Manifesto

I just read the final version of the National EMS Scope of Practice Model, a document intended to provide a unified guideline for the scope of prehospital providers in the coming years. While I like the idea of cleaning up the fragmentary levels of training and scopes of practice across the nation, I cannot help but be frustrated when I read this document. It doesn't really change anything, it makes the system as confusing as ever, and it doesn't really work to bring the profession forward.

Therefore, I'd like to present my own scope of practice model -- okay, more of a manifesto -- for where EMS should be in 10 years.

Providers

Emergency Medical Technician - Essentially unchanged from the scope they retain today, the EMT should be able to provide life-saving care for critical patients until more advanced providers arrive, and transport patients who do not require advanced care.

Specific EMT skills: OPA/NPA, BVM, King Airway/Combitube, AED, oxygen, spinal immobilization, ASA for chest pain, SQ epi for anaphylaxis.


[ EMT-Rural - An optional intermediate life support module only for rural areas where there is no availability of paramedics. Adds basic 4-lead ECG monitoring, peripheral IV access, fluid administration, first-line code drugs (epi, atropine, amio, lido), and a few other basic medications (albuterol/atrovent nebs, NTG for chest pain, pain medication if transporting provider). ]


Paramedic - An improved version of the current paramedic standard, with a two-year schooling program and increased clinical/internship time. An Associate's degree and state licensure (NOT certification) are mandatory.

Specific Paramedic Skills: Endotracheal intubation, Rapid Sequence Intubation (with paralytics), surgical cricothyrotomy, nasogatric tubes, adult and pediatric IV and IO access, 12-lead ECG monitoring, interpretation, and transmission, cardioversion and pacing, IV fluid, expander, and blood administration, needle chest decompression, CPAP/BiPAP, and administration of a wide variety of medications with few, if any, mandatory OLMC consults.


Prehospital Physician Assistant - The PPA is an experienced paramedic who has gone to a fully-accredited PA school. They are deployed in small numbers throughout the system to address two populations of patients: first, the patients that require simple procedures or care which can be accomplished in the field and eliminate their need for transport; and secondly, the patients who require more advanced critical care interventions which are out of the paramedic scope of practice.

Specific PPA Skills - Critical care: Additional advanced airway options (retrograde intubation, LMA/ILMA, fiberoptic intubation), chest tubes, certain central lines (IJ/femoral), advanced medications (additional pressors, beta-blockers, mannitol, and others), Foley catheterization, pericardiocentesis, and more. Primary care: Wound cleaning and suturing, Foley/G-tube replacement, trach tube replacement, point-of-care lab testing, evaluation/referral option for non-emergent patients.


System Model

Prehospital emergency care in the urban area should consist of a tiered system of BLS, ALS, and advanced providers. A system should deploy a mix of EMT and paramedic ambulances, with a small number of single-PPA "fly cars" in the system.

Calls should be triaged according to an evidence-based model; for most calls both an EMT and paramedic ambulance should be dispatched. 4 providers onscene is an optimal number for managing both patients, and except in the simplest cases there will always be a paramedic evaluation of the patient. Patients will be transported by the appropriate ambulance, and if the patient is critical the EMT crew will assist the paramedic crew with transport (allowing both paramedics and one EMT to function smoothly in the back of the ambulance). On certain critical calls (cardiac arrests) a PPA unit will be dispatched as well, but in most cases they will be requested by providers onscene for either critical or simple patients. In the event of a critical patient the PPA will assume patient care and work with the paramedics during transport; on a simple patient the PPA will be able to free the ambulance and remain onscene to resolve the issue.

Fire department personnel will retain CPR/AED or First Responder certification, and will respond on traffic accidents, EMS requests for lift assists, and cardiac arrests, and other specific calls as needed. EMS systems will be encouraged to develop in-house tactical, extrication, and technical rescue teams.

Medical directors will provide primarily offline protocols with a high amount of ongoing education, case review, and training, particularly in high-risk/low-frequency skills. Wireless communications technology will be in place to allow providers fast access to physician consults if needed, with easy transmission of monitoring data.



That's my pipe dream...

Responsibility

Things change, as they always do. With my promotion to senior medic comes (along with other things) my own shift, my own car -- and a junior partner.

You never know who you will get, and it's the topic of discussion among the senior medics when the junior spot on your car is open.

"You'll get someone who's brand-new."

"They won't even know their way around."

