Airway

In the prehospital setting, we are taught that airway comes first. A before everything else. And as paramedics, we're taught that the definitive airway, when we need to protect it, is a properly placed endotracheal tube.

But is this really the best for our patients? Certainly an ET tube is the right definitive airway for the hospital, but a plethora of recent studies suggest that paramedic intubation success rates are relatively poor. I'm not even talking about the effect on morbidity and mortality; it appears to be a fact that we're no good at getting the tube in the right hole on the first try.

A prospective multicenter evaluation of prehospital airway management performance in a large metropolitan region.
Denver Metro Airway Study Group.
Prehosp Emerg Care. 2009 Jul-Sep;13(3):304-10.

"Nine hundred twenty-six patients had an attempted intubation. ... For transported patients, 74.8% were successfully intubated, 20% had a failed intubation, 5.2% had a malpositioned tube on arrival to the ED, and 0.6% had another method of airway management used. Malpositioned tubes were significantly more common in pediatric patients (13.0%, compared with 4.0% for nonpediatric patients)."

Review of endotracheal intubations by Ottawa advanced care paramedics in Canada.
Tam RK, Maloney J, Gaboury I, Verdon JM, Trickett J, Leduc SD, Poirier P.
Department of Pediatrics, University of Ottawa, Ottawa, Ontario, Canada.
Prehosp Emerg Care. 2009 Jul-Sep;13(3):311-5.

"The study population comprised 1,029 intubated patients ... ETIs were successful for 64.6% (95% CI: 61.7, 67.5) of the first attempts; 79% of successful intubations were achieved within two attempts."

We get upset when we read these studies. What are they saying? We can intubate people! Our skills are solid! And yet, the numbers would seem to indicate this is not the case.

Many, many people have weighed in on this issue, and a few recent calls I've run have made me ponder these issues. I cannot argue that some of the data out there shows that paramedics are bad at intubating people, and there's no doubt that we're not doing our patients any favors by screwing around in the field.

The questions I want to ask are why are we bad at intubating people and how can we do better?

There are some of the local first responder agencies I work with that prefer alternative airways. The King Airway, in particular, has become popular lately. While I feel that the King is a great rescue device, I see red when I hear agencies espouse a culture of de-emphasizing ET intubation in favor of just "tossing in a King." Here's the facts in my experience: King airways allow you to ventilate and oxygenate a patient, so they're good for the purpose of a rescue device. They get the job done temporarily. They do NOT protect a patient's airway and lungs against vomit. If you bag too forcefully, you WILL end up with subcutaneous emphysema in your patient's neck. They do NOT always work, and if "Insert Tab A" is your ONLY plan, when that doesn't work you are hosed. (Yes, I'm looking at you, Mr. Non-Transporting Firefighter Paramedic.)

The three major reasons paramedics have issues intubating patients, in my opinion, are EXPERIENCE, VERIFICATION, and TOOLS AND TECHNIQUES.

Experience is the biggest factor. We don't perform enough intubations to be truly proficient. A physician will perform hundreds, if not thousands of intubations before they are even out of residency. A paramedic may perform ten, if they're lucky. Maybe more, in a good paramedic training program. This is not near enough. No wonder we're no good. If we expect to be good at intubation, we need to do a LOT more of them.

Verification is the second most important factor. I firmly believe that there is NO, zip, zero excuse for a misplaced ET tube in this day and age. If your agency isn't using continuous waveform capnography, you're behind the times. Visualization, lung sounds, tube misting, sure, but ETCO2 is the gold standard. You cannot have a misplaced tube with a good ETCO2 waveform on your monitor. If every patient you secure a tube in has that waveform, you won't misplace tubes. It's as simple as that.

Tools and techniques are the final factor in why we don't get our tubes in the right place. When's the last time you pulled out a bougie? Are you proficient using both Miller and Mac blades? Do you have a video laryngoscope? When's the last time you practiced -- let alone performed -- a NASCAR intubation, a digital intubation, or your surgical airway procedures? Do you know two-person intubation techniques to improve visualization? Do you know exactly how and when to use your rescue techniques and devices? If you answered NO to any of these questions, I don't think you should be intubating people in the field.

All of these ideas are nice, but how can we actually implement them, and do better at airway management? For the answer, I've got one more paper.

