. Everyone got on oxygen (just imagine the hoses snaking from two wall-mount ports and two portable tanks).

At some point my training officer stuck his head in the door and told us, "I declared a Multiple Patient Scene [sort of a low-grade Mass Casualty Incident] and we have a second ambulance coming. Do we need more?" My trainee partner and I looked at each other, looked at the kids, and shook our heads.

The denouement of the story is sadly -- or rather, happily -- quite boring. The other ambulance (coincidentally our sister car, working the same hours as us) took the two older kids, and we took mom and the youngest. I drove, with my partner trainee and FTO in the back. They thought about tubing mom -- apparently in the right sniffing position you could see soot all the way to her epiglottis -- but decided to hold off.

Everyone did fine at the hospital. Mom never did get tubed, and everyone's carbon monoxide levels came back low enough that they didn't need hyperbaric oxygen or even to be admitted. They left the hospital before we were off shift.

And our original patient that we never actually saw, with the lacerations? The heroic neighbor kid who discovered the fire, and punched out a plate-glass window to alert the family when he couldn't get in the door. He went by personal car to the hospital, and got all the media attention.

Well, almost all -- there was a lovely shot of our FTO's butt on the 6pm news. You'd better believe he heard about that.

Glimpses

Friday, noon: We crouch and kneel and stand, six of us, around a middle aged woman sitting on a chair in a department store. "I took a bunch of my anxiety pills," she says, sleepily, with pinpoint pupils. We struggle to start an IV, and eventually give her IM narcan. She perks up, and as we take her out to the ambulance she asks me, all of a sudden, "How long ago did you narcan me?" In the back of the ambulance she gets upset with my partner. Shouting, screaming, cursing, she admits to using heroin. She rips out the line we'd finally established, and tries to get off the gurney. A flexcuff keeps her down. As we take her into the hospital, she asks, "Why'd you have to f***ing narcan me, you a**holes? Why don't you just put a f***ing bullet in my brain? Just put a bullet in my brain!"

* * *

Friday, sunset: I sit in the cab of the ambulance, at a post that is close to huge bluffs overlooking the shipyards. It's unseasonably warm and smells like spring. I turn up the radio, roll down the window, pick up my book, and marvel that they're paying me for this.

* * *

Friday, night: She looks up at us sleepily. "I don't want to be here anymore," she says. As the firefighters try and get vitals, and the fire officer and some cops try and make sense of the pill bottles, I ask what she took. Something. Everything. We finally get a good list of the empty bottles: Atenolol. Xanax. Prozac. Nifedipine. Digoxin. We take her to the nearest hospital, code 1, no lights but a quick trip. They put her down, tube her, muttering urgently about the Digoxin in particular. I listen to a nurse talk on the phone as she draws blood. "We need ten vials of Digibind. ... What? You've only got five in the whole hospital? ... Well, get more! I don't care where from."

* * *

Saturday, evening: The three huge beers he had only compounded the pre-existing brain injury from a long-ago trauma. Somehow he set his hair and head on fire with a lighter. His wife, anxious, says he told her the lighter exploded. I look the offending implement over with the fire officer. "What do you think?" I ask him. He looks at the patient, looks at me. "Operator error," he says, sotto voce. We take him to the hospital with a burn center. On the way my partner pulls up his shirt to look for burns elsewhere, and he laughingly accuses her of getting fresh. His wife tells him to behave, and we all chuckle.

* * *

Saturday, after midnight: I agreed to work a double. Now we go code 1 to a club downtown. As we pull up we spot five or six cop cars, all lit up. "This must be us," I quip. Our patient is sitting on the curb, in handcuffs. Nasty cut above his eye. "I wasn't even involved!" he protests. We ask him which hospital he wants to go to. "None!" he says. "I want to go home!" We talk to the cops. I crouch next to him, touch his shoulder briefly. "Look," I say, trying to be kind and not condescending. "You've basically got two choices. Go in the ambulance, no handcuffs, a citation for the charges, and go to whatever hospital you want. They'll fix you up and send you home. Choice two, go in a cop car, still go to the hospital, and then go to jail." He eventually agrees, and falls asleep on the way up to the hospital.