"You'll have to babysit them, all night."

"I had a junior once, new guy, and you won't believe what he did..."

So with all this in my head, it was with no small trepidation that I waited to hear who my permanent partner would be. It could be someone experienced, I told myself. There are a few people who might want on my shift ... my night shift ...

Crap.

And then the phone call, giving me the heads up and a name I didn't recogize. "Did she come from B shift?"

"Nope," said the voice on the other end of the phone. "She's brand new."

Perfect.

* * * *

So she came on the car. Young but sharp was my first impression, with a good attitude and a willingness to learn. But short on experience, she freely admitted, short on codes and tubes and all that fun. A white cloud, a medic who doesn't ever seem to get the critical calls.

Great. Just like me. We'll never have anything.

In the first week we had a truly critical call every single day.

And by the end of the week, I knew she was, indeed, solid; already a good medic despite her lack of experience, and with the potential to be a great medic.

* * * *

Of course, that's not all the responsibility I have to bear now. There's the narcotics, and making sure everything is in order, and doing little bits of paperwork for this and that.

And I guess there is one other thing.

* * * *

"Etomidate is in!" the fire medic announces, and swaps syringes. "Sux going in."

I look down at the patient. Sick, bad sick. Head injured. Unconscious. Jaw clenched. He needs an airway, needs PVC down his windpipe, and there's only one way to do that.

When you can't be trusted to breathe for yourself any more, we take over.

The drugs take hold, and he stops breathing.

"Okay," I say, softly, to myself, twisting my cap backwards and out of the way, clicking the laryngoscope open with a soft snick, taking a deep breath.

"Here we go."

Snippets

"... all units, stand by for dispatch."

* * *

"Man, I don't, I mean, you don't, I mean, I don't have to have this collar on my neck and be on this board!"

"Well, sir, I respect your feelings, but seeing as how I'm the paramedic and you're drunk, I'm going to go with my first instinct."

* * *

"... Trauma communications, got an entry for you, bicyclist crashed, no helmet, confirmed loss of consciousness ..."

* * *

"... Big poke in your arm here, sir. "

* * *

"Well, yeah, it hurts worse when I take a deep breath, and when I cough -- see, I've had this cold for a few days..."

* * *

"Medic 38, in service ... Ready for more."

Test Post

This is a test of blog posting from my phone...

Memories

We do a transport from a group home, an uncomplicated chronic problem. The patient is friendly and cooperative, but as a matter of policy the group home sends a staff member to escort him. The staff member is only a few years older than me or my partner (we're a "young" car) and he laughs when he gets in the front seat of the rig.

"Yeah, man, last time I was in one of these I don't remember it!"

Of course I am curious.

"I was shot, man! Two times, I was fightin' for my life."

Wow, we say. Crazy. He laughs again, and agrees, and we go off to the hospital.

* * * *

We're sitting in the bay, doing paperwork, just about ready to go back in service, when the staff member comes out to smoke a cigarette. As he walks by he stops for a second.

"I know I don't remember when y'all took care of me, but I know I was in good hands, man. Y'all are heroes."

Thanks, we say. Thanks very much, and we hope not to ever have to help him again.

"Yeah, man, I hope I don't ever have to see y'all either. Hey, you know what they call you guys in the hood, right?"

Uh. No?

"Ghetto angels, man."

(Mis)information

I've said a few times before that all I really want to know before I go to a call is where I'm going. Every call we go on, we get a typecode (breathing problem, chest pain, bleeding problem, trauma, etc), and then whatever information they have recieved from the caller about what is going on. This should allow us to prepare for the call in terms of equipment, resources, protocols, and so on.

Unfortunately, they're often dead wrong.

It's not the fault of the calltakers; they can only go on what they are told by upset, untrained, concerned, and often confused callers. That they get as much information as they do is, quite frankly, amazing to me.

Even so, it's often a better idea to not even read the call on the computer.

* * * *

There are the tapouts that make the hair on your neck stand up.

ENTRY: M, 18MOS, UNC, NOT BR

ENTRY: 1 Y/O FEM, NO BR, BLU

ENTRY: BABY NOT BREATHING, LANG BARRIER

All of these will be febrile seizures, with updates saying the baby is breathing and crying, and a hale and hearty baby with a fever who needs some Tylenol.

* * * *

There are the ones that make you think you're in for some serious work.