An analysis of advanced prehospital airway management.
Bulger EM, Copass MK, Maier RV, Larsen J, Knowles J, Jurkovich GJ.
Department of Surgery, Harborview Medical Center, Seattle, Washington 98104, USA.
J Emerg Med. 2002 Aug;23(2):183-9.

"The results showed there were 2700 patients intubated... The indications for intubation included medical emergency in 82% of patients and traumatic injury in 18%. Fifty percent of patients were intubated with the use of succinylcholine. The overall oral intubation success rate was 98.4% and definitive airway access was achieved in all but 12 patients (0.6%), with 30 patients receiving surgical airway access (1%). The successful intubation rate for patients receiving paralytic agents was 97.8%."

Wow! Look at that! Paramedics can intubate people! So what the heck is so difference about the system in Seattle, that they have such success rates?

The system in Seattle is tiered, with a small number of ALS ambulances backing up a larger system of BLS first responders and BLS ambulances. The initial training program for ALS providers in this system is extensive and stringent. While there are some unrelated issues with this system, the fact is that a SMALL number of HIGHLY TRAINED paramedics can and do intubate people effectively.

What's the implication? First off, I'm sorry, but paramedics need to get the hell off fire engines. We need to reduce the number of paramedics in almost every EMS system, and removing ALS first responders is the way to start. More and more studies are coming out which question the efficacy of ALS for critical patient (cardiac arrests and trauma patients in particular). First responders need to focus on solid BLS skills -- that's where the lives will be saved.

Second, every patient does not need an ALS ambulance. While systems need to have effective triage tools and constant, vigilant QA to make sure that the patients who need ALS get it, there's nothing wrong with BLS transport. Simple logic says that if you reduce the number of paramedics in a system, those paramedics who remain will see more critical patients and perform more procedures.

Finally, we need to change paramedic education. Three terms at a community college is ridiculous. Two years of full time college to be a paramedic. End of story. If that's too much time for you, if that's too hard, TOO BAD. We have too many medics, I said it above, and making the entrance and educational requirements tougher will only improve the quality of our providers.

We need to change our systems from paramedic-saturated over-ALS'd behemoths where each medic is maybe managing one or two airways a month, to lean, mean, highly-trained and highly-experienced systems with a small number of medics who can consistently, effectively manage airways the right way, the first time, definitively.

Tricks

I don't think I am alone among medics in that I have a small "dirty tricks" bag that I bring to work. I don't mean "dirty tricks" in the sense of pressure points or joint locks -- though those have their place -- but instead little items that are not standard issue which we have found to be useful.

I recently went through and organized my little black bag, and when I was done, here's what I had:

- O2 wrench
- Small zipties
- Needle-nose pliers
- A Code Strap
- InforMed Emergency & Critical Care Pocket Guide
- Tarascon Adult Emergency Pocketbook
- County Protocol Pocket Guide
- RSI Dosage card
- Booties
- Extra-large Tegaderm
- One each adult and pediatric single-use adhesive SpO2 sensors
- King Airway syringe
- A Zerowet Supershield

So, readers, I ask you -- what do YOU bring to work that isn't standard issue, but you've found to be useful, or want to have in case of that particular unusual situation coming up?

Protocol 36

As part of our ongoing Web Based Continuing Education series, we here at Drug-Induced Hallucinations hereby present, for the discerning medic or EMT, a list of "street" synonyms for pandemic H1N1 flu that we may encounter in the course of our duties. Collected from various¹ sources².


Hamthrax

Tuporkulosis

Porklio

The Other Yellow Fever

Sowmonella

Whooping Oink

Porktussis


1. H. Tayler.
2. My "lady friend."

Freezeframe

03:30:00 - I'm fast asleep, curled up sideways in a recliner, jacket zipped all the way up. Out hard, REM-land, dreaming.

03:30:05 - Fire dispatch drops tones for a breathing problem in our district.

03:30:12 - EMS dispatch taps us out.

03:30:15 - My partner slaps my boot. I barely heard the EMS alert.

03:30:26 - I pop the tab of a Red Bull on the way to the bay. The motor on the garage door whines softly as it opens, letting the night in.

03:30:42 - My gut reels at a depth charge of caffiene, carbonation, and chemicals. My partner is talking to fire ops, pulling up the map on the laptop, and trying to find his seatbelt, all at the same time. I put the car in gear, slap the big red button, and away we go.