Hey, Is That ... ?

Friday morning, we're dispatched to a sick person. Not many details on the computer beyond "80s female, flu-like symptoms." We're a few minutes out when the fire engine slows us to code 1 (no lights/siren). Must not be anything serious.

* * *

We walk in to find the engine company (three EMTs, one paramedic) standing around a woman in a wheelchair. She looks a little out of it, but not bad on first glance. The fire medic says that she's been lethargic, a bit confused, weak. Seen at the ER yesterday for flu. Looks like it just got worse today.

Right then the last sticker for the heart monitor goes on.

My partner starts, as do I. We saw the rhythm from the second it appeared -- and that's a scary thing to see pop out at you! The fire medic is still talking to the patient, and my partner taps him on the shoulder.

"I don't know about you," he says with the hint of a grin, "but I'd call that v-tach."

The fire medic's face goes white.

* * *

We Georgia her to the stretcher in the living room. I get the patches on her chest. My partner looks for IV access, doesn't see anything good for the big line we may need, and goes to his favorite fallback: an external jugular. I draw up 150 of amiodarone for an infusion in a minute as my partner and a couple of the fire EMTs get BLS airway gear set.

When we're all ready, my partner pushes 5 of versed into the line. We've been talking to the patient and her husband all along, and now I turn to him.

"Basically, sir, like we've said, her heart is in a pretty unhealthy rhythm. We need to get that fixed, and how we're going to do that is by shocking her -- basically pushing the reset button and letting her heart start back up in a normal rhythm. So that's what you're going to see, in a second."

He seems taken aback -- who wouldn't be? -- but nods. We sync up, charge to a hundred, and I say "everyone clear," calmly but firmly.



Beautiful. I announce in the same calm voice -- at least, I hope it sounded calm -- "Looks like normal sinus, guys." I go to get the amio infusion ready, and the fire medic starts getting 12 lead stickers on, when my partner pipes up from the head.

"I think we've got a bit of a problem." All three of us medics huddle up. "The versed took her down too far, which isn't a bad thing, since we shocked her -- but now she's not really protecting her airway." The fire medic and I nod, and I rip the intubation roll out of the airway kit and start getting set up. She's a moderately difficult tube, and I've had issues with tubes lately, but a little help from my partner and we've got it in.

Back to what we were doing. I get the amio infusion -- 150mg over 10 minutes -- running, and the fire medic and my partner get a 12 lead going. She's not having a STEMI, which is one concern down. She has a heart history, we've found out, and in fact was already on oral amiodarone.

Just as it looks like everything is calming down, the faithful Lifepak cycles a pressure again -- 90/40. Crap. Down from what it was a few minutes ago. We open the line wide for a fluid challenge, but it's obviously cardiogenic shock, and my partner asks me to go get the dopamine out and call for orders. About the time they get her out to the ambulance, I've got orders from a doc, and I'm on the way to having the pump ready.

It was my partner's patient, so I give them a quick, smooth code 3 ride to the hospital. Her pressure goes up, and then back down again, to a low of 70/30, and they do end up starting the dopamine just before we get to the hospital. We turn her over to the ED staff, and she looks to be doing pretty good.

Outside, the fire medic apologizes -- "I never would have slowed you guys if I'd known!" and my partner (who's been a medic for twenty years) says, "Dude, never in a million years, I'd never have guessed. No worries. No worries at all."

* * *

Eight hours later we're in the ICU at the same hospital, and we check in on her. She's extubated. We talk to the nurse for a few minutes. The patient is tired, but awake enough to say hi briefly when we poke our heads in the room. She doesn't remember us, and we both agree later that this is a very, very good thing.

Talking later, we get laughing. My partner says maybe he'll quit being a training officer and just work with me. "After all," he quips, "I may be a sh*t magnet" -- something he told me on my first day with him, which has seemed pretty true -- "but together we're a storm."