ENTRY: 2 CAR ACC, ONE VEH ON ITS TOP, INJS

ENTRY: SINGLE CAR INTO POLE, OCC PINNED INSIDE

ENTRY: M, 20S, ARM CAUGHT IN MACHINERY

All of these people will be out, relatively unscathed, and all the resources that have gone screaming out from stations and posts will be recalled, Hurst tools and prybars and plasma torches left in trucks.

* * * *

And then there are the ones that make you cuss, because it's the end of your shift and you can't believe they are calling for this.

ENTRY: M, 30, ABD PAIN, VOMITING

"Really?" I shout at the computer. "Seriously?!" My partner doesn't rise to the bait, just swings the car around and lights it up, headed way up north, twenty minutes before logoff. I keep my rant going, because it's Friday and I'm tired and seriously.

"Come on, dude. You're sick! You've got the flu! Drink fluids! Suck it up! You don't even need to see a doctor, let alone go to an ER, let alone take an ambulance!!"

The fire truck arrives well before us. Of course they keep us coming lights and sirens, because their shift change is soon, and they want to be off on time too. I punch the REFRESH button on the computer, but there are no updates from dispatch.

We finally pull up to the apartment complex. The open door is way in the back, a decent walk from the closest place we can park, on the second floor, up a rickety-looking staircase.

I sigh, and shrug at my partner. "Tell you what, just get the gurney to the bottom of the stairs. I'll go up and see if he can walk down, so we can get this show on the road."

He nods assent, and I trudge over to the stairs, up and around the turns, and into the apartment.

A man in his 30s is sprawled in the middle of the living room floor, on his back. He's blue, covered in vomit, and maybe breathing six times a minute. Fast patches are stuck on his bare chest, and beside him the Lifepak calmly announces in glowing yellow numerals a heart rate of 38 and an oxygen saturation of 79%. The fire crew is ripping out airway and IV access gear. Their medic is at the man's head, bagging him. He looks up at me.

I gape, wondering if somehow I'm in the wrong house.

"We gotta sux this guy," the firemedic says, and I nod. Yeah. Duh. Crap.

I step out the front door, look down to where my partner is leisurely working the cot between cars.

"Hey!" I shout. "Forget the bed, get up here!"

Uprooted

I am sorry, dear readers (all three of you) for the absence. There have been some drastic changes in my life in the past few months -- all of them good. In brief, I have more responsibility at work now, more space at home now (and a different address), and someone who I am spending a lot of time with.

So, while I have not had the time to really write up any good stories recently, I do have a tidbit of wisdom to share.


You see, I left my old partner, albeit not very willingly. Promotion, in my agency, is almost forced, and of dubious value; I accepted nevertheless, and am left wondering if I lost more than I gained. No doubt I am simply unsettled by the transition, shifted from comfortable tracks to uncharted territory, but just so, I am unsettled and find myself missing the comfortable partnership I had for such a large chunk of my (relatively short) career. I feel a bit uprooted, and I fear it will be some time before I relax again.

That aside, on our last night I asked him what the secret wisdom to being a truly excellent paramedic was.


He thought long and hard, and finally told me he had no clue what the secret to being a truly great paramedic was.

"Here's what I do know," he told me. "Here's what I have learned:

Go to work.

Don't get in trouble.

Go home.

Forget about it."


Words, I feel, to live by.

Crunch

Sometimes, in EMS, particularly in the jaded urban world, we get a tendency to discount the opinions of bystanders -- or anyone except us and our partner (nursing home staff, fire dept, etc). How many times, either through intent or stupidity, have they told us something completely wrong?

"She's having a seizure!" the man shouts, as his wife screams and beats her fists on the floor. No, she's throwing a tantrum -- at fifty years old.

"He's having difficulty breathing," the CNA tells me, holding out a packet of paperwork. On the bed behind her, the man is pale and still. His chest does not move at all, I feel nothing on either side of his throat when I dig for a pulse. "Medic 38," I snarl into the radio, as I help my partner yard him onto the floor, "with patient, working code."

"She's having an asthma attack, it's her asthma, you've got to give her the medicine!" But sixty seconds of assessment show me clear lung sounds, perfect saturations -- and a CO2 of 15 with a respiratory rate of fifty. "No, ma'am, ma'am -- ma'am, listen to me -- ma'am, look at me, right here -- you are breathing just fine. You are hyperventilating. Listen to me, we're going to slow your breathing down, okay?"