Conclusions

(If you haven't already, read the previous three posts.)

* * * *

I.

We scream down into the small town, and hockey-stop in front of the fire department. A young man in a fire dept t-shirt jumps in the back, wide-eyed and freshly awoken.

"I'm just a basic," he says, and I point with a free hand to the airway seat.

"Not a problem. Sit up there." I lean forward, towards the breezeway to the cab. "Okay, let's go."

Both lines are running wide open, and before even a few hundred of fluid are in he's looking better. His heart rate slowly creeps up, and his blood pressure slowly improves. The arrival at the hospital is anticlimactic, after the adrenaline rush of before, and the dozen providers waiting in the ER slowly disperse as it becomes apparent that the patient is now relatively stable.

Later, charting, I puzzle over the case, and the numbers. I look at the overall curve of the blood pressures, the heart rate, and slowly a conclusions dawns. Under the cover of my concern about a GI bleed, a relatively simple vasovagal event -- overstimulation of a nerve in the heart, causing heart rate and blood pressure to drop -- appeared to be something much more serious.

* * * *

II.

He has a head injury, probably a concussion, and repeats his questions. He wants to know everyone's names. Was he in a car accident? What's happening? Can we call someone for him?

The answers are patiently provided as he's IV'd, medicated, backboarded, and ultimately medicated. The flight nurse is standing there for the last moments of the extrication, and introduces herself to the patient as we start rolling the stretcher down the road to where the helo waits.

We roll past the other car, still on its top. A yellow blanket covers one window.

He asks where he's going, and again is told that he's to be flown to the trauma center.

And yet, when we reach the bird, and go to load him in, his eyes light up, and he reaches up to touch it.

"Whoa," he exclaims, "Is this a helicopter?"

* * * *

Moments (III)

3am. Another chest pain call.

Neither of us recognize the street name. Unfortunately, neither does the mapping program on our MDC. Or the map-book.

Finally, after turning into a dead-end, thinking we were right, and groaning at the absence of the bright red marker truck, we call them on the radio, get the lieutenant to guide us in.

He meets us at the door. "More like abdominal pain, not chest pain, guys." He shrugs, apologetically, as if this makes it a less important call.

Upstairs, on the bed, is a woman in her seventies. She is obviously uncomfortable, holding her belly, and rapidly trying to tell us everything we need to know about her symptoms and history.

At least, that's what I assume she's saying. I don't speak Cantonese, so it's hard to be sure. Her son tries to translate, with some success. Abdominal pain is her only complaint. Right here, pointing just above her belly button. One of the EMTs says he felt a lump there. My partner asks if it was pulsating. No, he says, he didn't think so.

As my partner leans over the bed to feel the woman's belly himself, he asks casually what the vitals are.

"Umm..." the EMT glances down at the monitor. "Pressure is 89/42. Heart rate is 48."

My partner does a beautiful double-take. I'm already going for the manual BP cuff, and toss it to him before pushing the button to run another automated pressure. Another firefighter asks what we need.

"Spike a bag," I say, "and check status of Podunk Hospital. And Big City Med Center."

The pressures are the same, and a 4 lead just shows a sinus bradycardia. My partner is concerned, and as soon as I have a wide-open 18 running in her arm, he starts saying, "Okay, let's go. C'mon, guys. Let's move."

We carry her downstairs on a blanket; as we do so, my partner and I share a terse conversation, like you do when things get serious.

"Thinking triple-A?"

"Mmm."

"Big City Med Center? Or one of the trauma centers?"

"Big City, I think."

"Take a friend?" Nodding at the firemen.

"Yeah, maybe."

We set her on the gurney, lift it up. I lay her back and pop her legs into Trendelenburg.

"Want help with anything?"

"12 lead, I guess. See about her rate."

I nod, and we hop in the back. He bustles with oxygen and getting a second bag of fluids together while I put the 12 lead on, pondering differentials for hypotension and bradycardia in abdominal pain.

Triple A? Definitely the front-runner.
Bad GI bleed? Could be, but no history for it.
Electrolyte imbalance maybe? T waves looked okay on the 4 lead strip. Hmm.

I reach around to stick V6 on. Out of the corner of my eye I see my partner pull pacer pads out.

"Okay. How old was she? Right. Uh, hold still, ma'am."

Click.

ACQUIRING 12 LEAD

Did we ever check hospitals? I snatch the radio off my belt.

"Firecom, Medic 601, status of Big City Med Center please."

ANALYZING 12 LEAD

"Medic 601, Big City shows green."

The Lifepak prints the short strip, calm and dispassionate.

*** ACUTE MI SUSPECTED ***

Moments (II)

"What's your name, man?" he asks, a little bit foggy, and I tell him, reaching in through the remains of the car window.

"I'm a paramedic with the ambulance," I add, lifting his arm up gently to wrap the blood pressure cuff around it. "What's hurting you?"

"My f'cking leg, man," he shouts, and I nod, looking at the door, shoved halfway to the center column. I can't tell, standing at the side, what model of car it is, or even the make. It's blue. Four doors. Sort of.

"I bet," I tell him.

On the other side, an off-duty medic and three volunteer firemen yard the driver out, onto a backboard, and set him on the ground. My partner stands back, spiking a bag of saline. A tiny flash of blue protruding from his thigh pocket betrays the syringe of fentanyl he has ready.

"Cutting!" a fireman shouts, and the Sawzall buzzes to work on the C-posts of the sedan. I step back, out of the way of flying glass. Diesels and generators rumble in the warm night air. Blue and red and yellow lights decorate trees and reflect off a stop sign, leaning halfway over.

Above, the helicopter does a slow loop over the whole scene, spotlight sliding over fire trucks and cop cars, debris and bystanders. Scoping the scene. Waiting.

Moments

We're a out deep, the rural end of our district extending far, far away from the station, into the lonely backcountry land of two-lane state highways and national forest roads and long, long driveways.

"And then, when I went, there was blood in the toilet, a lot of blood, you know?" he says, calmly enough. "I was going to drive in, but when I went in the living room I got dizzy, and saw stars, and almost fell down, and I figured I'd better call you folks."

I nod, and glance at the volunteer EMT, kneeling by the patient, blood pressure cuff hissing down.

"It's good," she says, "124/76."

"Perfect," I reply.

A few minutes later, in the ambulance, starting the thirty mile trip to the hospital, I punch the NIBP button on the Lifepak.

112/64. No worries at all. I putter through the comforting routine of starting an IV, chatting to the man about what I'm doing and what's going on.

I punch the button again.

101/62. Huh. I inch the roller clamp on the IV tubing upwards. The slow drip-drip-drip in the chamber becomes a steady patter. His heart rate stays low, not even 70 -- but there it is on his med list, the telltale -olol holding his heart rate down.

I force myself to wait three or four minutes. A hundred cc's of fluid run in. I run my finger over the blood pressure button in a tiny, nervous motion before thumbing it.

89/62. I take a deep breath, smile at the patient, and stick my head up front. We're still ten or twelve miles from the nearest town, and the hospital is another ten miles past that.

"Okay," I say to my partner. "Let's get there a bit faster." His finger goes down on the big red switch at the same time his foot goes down on the gas pedal, and the rumble of the diesel rises to a throaty roar.

I scoot back to the patient, ask how he's feeling. Yeah, we're driving a bit faster -- your blood pressure is a bit low. Nah, I'm not worried, but we don't want to dally. Feeling a bit faint? Here, I'll lay you back. Any pain? Trouble breathing? All this as my hands quickly run through the motions of spiking a second bag of fluid.

Poking what is rapidly becoming my least favorite button on the monitor, I glance out the back window. We're a few miles outside of the town. I grab a big, gray sixteen out of the cabinet and wrap a tourniquet around the man's right arm. Kindness and grace, he's got a big AC. Maybe his pressure has come back up.

62/43. And his heart rate is slowing, ECG complexes stretching out, further apart, big yellow numbers dispassionate on the screen: 45.

I swab the inside of his arm with alcohol, and yell to my partner that hey, while we're in town, we should grab a friend. I've barely got the needle in when my portable radio, forgotten on the bench seat, starts quietly whistling tones.

"Tones for Fire District 17 ... Station 30, meet Medic 601, enroute to your station, code 3 and requesting personnel to assist ..."

Overheard

I'm standing near the nurses station at one of the larger and busier local emergency departments, when I happen to catch two staff members discussing a patient...

Physician Assistant: "Hey, have you seen my crackhead?"