So with all these -- with all these tales, and a million more that could keep me and my coworkers telling stories for an entire night, laughing over beers at the poor diagnostic skills of laypeople with no medical training, clearing the inevitable ring of tables around us -- with all these, can you accept our inclination to be disbelieving? Or, if not accept, can you at least understand?


* * * *


Last week we were first onscene of a motorcycle vs. car wreck. The motorcycle rider crouches, holding the shoulders of a child sitting on the ground next to the bike. The rider -- the father -- looks up at me. "His femur is broken."

I couldn't help thinking, Yeah, okay, sure thing, buddy. I think I simply told him "Okay, let us check him out," and moved in on the kid. We cut his pants leg open and see a nasty open tib-fib fracture. I do a half-assed palp of his upper leg and glance at it, keeping half an eye on the firemedic doing bleeding control and stabilization on the lower leg, and half a mind on managing the rest of the scene. Ask the kid where it hurts, and he says his ankle.

Two minutes later, we're getting a vacuum splint in place around the kid's leg, and we cut his pants leg a bit more. The lieutenant from the engine abruptly says, "Whoa, what about that femur?"

And indeed, the deformity that wasn't obvious from my viewpoint with the pants half-cut is now very obvious. Totally fractured. Balls. We can't do a traction split because of the ankle fracture, our treatment won't change, but balls on missing that first go around. And a big pat on the back to the knuckle-dragging clipboard-holding EMT-Basic lieutenant. They say basics save medics, and I'm here to tell you it's the truth, more times than I can recall even in my short career.

As we're loading the kid up, I talk to the dad briefly, tell him what's up, what we're doing, where we're going. "And," I finish, "good call on that femur; you were spot on."

"Hey, man," he shrugs, "I was a field medic," and by this and his age and bearing I can only guess military.

"Besides," he says, "I felt that shit move."

From a Streetcorner, 3am

And once again, here we are. Sitting. Waiting. Burning diesel, subsonic rumble the constant backdrop to my work-night. Orange skyglow, dark trees. Soft teal instrument panel lights. Muted computerglow. Streetcorner. Low levels. The usual.

For seventy-five miles around, we are it, for transporting ambulances. I am it, sitting rightseat, next up. Such is rural EMS. I like it.

Driving down the mountain earlier, we pass through a long, dark chute, trees wrapping high and close around the long downsloping two lane road. The forest is still deep and cold and merciless in the uncaring way of nature. We are it for that too, the sum total of backcountry-capable ALS resources on-duty in two counties.

The woods are vast and thick and trackless and above all dark. I have a headlamp. A backpack. Boots. A few more toys. Seems very little, against the immense, endless, towering evergreen-filled snow-covered hills.

In the end, I suppose, if it comes to it, it'll be enough.

Vignettes

She is old, body withered with osteoporosis and arthritis, mind withered with Alzheimer's and dementia. A bloodstain spreads out across the carpet from where she fell. She has a cut and goose-egg, swelling over one eye. She has neck pain, when I gently palpate it.

She is not happy.

We put her on the backboard, reluctantly, but recognizing it as the right move.

She does not agree.

"Put me back! You don't know what you're doing! Put me back, you little sh*ts!"

We trade glances with each other, with the staff. One of them shrugs, half-apologetically. She's always like this, they say. We nod, and load her up. My partner smirks, first from the rear door, and then from the rear-view mirror as we drive in, and I am bombarded with confused, frustrated, furious insults.

"You're a bunch of brainless farts! You don't know what you're doing! Brainless farts!"

"Ma'am, you fell, we're taking you to the hospital, you need to see the doct--"

"Shut up!"

"Ma'am, we're taking care of you, th--"

"Shut UP!"

"Ma'am, I--"

"Shut up shutupshutupSHUTUP!"


* * * *

He sits on a bar stool, holding his belly. We carefully help him step to the stretcher. Flickering LED lights from the eight or ten police cruisers outside illuminate the club in sporadic bursts of light. He doesn't seem to be bleeding too much.

Quickly we load him up. My partner grabs a set of vitals while I put him in the trauma system. We're less than fifteen blocks from the Level I; a ten minute walk, let alone a drive. My partner reads off the pressure and heart rate and then bails out for the driver's seat. I wipe the man's belly off with some gauze, and see that there's only a single stab wound. Doesn't even look that bad. His blood pressure and, more importantly, heart rate are fine.

As we pull out from the club, I quickly pull down supplies to put an IV in. This close, I can't do the two I prefer, but I can at least get one.

We've been driving for thirty seconds when I realize I can still hear the strobes clicking. I shout to my partner.

"Code one, code one, shut it down! We're fine going code one."

"Right," he says, and I hear the lights go off.

"Ain't got no damn time anyways," I mutter to myself, taping the IV down ninety seconds later as we turn into the hospital driveway.

Ten minutes after that -- and maybe half an hour after the call came in -- he's on the operating room table. Despite my earlier frustration, I smile to myself. That, I think, is good trauma care, right there.

* * * *

She is younger, and the confusion comes from the case of tallboy beers, not dementia, but just the same she too does not want the backboard, or our help. A giant scalp laceration, easily a foot long, winks at me as we tape her head down.

In the ambulance, she calms down. I explain what's happening, repeatedly, kindly, and gently coax the facts of what happened out of her. As we drive in to the hospital, she goes from argumentative to cheerful, albeit confused.

"'zis'sh an airplane?"

"Uh, no, ma'am, it's an ambulance."

"... sounds like we're in'na air."

"We're on the freeway, ma'am."

She chuckles. "No! You're full of it. Stop messin' wi' me."

I smile, myself. "I would never mess with you." I stand up, so I can meet her backboarded gaze.

"Whoa! How'dsh you do that? 'm I standing on m'head?"

"Uh ... no, ma'am, you're flat, and I'm standing next to you."

She can't seem to figure out how the stretcher and ambulance configuration works, and chortles the whole rest of the way that I'm messing with her, and it must be some kind of a trick. But she's jovial enough. I explain three more times that she needs stitches, and to make sure her neck isn't hurt.

"Whatever," she says, patting my knee. "I'm fine, I know it."

When we get to the hospital, on the way in, she holds up a hand. "Thanks," she says. "You've been really nice to me."

I shake her hand. "You're very welcome, ma'am. I just hope you get well."

She twists under the tape and collar, trying to look at me. "You do good work, sonny." The hospital doors open smoothly, and she looks up at the bright flourescent lights and white walls.

"Oh hell, whatsh this?"

* * * *

He is old, but not that old.

He is naked, lying on the living room floor.

He is dead, most assuredly, even though my partner is still doing CPR, a fireman is still bagging, and another fireman is watching the monitor and pushing drugs.

We've been here for half an hour, through a few rhythm changes, none responding especially well to treatment. Vasopressin kicked the asystole to fib, but shocks kicked the fib to PEA, and there it's stayed, complexes widening and bradying, despite epi, fluid, atropine, and good CPR. His head and neck have begun to purple and mottle.

Finally the firemedic running the code nods to himself, and starts reviewing the drugs we've given. "We're at 35 minutes. Our end-tidal is--" he glances at the Phillips monitor and winces, "--8. Anyone have any other ideas?"

A roomful of silence. "Okay. Four-twenty-two, then."

I stand, walk outside, take a breath of cold night air. Walk down to the idling ambulance. Grab a white hospital blanket and a couple of red plastic biohazard bags. I pass the bio bags to my partner and spread the blanket over the dead man.

Five minutes later we're outside again, my partner with a copy of the paperwork. The firemen agreed to wait for the M.E. and cops -- only fair, as they arrived first.

I reach up, key the mic riding my shoulder. "Medic 38 in service."

Sunset

Another beautiful afternoon. The first inklings of spring have begun to push their way through the clouds and rain of winter. Today is sunny, if cold, and the dog happily sniffs her way along the blocks near my house.

Last night we walked down these same streets, heads down, pelted by ice-cold windblown rain, soaking through clothes and fur alike. Today is much nicer. We can agree on that.

But she doesn't agree on what has to come next; getting shut up in the house, watching me get in the car and drive away. She'll sit on the couch and look out the window. For all I know she'll sit there for thirteen full hours, until my car pulls up again, in the dawn light.

I think that I run the risk of conditioning a Pavlovian response in the dog; risk making her sad every day when it gets dark, because she knows it's probably time for me to go. Most days, anyway. Today, certainly.

The sun is setting, everyone is coming home, and it is time for me to go to work. In my locker is a blue uniform and scuffed boots. In the crew room there is a rack of radios, and another of keys. In the bay is a gleaming white ambulance. In houses and cars, on sidewalks and streets, in backyards and bars and businesses, are men and women and children, not yet sick or hurt enough to pick up the phone and dial those three magic numbers.