ED Tech: "Uh .. you're going to have to be more specific."

Truths (II)

EMS is not what they teach you in classes, in books, in school.

Or, rather, that is merely the surface of EMS, the way a history textbook's account of politics is merely the surface of the sweaty, ugly truth of marches and protests and speeches and backroom deals.

EMS is a journey, much like grief, with defined and common stages, and yet a differing experience for everyone.

EMS is opening a bar at 7am, rather than closing at at 2:30am, but getting just as drunk, stumbling tired into the daylight, cussing because now you'll sleep the entire day and get nothing done and you only have so many days off.

EMS is becoming comfortable with things than would have horrified you a few years ago, and finding wholly new things to horrify you.

EMS is an arranged marriage to a stranger who you will spend 48 hours a week with, locked in a box, in stressful situations, talking and eating and sleeping and laughing and fighting and working it out and fighting again and learning more about them and yourself than you ever wanted to know.

EMS is standing in the house of a stranger, telling his wife he's dead, and putting your hand on her shoulder or hugging her or making her a cup of tea, like you've been friends for years, because there's no one there but him, and he's three flat lines on a LifePak screen.

EMS is rolling into a trauma center with a critical shooting victim, more holes than you can count, walking right up to the senior attending trauma surgeon, and telling him, not asking but telling him that he needs to put this patient directly in an operating room, do not pass go, do not stop in the emergency department, and here's exactly why, do it now, sir.

EMS is pushing PLAY on the CD when the tones go off, cranking the rock up until it drowns out the siren, and cranking the radio up so you can hear Ops over the rock.

EMS is realizing that as much as you are there to help and care for your patients, you must help and care for yourself and your partner and everyone else in blue first, and learning that sometimes your "primary survey" will be their hands against the side of your bus as you search them for weapons.

EMS is walking into rooms or onto streets or into buses or onto planes with people who are dead, dying, bleeding, puking, crapping, coughing, and in many cases are just fine, and holding the same calm expression on your face.

And that's only the beginning.

Class

We're all in National Registry refresher class. A fellow medic is giving a pretty solid lecture on cardiac physiology, with plenty of audience participation.

This may or may not be a good idea.

* * * *

Instructor: "So, what causes cardiomyopathy in young, healthy adults?"

Medic In The Next-To-Back Row: "Cocaine!"

Instructor: "Yes, indeed, that's one cause ... What about our elderly population? What causes cardiomyopathy in old people?"

(pause)

Yours Truly, In The Very Last Row: "... Cocaine!"

Elevation

We've had a long night already, and we're not even half done. We finally got dinner, and we're eating on the move when the tones go off again. Male, 40s, chest pain, I read on the computer before I haul the ambulance around in a sweeping u-turn. We're maybe half a mile from the address, too.

My partner snorts, through a bite of tuna fish. She's tired and in no mood for the standard crap. "Unless it's a STEMI, I'm not interested," she chuckles.

* * *

The man lays on the bed, sweating and nervous. He was working out when his chest started hurting. He's never had heart problems before, but he did get checked out for chest pain recently. Everything was normal. He's got a history of anxiety, though. He's breathing fast. His fingers are tingling, and oh god the pain.

Hmmm, we say. Slow your breathing down. We'll take good care of you. My partner collects history while I get vitals. I slap the ten round stickers on arms and legs and chest, ask him to lie still, and thumb the 12 LEAD button. Glance down at the printout, expecting to see nothing remarkable.




* * *

Things move quickly then. I run to the ambulance and grab the phone, to send the EKG. My partner starts the workup - oxygen is already on, aspirin, nitro, and oral zofran follow. The firemen grab the stretcher. I've got the 12 sent and the hospital alerted before he's even on the stretcher. We load and roll. The strobes make flickering freeze frames of the snow that is falling lightly.

We get to the hospital, one of our favorites, and the doc (best in the city, in the opinion of most medics) all but meets us at the door. Nurses and techs and x-ray are all waiting. I ask if they've called the cath lab. "Of course," the doc replies. "They've been headed in for twenty minutes now."

When the patient thanks the doc, he points out the door to us - me making the gurney, my partner charting. "Thank them. They got you here fast."

By the time I come back in after cleaning up the rig, the patient is gone to the lab.

* * *

The standard of care for interventional cardiology, the benchmark everyone strives to make, is 90 minutes door to balloon. That is, 90 minutes between the time the patient rolls or walks into the ER until the time the interventional cardiologist inflates a tiny balloon to re-open an occluded artery.

Tonight, everything came together and the system worked perfectly. From the time our patient called 911 until the time the balloon went up in his occluded LAD, barely 78 minutes elapsed.

Holidays

He's messed up on something, messed up badly. Christmas Eve morning and he's broken into a swanky condo building downtown and started trashing the place. The police were called by the neighbors, and soon after their arrival asked for medical to respond, lights and sirens.

* * * *

My partner and I are standing in the elevator, all burnished steel and soft lighting, with four firemen and a cop, who's come down to lead us up to the patient. We've got a monitor and airway kit and medical kit, probably fifty pounds of gear.

The elevator doors open. Shattered glass covers the floor, a giant wall display of art pulled down and shattered. We gingerly step over it. The cop explains, apologetically, that he's all the way around the back and there's only one elevator bank.

We walk down twists and turns to the back side of the complex. We turn a corner, and here a fire extinguisher lies on the floor, ripped off the wall. Another corner, and a single shoe sits in the middle of the hallway. A quick zig-zag turn and a shattered 2x6 sits next to another fire extinguisher. We turn down the penultimate hallway, and for a second I think there is a fine filligree of string across the floor, with small black boxes scattered here and there.

Then I realize the boxes are spent Taser cartridges, and the string is the spaghetti tangle of probe wires. There must be four or five spent cartridges along the hallway. Bad news.

The patient is a little further on, handcuffed and hobbled, bloody, spitting, cussing, but not actually fighting. The police tell us he was on a violent rampage, that he made no sense, was chewing on glass, took threats and force and multiple taserings to subdue.

Faced with this, my partner -- for it's her call -- takes no chances, and we give him the full work-up. Backboard, restraints, oxygen, IV, 12 lead, the works. His mouth is swollen from the glass, and he responds poorly. He hasn't fought us at all. His blood pressure and heart rate are high. I press her to run him in code 3, lights and sirens, as something is saying "not right!" at the back of my head. She agrees, and halfway to the hospital we both realize that he's too subdued, he's too obtunded, something has changed.

* * * *

We pull into the hospital, and as we take the stretcher out I'm thinking about the cleanup we'll have to do, the low county levels, the chance that we'll get off on time, so that I can get my stuff together and load up the car and head south for Christmas with the family. And what the hell is going on with our patient. I ask my partner as I punch in the door code. Nothing has changed.

We slide him into one of the trauma bays, and as the staff gathers I catch a glimpse out of the corner of my eye, and there she is, standing back quietly, black fleece over blue scrubs. My heart lifts, a bit. We haven't made it here yet tonight, and I didn't know if I'd get to see her. It's a little spot of light in a generally grumpy morning (sometime around five am).

Maybe, I think, maybe I'll even find an excuse, a chance, to talk to her. I wonder if she has noticed me. How could she not have?

We move the patient to the bed, and I slide the stretcher out of the room, then scoot back in. I listen, and try not to interject too much, as my partner gives report. The doctor comes in, looks the patient over, and decides he needs to be evaluated by the trauma team.

"Okay, folks," the MD says tersely, "this is now a Level 2. Clothes come off, now."

I see her go for one pants leg, pulling trauma shears out of her scrubs pocket, and I pop the trauma shears off my leg, going for the other pants leg.

The patient groans unintelligibly, splattering the doc's faceshield with specks of blood. On one side, a nurse is drawing labs from a hastily-inserted second line; spots of red drip onto the floor from where he didn't occlude the vein quite enough. The speaker overhead is blaring, "Trauma activation, level 2, in department now. Trauma activation..."

She looks up as we both start cutting the man's jeans. Soft brown hair frames startlingly blue eyes. She smiles, shyly, with just a hint of a twinkle in her eyes. Oh, they seem to say, I didn't expect to see you here.

I smile back, and lean in to say something, just to her, under the growing bustle in the room.

"Merry Christmas, baby."

Wisdom

"First Rule Of Streets: In any given city, there will be a Main Street and a Martin Luther King Boulevard.

"And, even though Martin Luther King preached peace and acceptance, in any given city, if you are on Martin Luther King Boulevard, you are in a violent part of town."