All of them waiting, waiting for me, just as sure as the dog waits at the window.

Truths

When I went to paramedic school, they taught me many things. Science and medicine, medications and procedures, techniques and tricks to stabilize - and occasionally save - those who are critically ill, slipping away. How to shock a heart, pop a chest, drop a tube. These are the things they need, the quickly dying.

But out here, a year and change later on the streets, I've learned something important. Its not about the quickly dying, not usually, not most nights, no.

We deal with the slowly dying.

The diabetics; the dialysis patients; the breathers, with emphysema and heart failure; the old and the sick. These are the people we deal with, day in and day out. These are the people who slowly get worse and better, who wax and wane like the moon, who we learn to know by name and face and address. Veins destroyed by years of access, for sugar in or dirty blood out. Sleeping in hospital beds crammed awkwardly into rooms into houses gone dirty and shabby from a lack of time, or energy, or motivation. Some try to keep their spirits up; some are sad and angry; some have already checked out.

And, of course, not all of these patients are slowly dying from some externally imposed condition. They're not all cursed by a vengeful God for acts of a past life. Oh no.

Some -- many -- of them are killing themselves slowly, with drugs and alcohol and tobacco. Coughing, lungs a riddled mass of scar tissue and collapsed alveoli, home oxygen cannula in their nose, sucking at a cigarette. Drunk again, stumbling and slurring, liver a rock distending their belly. Barely breathing, pupils tiny pinholes, locking them away from the pain of the real world.

And so we drive around, in endless circles, and take the slowly dying to the hospital, over and over. Maybe we'll do something for them, more than just transport. Probably not.

So occasionally, when we do see the quickly dying, we get excited, and we must ask forgiveness for our enthusiasm. We are not excited that someone is so sick, so hurt. We are excited at the chance to use our tools, our toys, our experience, our training; to be more than just a big white taxi.

Streets

Been a cold snap in the area. The Red Cross opened warming shelters in the downtown core, for the homeless population. At breakfast today, after work, one of my coworkers, another nightshifter, railed against the city's policies.

"I don't know what it is, they love the homeless here. I think they're way too nice. That's why we've got such a problem!"

I sat quietly, eating my eggs, and didn't disagree.

* * *

Two nights before, we got called to a shelter on chest pain. An elderly man lay on the ground.

"My arm hurts," he told us, fumbling in a pocket. "S'my angina. Gotta take my nitro."

Someone had told the dispatcher he'd been drinking, so a couple cops showed up and watched as we loaded him on the stretcher.

As we worked him up, in the ambulance, ECG and IV and all the rest, I tossed a few social history questions in with the medical ones. Homeless? Yes, he said, and I winced, looking down at my notes. He was well over 70. Too old to be on the streets, especially with his medical history.

Why was he homeless? Did he drink? Not really. Drugs? Hell no, he told me. Finally he told me he was a few months out of prison. Had been in for the better part of two decades. I nodded. After a few minutes, my curiosity got the better of me.

"Sir, can I ask, what were you in prison for?"

"Eh. Some guy. In a bar. Committed suicide."

"Suicide? And how--"

"Committed suicide on my icepick, he did."

I was glad he said it with a smile; that way I didn't have to hide my own chuckle. Shouldn't be laughing about a crime like that, but I couldn't help myself.

Later, sitting on a streetcorner, I told my partner how bad I felt for the man. Made a mistake, did his time. Polite, friendly, nice as any other patient I deal with. Left out on the streets. Ain't fair.

* * *

I've been doing a lot of thinking, lately, about the homeless and disadvantaged populations that we so disproportionately serve in EMS.

It's easy, so very easy, to get frustrated with people who are abusing the system. To simply see the endless repetition of fradulent complaints, transparently intended to get a warm bed for a few hours, a meal, pain medication, attention. And to be stuck in a system that is vulnerable to such abuse, because they might just have a medical problem, and everyone is entitled to emergency treatment and care.

On the one hand, I believe firmly in personal responsibility, and I think that individuals should attempt to help themselves before they reach out for help. That means sucking it up, dealing with the nausea and vomiting of a viral illness, taking a cab or the bus to the hospital for your foot pain, and basically not using emergency services for primary care. Or for a warm bed and hot meal.

On the other hand, I recognize that a big part of the problem is the system. We're afraid, in this country. Afraid of lawyers. Afraid of giving our medical providers the discretion to triage out people who, 99% of the time, don't have an emergent medical need, for the sake of the 1%, or 0.1%, who present completely atypically. It's a delicate balance, but we're way on the wrong side of it. If I could take half the patients I see, evaluate them with all the tools I have, and refer them to a primary care resource, the overall burden on the EMS/ED system, as well as society, would be greatly reduced.

Likewise with the homeless population. I know that 90% of the people who are homeless have, as a contributing factor, substance abuse or mental illness. I know that these are the people who are hardest to reach and help, even with shelters and programs and social services. I recognize that these are the people who have the deck well and truly stacked against them. I don't really want to be another part of the system that doesn't care and keeps screwing them over.

But I wish, I truly wish, that when I get called down under the bridge at 4am for unconvincing chest pain with no supporting history, 12 lead, or vitals, I could just look them in the eye and say, "Seriously, are you just cold? Be honest. We'll run you over to the shelter. Let's get you a meal."

Because I feel -- on the basis of no evidence, simply my anecdotal experience -- that this is really what a significant portion of our homeless patients want.

Maybe I'm a jaded, cynical asshole. I don't know.

* * *

Last night we ran a call in a suburb for "frostbite." The east wind coming down off the mountains made it bitterly cold, and I turn up my collar and pull down my wool hat as we get the kits out of the ambulance.

The man, in a convenience store, is concerned about his hands. They're fine. He's not, however; he's a transient, out in an unfamiliar part of town, and the more we talk to him the more it becomes apparent he has serious mental health issues. He's high-functioning, relatively speaking, but paranoid, and maybe a bit delusional. But he's alert and oriented, and when we tell him he doesn't have frostbite he refuses transport. He says he's trying to get up to Washington, on the bus. He's thirty miles from the bus station.

My partner pulls me aside. "Is there a warming shelter out here?"

I shrug. "I don't think so. Let me call the comm center, see what they know."

The dispatch supervisor doesn't think there's a shelter out in this area, but says he'll send police by, to see if they can help us facilitate some solution. We wait onscene, talk with the man some more.

When the cop shows up he seems grumpy. Asks why we aren't taking him to the shelter. I explain we can only go to the hospital. Why don't we take him there, then? I bite my tongue, take a breath. He doesn't have a medical problem and doesn't want to go.

"Alright," the cop says, finally getting out of his car. We leave him talking to the man. I'm sure the cop will just check him for warrants and take off. Especially if the only shelters are all the way back in the core.

An hour later I pull up the police call on our computer. A single line of text, down at the bottom, tells me that the officer transported a male all the way into town. To the warming shelter.

Well, then.

Entry

I'm working overtime, days, with my old partner. Near the end of our shift, we're sitting by a park, chatting and eating lunch, when the radios tone and the computer lights up. The dispatcher gives us an address not too far away, a neighborhood burger joint. On a possible cardiac arrest, man locked in the bathroom, said he was sick. Not answering the door now. Been in there for a while.

We scream down the street, in one of the up-and-coming trendy districts of town, and park (on the wrong side of the street, blocking traffic) in front of the restaurant. The fire engine rolls to a stop behind us as I grab the monitor and airway kit. My partner grabs the suction and airway bag, and we all tromp in. Customers look up in surprise.

An employee leads us to the bathroom. I rattle the door. Locked. Small door, though. Old building. I look at the fireman next to me. I'm the scrawny, geeky medic. He's two hundred plus pounds of American Hero.

"You wanna?" I ask.

He doesn't answer, just boots the door. It's a gorgeous kick. If Busting Doors Down was a professional sport, he'd qualify for the Olympic team. In my mind's eye a row of judges hold up cards and there's nothing below a 9.

Back in the real world, I see a flash and hear a ping! as the hasp ricochets off the ceiling. We look in, and see ...

... nothing. The bathroom is empty.

As we're staring, my partner opens the second, unlocked door on the other side of the bathroom, opening into the other part of the restaurant. I blink, and turn back to the helpful employee.

"The, uh, second door?"

He looks over my shoulder. "Oh, yeah. Uh, we didn't check it?"

I raise my eyebrow at the firemen, and key my radio. "Dispatch, Medic 14 and Engine 81 will be clear here, unable to locate. Patient has left."